Improving Access to EHRs



Why we built it 

This toolkit is intended to help state, tribal, local, and territorial health departments improve access to EHR systems for outbreak investigations. Currently, EHRs are not standardized and interoperability is not universal. As a result, we know that EHR access differs depending on the type of system used. Many health departments still rely on a combination of types of access to needed information including onsite EHR access, remote EHR access, paper printouts, faxed copies, and emails.

This toolkit is meant to evolve as the needs of health departments change, as information technology evolves, and as further collaboration occurs between health departments and healthcare facilities.

This first version of the toolkit reflects perspectives from public health professionals. The next version will add perspectives from professionals working in different types of healthcare facilities. This toolkit also aims to inspire you to follow best practices by sharing quotes highlighting the experiences of health department staff who have already put into action the practices described here. Please provide any feedback or best practices to

Who built it

The Keystone Policy Center developed this toolkit in partnership with ASTHO and the CDC. Funding for the effort was provided by a CDC grant administered by ASTHO.

Who provided input

This toolkit incorporates the experiences and perspectives from public health stakeholders, through health department staff interviews, steering committee member calls, a stakeholder meeting, and input from the project team.

Health department staff:

We conducted qualitative interviews with health department employees in 12 states. In selecting states for the study, CDC and ASTHO prioritized those affected by the 2012­-2013 fungal meningitis outbreak but also took into account experience with other outbreaks, notable technological and other innovations by health departments, and geographical diversity. The project team relied on state HAI Coordinators as the primary initial contact, and asked them to identify appropriate individuals in other professional categories. Interviewees discussed their capacity and ability to use EHRs during the 2012-­2013 fungal meningitis outbreak and subsequent outbreaks (information collection was approved by Office of Management and Budget, 0920-0879).

The Keystone Center interviewed health department officials in the following roles:

  • HAI Coordinators
  • Epidemiologist
  • Legal Counsel
  • Informatics Directors

Within the following states:

States represented by interview participants

Florida, Indiana, Kansas, Maryland, Michigan, Minnesota, New Hampshire
New York, Oregon, Tennessee, Texas, Virginia

The methods we used and the questions we asked

We requested participation from 55 public health department officials and successfully completed 45 phone interviews with 52 state health officials in the following roles: healthcare associated infection (HAI) coordinators (n=14), epidemiologists (n=15), legal counsel (n=6), and informatics directors (n=17).

Prior to being interviewed, participating individuals received a fact sheet explaining the goals and basic design of the study, and the purpose of the interview. Data were collected using telephone interviews.  Interviews were conducted using interview guides specific to the role of the interviewee. Two CDC employees tested all the interview guides with health department officials experienced in the topic of the interview. Feedback was used to refine questions and probes and estimated burden hours. All interview guides included the following six overarching questions:

  1. What is your official title?
  2. What has been your experience with the health department requesting and/or getting access to electronic health records from clinical providers in your jurisdiction?
  3. How do you define electronic health record access in your jurisdiction?
  4. What were some of the barriers [real or perceived] you experienced or heard about to help address requesting and/or getting electronic health record access?
  5. What are the greatest lessons that you learned when requesting and/or getting electronic health record access?
  6. What would you like to see in the toolkit that could help us to address health departments’ access to electronic health records?

The interview guides assisted in the comparative analysis of findings, with six overarching questions and related probes that focus questions to the role interviewed. The probes, specific to the role interviewed, served as a guide for the interviewers to help ensure the interviews addressed all project objectives to the extent possible; therefore, not all of the probes were used in every interview.

Steering committee

The steering committee was consulted throughout the development of this project. Members participated in two one-hour conference calls to review and discuss the overall project plan, instruments, and findings.

The steering committee, comprised of experts in HAIs, law, policy, and public health included the following people:

  • Andrea Alvarez, Virginia Department of Health
  • Denise Chrysler, University of Michigan
  • Jennie Finks, Michigan Department of Health and Human Services
  • Janet Hamilton, Florida Department of Health
  • Marion Kainer, Tennessee Department of Health
  • Lisa McGiffert, Consumers Union
  • Lisa Tomlinson, Association for Professionals in Infection Control and Epidemiology
  • Jennifer Ward, Tennessee Department of Health
  • Melanie Young, Society for Healthcare Epidemiology of America

Stakeholder meeting

An all-day stakeholder meeting was convened at CDC in June 2015 to review the EHR toolkit    website with key public health stakeholders. The toolkit was edited to incorporate their experiences and feedback. The stakeholder meeting was comprised of experts in HAIs, law, policy, and public health and included the following people:

  • Cheryl Bullard, South Carolina Department of Health and Environmental Control
  • Angela Dunn, Utah Department of Health
  • Jennifer Gutowski, Philadelphia Department of Public Health
  • Katrina Hansen, New Hampshire Department of Health and Human Services
  • Marion Kainer, Tennessee Department of Health
  • Jeffrey Kriseman, Tennessee Department of Health
  • Myra Maldonado Colon, Puerto Rico Department of Health
  • Jeanne Negley, Georgia Department of Public Health
  • Kyle Stone, Illinois Department of Public Health

The project team

The project team provided leadership and direction throughout the project. The project team’s perspectives and input contributed to the steering committee calls and the stakeholder meeting. The project team is comprised of experts in HAIs, informatics, law, policy, public health, research, and evaluation, and included the following people:

  • ASTHO: Catherine Cairns, Marcus Rennick, Elizabeth Ruebush, Anita Samuel, Paula Soper
  • CDC: Laura Conn, Akshara Menon, Elizabeth Mothershed, Matthew Penn, Christine Prue, Anjanette Raber, Tara Ramanathan, John Saindon, Cason Schmit, Jacqueline Watkins
  • The Keystone Policy Center: Brianna Brumbaugh, Lorez Meinhold, Brad Sperber, Brooke Trainum

How we analyzed the data

The Keystone Center used an iterative, qualitative approach. The project team drafted data categories prior to the interviews, and then evaluated and revised the categories after approximately 10 interviews. Using the interview transcripts and interviewer field notes, the team sorted the input according to themes in the responses, and prioritized themes according to frequency and topic. The Keystone Center staff met regularly with the project team during this process to ensure consistency in interview techniques, application of any adjustments to the interview protocols, and data categorization. In addition to conducting interviews, we also used expert input and feedback from the steering committee members, participants in the stakeholder meeting, and the project team to develop the toolkit.


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