ASTHO Phase II Tracking Fellowship Program Cincinnati Health Department

Environmental Public Health Tracking ASTHO Phase II Fellowship Report

Submitted by Denisha G. Porter Public Health Educator/Creating Healthy Communities Program Director 3101 Burnet Ave. Cincinnati, Ohio 45229

Submitted to

Association of State and Territorial Health Officials Environmental Public Health Tracking: State to State Peer Fellowship Program 2231 Crystal Drive, Suite 450 Arlington, VA 22202

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I. Introduction and Background

The Cincinnati Health Department (CHD) is an organization dedicated to improving the health of the Cincinnati community and is responsible for the promotion, protection, and maintenance of public health in the City of Cincinnati. Environmental health, public health and clinical care services are integrated in the Cincinnati Health Department, employing methods that include surveillance, assessment, disease prevention, health education and assuring access to public health services. The CHD is governed by a nine member Board appointed by the Mayor and meets on a monthly basis; day to day functions are under the leadership of the Health Commissioner, who has expressed strong support for submission the grant application.

II. Proposed Tracking Activities

Small Project: Overview The Centers for Disease Control and Prevention National Environmental Public Health Tracking Program was established in 2003. The goal of the tracking program is to collect environmental, human exposure and health data such as asthma, air pollution, and childhood lead poisoning for the purposes of integration, analysis, interpretation, and dissemination. Participating sites include California, Colorado, Connecticut, Florida, Maine, Maryland, Massachusetts, Minnesota, Missouri, New Hampshire, New Jersey, New Mexico, New York, New York City, Oregon, Pennsylvania, South Carolina, Utah, Washington, and Wisconsin. Although, Cincinnati, Ohio was not funded in the last round we were very thrilled to be selected as an Association of State and Territorial Health Officials (ASTHO) fellow. As an ASTHO fellow, the Cincinnati Health Department completed a pilot project by developing a data portal that displays vital statistics data.

Summary and Specific Aims In Phase I of the ASTHO Fellowship, the purpose of the CHD pilot project was to encourage data sharing between the CHD Vital Records Department, City of Cincinnati Information Technology Centers, and the Ohio Department of Health by working with internal programs as well as external database managers to reformat the data for presentation through the NEPHT portals. In Phase II of the Fellowship we continued these efforts and expanded the portal by adding additional data sets. Special emphasis will be placed on developing the IT infrastructure, the design/look for the portal front page, orienting and training advisory committee members, and forging strong relationships with state and local agencies.

Benefits and significance to his or her state and EPHTN The long term goal of the project is to compare maternal, child health, vital statistics and chronic disease data between neighborhoods or neighborhood groupings, and identify patterns ascribed to infant mortality, cancer, asthma and other chronic diseases. This project may form the basis for linking geographic data on exposures to environmental hazards to maternal, child health, and chronic disease data and for encouraging data sharing among data stewards by working with internal programs as well as external database managers to reformat

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Draft 3/19/2013 the data for presentation through the NEPHT portals. The project aims to ensure equity in health service delivery and equitable protection of the Cincinnati population.

Research design and Methods The pilot tracking project activities in Phase I of the Fellowship which was completed included: 1. Evaluating the CHD database 2. Assessing Data Building, Sharing and Confidentiality 3. Researching Legal Aspects including Statutes and/or Rules 4. Analyzing Compatibility of Data with the National Environmental Public Health Tracking website

In addition to completing the tracking activities of Phase I, members of the EPHT committee visited the host site in New York City and attended the National Environmental Public Health Tracking Conference in New York City.

The Committee developed the following next steps for the Phase II of the Fellowship: 1. Enrich current portal by adding birth defects and explore adding population data and mortality data sets. 2. Create an implementation plan including consultant needs and developing and implementing a technical advisory committee (TAG) orientation program. 3. Members of the EPHT committee will revisit New York City, our previous ASTHO fellowship mentor city, and propose that the Mayor of Cincinnati also visit New York City to be educated on EPHT as well to show the power of a well developed tracking system. 4. The CHD EPHT Committee will also communicate with and visit with the Ohio Health Department. 5. We will investigate additional partnerships with the University of Cincinnati’s Institute for Policy Research, the Health Foundation of Greater Cincinnati, the US Environmental Protection Agency, The Ohio Public Health Informatics Committee (TOPHIC), and the Cincinnati Health Department’s Emergency Preparedness Program.

Key Personnel The Environmental Public Health Tracking Committee consists of the following:

Dr. Camille Jones, MD, MPH, Cincinnati Health Department, Assistant Health Commissioner Tunu Kinebrew, MPA, Cincinnati Health Department, Vital Statistics Coordinator Sean Ware, Enterprise Technology Solutions, Computer Systems Analyst LiAnne Howard, MCP, MEd, Cincinnati Health Department, Senior Administrative Specialist - Community Planning and Evaluation Denisha Porter, MPH, HHS, RS, Cincinnati Health Department, Public Health Educator/Creating Healthy Communities Program Director

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III. Statement of Need

According to 2010 census data Cincinnati’s population was 296,943 people, occupying over 77.2 square miles. Cincinnati’s median household income was $33,855 compared to $47,144 statewide. Poverty still plagues a large portion of Cincinnati’s population. In 2005-2009 25.3% of people of all ages were living below the poverty line compared to 13.6% statewide. In 2008, the American Community Survey ranked Cincinnati the seventh poorest city out of 75 cities surveyed with 25.1% of the residents living in poverty. Some of the adverse health impacts of living in poverty include: increased likelihood of living in a geographic area that is exposed to environmental toxins, as well as poor nutrition, inadequate access to preventive health and pre-natal care, housing that is infested with rodents and insects, housing without smoke detectors, and housing with lead hazards. Cincinnati has one of the lowest home ownership rates of comparably sized cities in the country with a rate of 34%. The housing stock is old with 93% of the housing built prior to 1980. Lead hazards from lead-based paint can be presumed to be present in the majority of the housing units. Based solely on the age of the housing, 37,972 occupied rental units and 39,090 owner-occupied dwelling units have a high potential for lead based paint hazards. The City of Cincinnati’s infant mortality rate (IMR) at 15.5 deaths per 1000 live births in 2009, is as high as some developing nations. The IMR is widely thought to reflect the overall health of a community as an indicator of a lack of education, poor hygiene, poor nutrition, lack of access to healthcare and other underlying health and social issues.

Table 1 – Infant 2002 2003 2004 2005 2006 2007 2008 2009 2010 Mortality Rate Cincinnati Health * * * * 5.6 7.1 Department 18.6 6.4 13.8

City of Cincinnati * 11.0 16.7 17.9 11.3 13.5 13.6 15.5d 12.6 Hamilton County, * * 9.8 9.6 11.0 13.9 9.7 10.9 11.1 Ohio * * Ohio 7.9 7.8 7.7 8.3 7.8 7.7 7.7 * * U.S. 7.0 6.8 6.8 6.8 7.0 6.8 *

In 2008, Cincinnati was ranked by the American Lung Association as the 8th most polluted city in the United States for Year-Round Particle Pollution. This coincides with resident perceptions that Cincinnati has poor air quality which results in a high prevalence of asthma. Results from the 2010 Greater Cincinnati Community Health Status Survey (GCCHSS) show that the average adult in Greater Cincinnati experienced 7.7 days – over one week – of poor mental or physical health per month. This is compared to just under a week (6.2 days) nationally. Both the national and regional rates have stayed relatively consistent since 2005. About 6 in 10 Greater Cincinnati adults report having been told by a doctor or other health care provider that they have a chronic condition such as high blood pressure, high cholesterol, depression, severe allergies, asthma or another condition. Although rates of many

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Draft 3/19/2013 chronic conditions have stayed relatively consistent since 1999, the percent of Greater Cincinnati adults who have been told they have high blood pressure or hypertension, high cholesterol or triglycerides, and depression increased. High blood pressure rose from 25% to 34%; high cholesterol rose from 20% to 28%; and depression rose from 15% to 21%. Recent analyses done by the CHD in conjunction with Xavier University show that Cincinnati residents have higher mortality rates than Hamilton County as a whole, than all large metropolitan areas in Ohio as a whole, and than the average mortality rates for the US. Mortality rates are higher in Cincinnati consistently across age, race, and sex subgroups. The question about why mortality rates are higher in Cincinnati is of high interest for residents, and the environmental tracking portal will be able to provide access to data to help the public think about this important question. Given the higher exposure to air toxins and other toxins in this area, environmental exposures will be a very relevant and interesting piece of data to evaluate. In 2009, the Cincinnati City Council passed the City of Cincinnati Environmental Justice (EJ) Ordinance, recognizing that the local governments must demonstrate leadership to address Environmental Justice concerns of their citizens and must enhance opportunities for meaningful public participation in all government decisions that have environmental and health impacts. The focus of the EJ Ordinance is the regulatory process for industrial activities, as an effective means to protect individuals from the material, cumulative and adverse impact of pollutants. While the EJ Ordinance has not yet been implemented, it remains an important indication of widespread public concerns about environmental impacts on health. Our data will possibly point to environmental justice issues that are clearly defined.

IV. Steps in Project Timeline for Phase II Project:

Travel to the CDC National Tracking Workshop in Denver, Colorado (April 30 – May 3, 2012) Two members of the Cincinnati EPHT Committee, Denisha Porter and Sean Ware attended the CDC Workshop in Denver, Colorado. Many of the breakout workshop sessions appeared to be of a technical nature. The EPHT Committee thought that it would be a good idea for Sean Ware, Senior Computer Analyst to attend the workshop technical sessions. The EPHT Committee received permission from ASTHO to amend our budget for Mr. Ware to attend the workshop along with Ms. Porter. Ms. Porter presented the success of the ASTHO Phase I EPHT Fellowship at an opening session of the CDC Workshop and was able to strengthen network connections with New York City, ASTHO, and CDC program officials. She focused on gathering information on how other agencies utilize population data in their portals to assist us with the ASTHO Phase II Fellowship. Ms. Porter and Sean Ware 1) The Share Point Server is a resource for CDC grantees. Perhaps our local EPHT Committee can have access to Share Point and can be utilized to help us recruit TAG members. 2) The complexity of the EPHT portals are found in the data sets, mapping, and relational data sets. The City has some of this infrastructure but will need dedicated staff to develop our portal complexity. 3) Mr. Ware attended the Health Department’s manager meeting as a follow up to learn more about the mortality data that has been compiled. 4) Mr. Ware was sent the bread crumb for the US Census population data that was used in developing the mortality data.

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Enrich Current Portal with Population and Mortality Data September, 2012 – March, 2013 We utilized population data for analysis by neighborhood. The City of Cincinnati is divided into 48 statistical neighborhoods. These are neighborhoods that closely follow census tracts. We were able to obtain the 2010 US Census formatted into 48 neighborhood profiles and upload this information to the EPHT portal. This will allow EPHT portal users to compare vital records data, also sorted by neighborhood, with population data without leaving the portal. The following data is included in each neighborhood profile:  Total Population  Sex by Age  Race  Household type  Housing type  Housing Occupancy  Housing Tenure  Commuting to Work  Occupation  Income  Poverty Status  School Enrollment  Education Attainment  Language  Renters  Gross Rent

2001 – 2007 mortality data is also formatted by 48 statistical neighborhoods. This will assist portal users to compare population and mortality data by neighborhood. The mortality data sets that we explored were recently updated to account for census tract overlap and now better represent what is occurring in the City of Cincinnati. Deaths by age and by neighborhood, is now uploaded to the pilot portal. The EPHT Committee also explored the mortality data sets for the top 10 causes of death in Cincinnati for each neighborhood and then by age and race. The pilot portal also presented the opportunity to provide additional quick link information including: Vital Statistics Fast Facts, Tracking Committee Members, Tracking Committee Meeting Notes, TAG Member orientation materials, and TAG Meeting Notes. During the ASTHO Phase II Fellowship, the Tracking Committee was able to respond to community concerns by posting the location of 700 demolitions to take place in Cincinnati in 2013. The demolitions are part of the Moving Ohio Forward program. Community concerns that the demolished housing will add lead dust in the neighborhood are addressed in a community outreach program to inform residents of scheduled demolition locations and methods to reduce demolition dust in residences. The posting and mapping of the demolition locations is in response to community concerns. In addition, we have posted proactive steps on the portal to inform residents to keep demolition out of their homes as part of the overall community lead safety outreach.

Develop a Technical Network Implementation Plan (TNIP) Development of the Cincinnati EPHT TNIP followed the following steps: 1. Review the CDC Technical Network Implementation Plan 2. Review the CDC National Network Implementation Plan

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3. Review CDC’s Guide to Building an Environmental Public Health Tracking Network 4. Review the Louisiana EPHTN Technical Architecture Plan Version 1.1 5. Draft Cincinnati TNIP Outline 6. Draft Final Document (Appendix 1)

Form and Orient a Technical Advisory Committee (TAG) June 2012 – March, 2013 The following steps were taken to develop TAG membership: 1) Develop a list of potential TAG members, 2) Invite 14 individuals to be on the TAG by contacting them individually by phone and followed up with a written invitation from the CHD Health Commissioner, Dr. Noble Maseru. One person declined the invitation, 3)TAG Committee member orientation materials were developed to include a 1 sheet summary, a folder packet, and power point slides.

The first TAG orientation meeting was held on September 18, 2012 at the Bettman Resources Center (Cincinnati Parks Department) and light refreshments were served. Some highlights of the first TAG meeting include: 1. Children’s Hospital has maps of asthma incidence rates that capture all asthma hospitalizations in the City. Asthma may be a potential NCDM to post next because Cincinnati has a high incidence rate of pediatric asthma as well as poor air quality. 2. It was determined that we can promote the TAG by identifying people who love data, health, and the environment. Debrief: a. Add a specific slide of where we are and where we want to go. b. Add slide numbers. c. Set a meeting with the researchers at Children’s Hospital d. Arrange a meeting between TAG members and the NYC EPHT during their visit to Cincinnati.

TAG Committee members met with NYC staff on October 12, 2012. Subsequent TAG Committee meetings were held on January 10, 2013 and on February 21, 2013. The January 10th meeting agenda included: 1) review of the pilot portal and future plans, 2) discussion and input from TAG members on the drafted Memorandum of Understanding (MOU), Mission/Vision, and 3) review of nationally consistent data measures (NCDMs). The February 21 meeting agenda and accomplishments included: 1) Finalized and approved the Mission/Vision and MOU, 2) reviewed mortality data sets for TAG Committee members and received their input on how they would like to see the data queried.

New York City Department of Health and Mental Hygiene (NYC) Visit to Cincinnati October 17 & 18, 2012 The original idea of taking the Cincinnati Mayor or a Cincinnati City Council Member to NYC was to build support of EPHT in Cincinnati and to develop the political will to accept future EPHT grants. Ultimately we envisioned introducing the concept of a multi-faceted, collaborative, information model that could not only serve as an external tool for the community, but also as a quality assurance tool internally for the City of Cincinnati. At the EPHT Committee’s May 5, 2012 meeting we decided it would be better to bring NYC staff to Cincinnati so that more groups could be involved beyond the political arena including the TAG Committee

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Draft 3/19/2013 members, Children’s Hospital researchers, University of Cincinnati researchers, and CHD middle management staff. The committee sought and received approval from ASTHO to revise our proposal to bring NYC staff to Cincinnati. The EPHT Committee formulated the following goals for the NYC Staff visit: 1. Generate political support for the portal through education and a an official presentation to the City of Cincinnati City Council 2. On-going technical assistance to the Cincinnati EPHT committee by assessing our Phase II Project workplan 3. NYC staff to meet with TAG members to introduce the portal basics and potential for growth in Cincinnati 4. Discuss the NYC program and present how they obtained buy in from city leadership and other NYC departments, explain their experience as it related to successes, challenges, and sustainability, and describe the first steps they took to develop the portal.

The NYC visit to Cincinnati itinerary and agenda outcomes are below. Nancy Jeffery RN, MPH and Wendy McKelvey, PhD were the two NYC staff members who made the visit and multiple presentations in Cincinnati.

New York City Department of Health and Mental Hygiene (NYCDHMH) Cincinnati Visit Environmental Public Health Tracking (EPHT) – Association of State and Territorial Health Officials (ASTHO) Phase II Fellowship Agenda/Outcomes Wednesday, October 17, 2012

10:30 – 12: 30 City Council: Rules and Government Committee -City Council Chambers 1. 15 to 20 minute presentation by NYCDHMH and Cincinnati Health Department (CHD) before the Council Sub-committee. 2. CHD presented our progress to date including: ASTHO Fellowships I and II, pilot portal, TAG, TIP, Ohio State-wide meeting and where we would like to go from here with grant funding and City Council’s support. We emphasized that this is an innovative project, grant funding may be available in the future, this is not a new program, however, it needs to be much more robust 3. NYCDHMH supported the vision of the CHD by presenting how they started out, discussion of the political support that they have received, and an overview of where their portal is today, including an anecdotal story or two about the portal. 12:30 – 2:30 Lunch with Technical Advisory Committee (TAG) - Marriott Kingsgate 1. The purpose of the lunch meeting with the TAG was to have a dialogue about EPHT and how outside data bases can be worked into the CHD portal. 2. NYC staff were introduced, there was a overview of the purpose of the meeting by sharing the status of the CHD portal, and learning from the NYCDHMH experience, NYCDHMH staff discussed their early experiences developing a portal, discussion, closing. 4:00 – 5:00 Children’s Hospital Researchers Meeting 1. Informal discussion.

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Thursday, October 18, 2012

9:00 – 10:30 Introduction to CHD Leadership – Dr. Englender (Preparedness), Dr. Holditch (Medical Director), Dr. Crumpton (Child and Adolescent Health), Dr. Maseru (Health Commissioner). 11:00 – 12:30 Lunch - Olives in Clifton 1:00 – 2:00 Group of 50 (CHD Management) – Delores Bowmen Auditorium 1. Overviewed the National EPHT Program a. Content Areas b. NCDM c. CHD portal development status 2. Introduced New York City Staff 3. NYC Staff presented their experience developing a portal 4. NYC Staff gave anecdotal examples of the uses of the portal in NYC 5. Discussion

The NYC Staff visit accomplished many objectives. Lunch with 7 TAG Committee and NYC Staff generated interest and input from TAG members, and TAG members who were not able to attend the orientation in September were able to catch up at the luncheon. Our City Council did “buy-in” to the importance of an EPHT. After the presentations one Councilmember asked “how much does this cost and how can we get this here (in Cincinnati)?” The EPHT Committee is cognizant that the City has budget constraints therefore, in response; the EPHT Committee is working on a strategic and conservative funding request that can be supported by our Technical Network Implementation Plan.

Committee will Visit with the Ohio Department of Health The EPHT Committee travelled to Columbus, Ohio to meet with representatives of the Ohio Department of Health (ODH) on 8/28/2012. Fortunately, we were also able to meet with staff representatives of the Columbus local health department. Notes from the meeting follow:

Present: LiAnne Howard (CHD), Camille Jones (CHD), Tunu Kinebrew (CHD), Judy Nagy (ODH- Vital Records), Betsy Pandora (Columbus Public Health), Denisha Porter (CHD), Sean Ware (Cincinnati Enterprise Technology Systems), Cynthia Weiss (ODH-Bureau of Environmental Health) Weiss covering meeting for Billings Nagy covering meeting for Friar Rosemary Duffy works with the CDC ODH Environmental Health -Ms. Weiss’ work is the outcomes of being exposed to poor air quality. They are tracking asthma hospitalizations, Emergency Department visits, and mortality along with nitrous oxide, temperature and weather. -The Ohio Hospital Association (OHA) is very particular about hospital data. They do not do surveillance. Do not collect race data. Everything the ODH puts out about hospitals is checked by the OHA. Rosemary Duffy worked with the hospital data, however she will be returning to Atlanta. Columbus Public Health (CPB) Betsy Pandora is the Healthy Communities Coordinator for CPB. 9

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-Mid-Ohio Regional Planning Commission is the MPO for Columbus City. -Biking and walking are related indicators and can be used for the Built Environment, Nationally Consistent Data Measure (NCDM). ODH Vital Records -Death data is going live the last quarter of 2012. Accident data will be readily available the last quarter of 2012. -Ohio Hospital Compare – certain data points must be common such as infection rates, accidents. The Division of Quality Assurance manages Vital Records. The ODH has 3 divisions: Quality Assurance, Family and Prevention. Ohio Vital Statistics falls under IT. -CHD EPHT Committee should get in contact with Bruce Hotte of ODH Office of Management Information Systems (OMIS) for more information to obtain Cincinnati City data. NCDMs Birth Defects, Asthma, Cancer (is slated to feed into the warehouse), prenatal visits. Asthma is from John Paulson’s group and is a rare death.

Data Warehouse -Should be able to see events specific to your city. Also data sets outside of our city. You can see actual residence, and gender, race, other attributes. The Warehouse is updated weekly. Death data will be up in October. Death data goes back to 2006 and 2007. -STEVE = state, territorial, electronic, verification, events: pushes ODH data to other entities. STEVE costs money to subscribe so many agencies do not have access. -Birth/death match – matches if a person was born and died in Ohio -7 Ohio counties have no hospital and residents go out of State to have a birth. -Asthma deaths can also be reported as chronic lower respiratory disease. Next Steps 1. Involve Ohio EPA 2. Find out how the collaboration between NYC EPHT and NY State works. 3. Develop a plan to guide collaboration with State and Local levels. 4. Start a data map of what we want and where the data will come from. Do We Want to Meet Again As a Collaborative Group? Yes.

Committee will Visit with Other Private, Local and State Agencies In addition to meeting with Columbus Public Health on 8/28/12, the EPHT Committee also had conversations and provided EPHT information to representatives from Dayton and Kentucky Department of Health. We forwarded our ASTHO Phase II application to Dayton and held an in-depth phone conference with Kentucky Department of Health on 2/5/2013.

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V. Discussion of Expected Outcome of Project

The expected outcome of the project was to add updated vital records information and population data to our demonstration portal. We also wanted to explore mortality data and, at this time, were able to add some mortality data sets to the portal. We were able to implement a system of banners on the portal with links to demolition data, outreach information on lead protection, CHD EPHT meeting minutes, and TAG orientation materials. We wanted to visit NYC EPHT along with Cincinnati officials; however, we succeeded in achieving the same goals by having NYC staff visit Cincinnati. With the help of NYC staff members, we were able to accomplish buy-in to the concept of a Cincinnati EPHT portal at the local city government level and within our health department and academic institutions.

VI. Conclusion

In conclusion, plans for future tracking activities include finding available funding that will assist us in further developing the web portal. Specifically we would like to be able to fund a full time Biostatistician to work on the EPHT portal. Now that we have buy in from City Council we will work on a proposed budget that links to our drafted TNIP of a modest funding proposal to City Council. We would like to follow-up with our first meeting with the Ohio Department of Health to pursue birth, death, and asthma data that is warehoused at the State level. We will proceed with adding more mortality data sets and birth defects to the demonstration portal and continue to refine the portal look. We want to utilize a focus group to make sure that the portal is easy to use and in compliance with CDC guidelines. We have tremendously enjoyed our Phase II Project experience and once again thank ASTHO for giving us this opportunity.

V. Budget Information

Travel Total $2813  Sean Ware and Denisha Porter attended CDC National Tracking Workshop in Colorado. Flight for 2: $1026 Hotel for 2: $1508 Expenses: $279 Total $2817  NYC Staff, Wendy McKelvey and Nancy Jeffery travel to Cincinnati 3 days, 2 nights. Flight for 2: $1564 Hotel for 2: $1024 Ground Transportation McKelvey: $137

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McKelvey Meals: $92.00

Enrich Current Portal Total $6558  Enrich current portal by adding population data and explore adding birth defects and mortality data sets for cleaning and formatting the data.

Development and Design of the Demonstration Portal Total $2160

Create a Technical Network Implementation Plan and develop Total $5419 TAG.

Lunch Meeting with TAG members Total $233

Meet with the Ohio Department of Health and Other Agencies Total $0  Room: In-kind donation from Columbus Public Health  AV Equipment: In-kind donation from Columbus Public Health  Transportation to Columbus: In-kind donation from the City of Cincinnati  Supplies: Binders, pens, pencils, paper, computer and phone calls were in-kind donation from the City of Cincinnati

The Total Budget for the ASTHO Tracking Fellowship II Program is $20,000

Appendix 1 Cincinnati Health Department Technical Network Implementation Plan (TNIP) Draft 3/19/13

1. Introduction A. Purpose of This Plan – the TNIP is designed to map out the capacity necessary for phasing in and maintaining a standardized Tracking Network based upon funding. The TNIP is recommended by the CDC in order to build the network.

B. Mission – Our Mission is to develop a secure electronic network for the collection, analysis, and dissemination of environmental public health data and information; to guide policy, practice and other actions toward improving the health of Cincinnati residents; and to foster collaboration among the state environmental public health partners. (Louisiana EPHT Program)

C. 5 Year Vision – a. Develop a local City of Cincinnati EPHT Network information technology infrastructure that is consistent with national standards and architecture. i. Metadata services: enables the efficient use of environmental and health data. ii. Data exchange services: enables timely access an utilization of EPHT data by providing stakeholders the ability to electronically transfer data in a secure and standard manner

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iii. Spatial enhancement services: enables stakeholders to enhance their data through automated process such as geocoding. iv. Spatiotemporal integration services: enables the linkage and analysis of health indicators and geographically-related exposure to environmental hazards v. Record level integration/linkage services: enables dynamic integration of confidential datasets and generates de-identified public-use information. vi. Visualization and dissemination services: enables creation of dynamic, custom materials in the forms of maps, charts, graphs, tables, and reports. b. Improve the availability and utility of existing data or facilitate the creation of new data to ensure the accessibility of core and other EPHT measures. Goals for the next 5 years: i. Hazard Indicators: 1) Air quality ii. Health Indicators: 1)Child asthma hospitalizations, 2) Vital Statistics, preterm birth, low birth weight, SIDS, 3) Lead Screening and Child Blood Lead c. Inform policies, practices, and other actions to prevent or reduce illnesses, injury and death related to environmental risk factors.

D. History - The Centers for Disease Control and Prevention National Environmental Public Health Tracking Program was established in 2003. The goal of the tracking program is to collect environmental, human exposure and health data such as asthma, air pollution, and childhood lead poisoning for the purposes of integration, analysis, interpretation, and dissemination. Participating sites include 20 states and one city. Although, Cincinnati, Ohio was not funded in the last round we were very thrilled to be selected as an ASTHO fellow in 2010. As an ASTHO fellow, the Cincinnati Health Department completed a pilot project by developing a data portal that displays vital statistics data. In Phase I of the ASTHO Fellowship, the purpose of the CHD pilot project was to encourage data sharing between the CHD Vital Records Department, City of Cincinnati Information Technology Centers, and the Ohio Department of Health by working with internal programs as well as external database managers to reformat the data for presentation through the NEPHT portals.

Cincinnati was selected to complete ASTHO Phase II Fellowship. In Phase II of we continued the efforts mentioned above and expanded the portal by adding additional data sets. Special emphasis was placed on developing the IT infrastructure, the design/look for the portal front page, orienting and training advisory committee members, and forging strong relationships with state and local agencies.

The completed pilot project tracking activities in Phase I of the Fellowship included: 1) Evaluating the CHD database, 2) Assessing Data Building, Sharing and Confidentiality, 3) Researching Legal Aspects including Statutes and/or Rules, and 4) Analyzing Compatibility of Data with the National Environmental Public Health Tracking website.

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Phase II accomplishments of the Fellowship include: 1) Enrich current portal by adding birth defects and explore adding population data and mortality data sets. 2) Create an implementation plan developing and implementing a technical advisory committee (TAG) orientation program. 3) Members of the New York City, our previous ASTHO fellowship mentor city, visited Cincinnati and presented before the Cincinnati City Council, TAG, and other partners. This way City Council and partners were educated on EPHT to show the power of a well developed tracking system. 4) The CHD EPHT Committee visited with the Ohio Health Department and Columbus Public Health for the purpose of developing working collaborations. 5) We have investigated additional partnerships with the University of Cincinnati’s Institute for Policy Research, the Health Foundation of Greater Cincinnati, the US Environmental Protection Agency, The Ohio Public Health Informatics Committee (TOPHIC), and the Cincinnati Health Department’s Emergency Preparedness Program.

2. Tracking Portal Standards Network:  Provide both public and secure grantee portals  Provide a link to the Tracking Network’s National Portal.  Maintain visual consistency among pages on the local portal and if we become a grantee with the National Portal.  Organize contents of pages to facilitate the identification of detailed information.  Provide a structured flow that links related information and data sources.  Comply with Section 508 standards for both secure and public portals.  Provide for the ability to search metadata in both secure and public portals.  Provide data results and information within three clicks of the search initiation.  Provide a path to return easily to previous screens. Analysis, Visualization, and Reporting:  Support the means to generate, in both secure and public portals, visual displays of data, including maps, charts, tables, and graphs.  Provide the ability, in both secure and public portals, to display both count and rates on a map.  Use in both secure and public portals standard color pallets from proven scientific research for color sections.  Provide, in both secure and public portals, the capability to combine multiple appropriate data sources in a single graph, table, or chart.  Ensure that in both secure and public portals analysis functionality provides for minimally aggregated data, as in counts and rates.  Provide the ability to disseminate information in various ways depending on user data access, including standardized reports and Web-based query results.  Provide users the ability to interact with data tools and displays.  Provide users the ability to see alternate views of the information.

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Data Content and Discovery  Provide the capability to execute queries to obtain data in both secure and public portals.  Provide for various levels of data access depending on the user’s role.  Provide both secure and public portal access to environmental, exposure, and health effect data. Specifically all data listed as core EPHT data/measures, and those subsequently adopted for inclusion in the network.  Establish a public portal and a secure, restricted-use portal.  Allow for export of appropriate data to a common format, such as comma delimited based on the user’s role.  Provide the capability to combine and to display multiple data query results.  Establish clear categories to facilitate data browsing and discovery.  Provide clear labeling for categorical information.  Break information into easily digestible subcategories. Documentation  Provide in both secure and public portals a set of Frequently Asked Questions (FAQ).  Provide in both secure and public portals clear definitions of terms.  Provide in both secure and public portals on-line documentation  Provide a phone number or email address that users may use to get additional information or clarification. Metadata  Allow for the discovery of data by searchable metadata using the Tracking Metadata template for all data available on the grantee’s portal.  In both secure and public portals, allow for metadata search and discovery. Secure Access  In both secure and public portals, provide data security and protection.  Provide a secure login where users will be authenticated and will be authorized access to data and services.  Provide access to varying levels of data based on a user’s role.

3. Evaluation of Cincinnati/CHD IT standards A. IT Environment – The City of Cincinnati is able to implement EPHT with our current infrastructure pending future funding to develop the portal. The following is available to support the portal pending: 1) reporting module, and 2) separate database server. The scale of a future portal will need funding to proceed with a portal of the scale and complexity similar to New York City Department of Health and Mental Hygiene for example. B. Style Guides – The Cincinnati EPHT portal will abide by the combination of style guides established by the CDC EPHT Technical Committee and by the City of Cincinnati. C. Policies i. Cincinnati Health Department Policy and Procedure: Internet and Intranet Publishing No person is to publish to the Internet or Intranet, or make available to anyone for the purpose of publishing to the Internet or Intranet,

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information regarding the Cincinnati Health Department (CHD), its programs, or its employees without proper authorization. The Procedure is: 1) No employee is to publish to the Internet, or make available to anyone for the purpose of publishing to the Internet, information regarding CHD, its programs, or its employees without written authorization from CHD’s Commissioner of Health or a written directive from Health’s Information Systems (IS) Information Technology (IT) Manager; 2) No information is to be added to or linked to the CHD Internet site without the prior written request/approval of the Commissioner’s Office or the IT Manager; 3) No information is to be added to or linked to the CHD.net home page or the IS site without the IT Manager’s prior approval; 4) No information is to be added to or linked to any CHD Program’s Internet site without the prior written request/approval of that program’s supervisor or their formal designee. ii. City of Cincinnati Administrative Regulation No. 59 - Social Media Policy, July 20, 2011. iii. City of Cincinnati Human Resources Policies and Procedures – Internet Access and Electronic Mail Policy, May 1, 2000. D. Security – The City of Cincinnati has a security policy to protect data with strong passwords, fingerprint access, security cameras, and standard IT back up (City of Cincinnati Information Security Policy).

4. Staffing/Equipment/Software A. 1 Administrative Technician B. 1 Epidemiologist/Biostatisticians C. 1 Computer Programmer D. 1 Computer Systems Analyst E. 1 Health Educator F. 5 Computers G. 2 Laptops H. Software: SPSS and SAS I. Separate server J. Reporting Module K. Graphics Module Package

5. NCDMs A. Availability to the national network B. Build capacity to track data

6. Schedule for key network start-up milestones a. Vital Records – April, 2011 b. Technical Advisory Group – October, 2012 Pending Funding: c. Mortality Data – In progress d. Hire an EPHT Biostatistician e. Track Users – 50th user f. Track Success Stories – 1st Story

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