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I. INTRODUCTION

Health Information Technology (HIT) is an over-arching term referring to various electronic information systems related to health care delivery. The following report by the Government Accountability Office (GAO), issued in 2005, summarizes the impetus behind the national movement toward HIT development.

Policy makers at the State and Federal levels have moved from calling for the use of health information technology (HIT) to taking steps to mandate the use of HIT in the near future. The implementation of a National or regional HIT program creates a number of challenges, many of which are especially complex in the binational, bilingual United States-Mexico border region. The technological challenges are presented in this paper along with information about three specific health concerns on the border as examples of the role of HIT in the field of public health.

Many experts agree that the key to a successful national health information technology (HIT) initiative lies in achieving interoperability of various systems, networks, and technologies, through the establishment of national standards that can be effectively implemented across a broad range of settings and service delivery contexts. Yet because of the high-tech nature of HIT and public health informatics, most efforts to develop applications occur in urban areas and are dominated by urban perspectives. Thus it is important to document the experiences and perspectives of HIT initiatives in the most challenging of settings to inform the development of flexible, appropriate, and functional national standards and guidelines.

This report will explore the current status of HIT technologies in the United States-Mexico border region. The region is characterized by predominantly frontier geography; dynamic and diverse populations; special health care needs with relatively poor access to health services; and relatively poor access to broadband information networks. This context creates unique challenges, opportunities, and uncertainties for the deployment of HIT by public health and healthcare agencies within the region. Examples of State, county, and local efforts to improve quality of care using HIT in public health organizations will be drawn from California, Arizona, New Mexico, and Texas in the U.S.; integration with public health efforts in the Mexican States of Baja California, Sonora, Chihuahua, Coahuila, Nuevo Leon, and Tamaulipas will also be considered.

Three health improvement objectives were selected for focus based on the priorities of the Healthy Border 2010 Initiative: immunizations, obesity/diabetes, and tuberculosis.

A.                Project Background

This report was prepared for the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Office of Rural Health Policy, under contract with the National Center for Frontier Communities (formerly the Frontier Education Center).

As the first phase of the project, the Frontier and Rural Expert Panel advisory group for this contract met in Tucson, Arizona, on March 9 and 10, 2006. Members of the Panel are listed in Appendix E. The meeting consisted of presentations by invited border health experts followed by a group discussion. Day two of the meeting included a field trip to Nogales, Arizona and Nogales, Sonora, Mexico (National Center for Frontier Communities 2006) .

The purpose of the meeting was to clarify and define further research topics on frontier border health issues.

B.                 Research Objectives and Methods

This report will examine the use of health information technology in public health programs at the United States-Mexico border, with an emphasis on frontier and rural health. This report has three main objectives:

·         To identify and describe contextual factors of the United States-Mexico border region that influence the adoption, implementation, and effectiveness of HIT;

·         To describe the experiences of public health programs with HIT and public health informatics; and,

·         To identify constraints, opportunities, and uncertainties regarding the advancement of HIT at the border.

This report is principally a literature review; documents reviewed include peer-reviewed journal articles, monographs, reports, periodicals, and organizational Web sites. Telephone interviews with expert informants supplement the literature and helped guide the inquiry.

“Border health” is a broad issue being addressed by numerous international, Federal, State, and local-level institutions as well as a number of private commercial and non-profit entities. The same is true of health information technology / public health informatics. Variations in terminology increase the complexity in developing a “representative” view of available information. Thus while the intent of this report was to produce an overview of these multiple disparate strands, given the enormity of the task, the findings are indicative rather than exhaustive.

II. BACKGROUND

A. The United States-Mexico Border Region

The United States-Mexico Border Region has been formally defined as the area within 100 kilometers of the international boundary between the United States and Mexico (United States-México Border Health Commission 2003-2005) . Administratively, this encompasses 48 counties in four U.S. States (California, Arizona, New Mexico, and Texas), and in Mexico, 80 municipios in six States (Baja California, Sonora, Chihuahua, Coahuila, Nuevo Leon, and Tamaulipas) (see Appendix A for a map of the border region).

Despite this formal definition, various formulations of the “border region” continue to exist. For example, the United States-México Border Health Commission counts only 44 U.S. counties as part of the border region, and the United States-Mexico Border Health Initiative of the U.S. Department of Health and Human Services includes 45 U.S. counties (the Arizona counties of La Paz, Maricopa and Pinal are excluded). These differences in definition account for some differences in demographic estimates between different organizations. For this report, 48 U.S. counties were included in the region, which corresponds with how each border State defines its border region.

 
1. Border Populations

The border region is nearly 2,000 miles long, with more than 12 million residents on the U.S. side (see table below) and more than 6 million residents in 80 municipios on the Mexican side (United States-México Border Health Commission 2003) . The border region is usually identified with its major border cities and 43 points of entry or border crossing sites. But, while 90 percent of the border population resides in 14 paired, inter-dependent sister cities, 3 out of 4 border counties were classified as “frontier” in 2000 among the most isolated and least populated areas of the United States (see page v for the definition of frontier, and Appendix B for a list of border counties and those classified as frontier).

Table 1: Border region population, by race/ethnicity, 2005

Data source: 2005 American Community Survey, U.S. Census Bureau

Yet these statistics reveal little of the diversity among the populations that inhabit the border region, and each group has distinct and significant impacts on health planning and services delivery. On the U.S. side of the border, 26 Federally recognized Native American tribes are located within the border region, and on the Mexico side, seven indigenous groups are recognized (U.S. Environmental Protection Agency 2006) . Some of these indigenous groups, for example the Tohono O'odham Nation of Arizona and Sonora, straddle the border with members living on both sides. Many U.S. citizens of Mexican or Latino ethnicity reside on the U.S. side of the border, yet prefer to obtain health care in Mexico from providers who share their language and cultural traditions.

The majority of people on either side of the border are permanent residents; some are binational, crossing the border daily for work, while others rarely cross the border. Some residents are temporary, such as international migrants who typically only spend a few days in the border region. Some border region residents are seasonal, including migrant agricultural laborers, as well as U.S. “snowbirds” living on both sides of the border.

Many U.S. retirees have relocated to Mexico or reside in the border region during part of the year, and may be dependent on affordable healthcare services in Mexico. For example, Arizona attracts many snowbirds who seek medical services across the border from Yuma. Baja California, Mexico, and other northern Mexican States have growing populations of American nationals on fixed incomes who have relocated for economic reasons (Bach & Kiy 2006) . Despite the fact that many residents of the region are elderly with significant health care needs, as is typical of most frontier populations, many border health programs focus on young adults and children.

2. Public Health Priorities – Healthy Border 2010

The Healthy Border 2010 Program is a binational agenda for health promotion and disease prevention. Established by the Border Health Commission in 2003, the framework builds on the Healthy People 2010 program, the Healthy Gente program (United States), and the Indicatores de Resultado (National Health Indicators, México). The framework sets 20 objectives for 11 focus areas (For a more detailed list of Healthy Border 2010 indicators, see Appendix C):

1. Access to Health Care – ensure access to primary care or basic health care services;

2. Cancer – reduce breast cancer and cervical cancer mortality;

3. Diabetes – reduce both the mortality rate of diabetes and the need for hospitalization;

4. Environmental Health – improve household access to sewage disposal and reduce hospital admissions for acute pesticide poisoning;

5. HIV/AIDS - reduce the number of cases of HIV/AIDS;

6. Immunization and Infectious Diseases – expand immunization coverage for young children, as well as reduce the incidence of hepatitis and tuberculosis;

7. Injury Prevention – reduce mortality from motor vehicle crashes as well as childhood mortality from injuries;

8. Maternal, Infant and Child Health – reduce overall infant mortality as well as infant deaths due to congenital defects, improve prenatal care and reduce teenage pregnancy rates;

9. Mental Health – reduce suicide mortality;

10. Oral Health – improve access to oral health care; and

11. Respiratory Diseases – reduce the rate of hospitalization for asthma.

(United States-México Border Health Commission 2003a) .

The “Hispanic health paradox,” in which Hispanics often appear healthier than their American counterparts on a number of health indicators despite lower socioeconomic development status, is largely the result of lower rates of chronic disease. U.S. border residents have lower age adjusted mortality rates (494/100,000) than the U.S. national rate (560/100,000), while border residents in Mexico have higher mortality rates than other Mexican residents (760/100,000 vs. 630/100,000).

However, Hispanics have a higher rate of diabetes, chronic liver disease, and cirrhosis than other ethnic groups in the United States (United States-México Border Health Commission 2003). Amerindian ancestry and prenatal exposure are two possible explanations for the higher rates of diabetes among Mexicans and Mexican-Americans than other ethnic groups (Martorell 2005) . Also, chronic disease rates increase with length of residence in the United States (particularly among those born in the United States) as they acculturate.

B. Access to Health Services

Basic access to health services in the border region remains one of the most critical problems. Over 80 percent of U.S. border counties have Health Professions Shortage Areas (HPSAs) (Bach & Kiy 2006) , with border populations having 25 percent fewer primary care physicians than the general U.S. population.

Residents of the border States also have the lowest levels of health insurance coverage, with an estimated 21 percent of the U.S. border population uninsured. Mexican-Americans have the lowest rates of health insurance among U.S. population groups (Sullivan 2004) . In 2000, an estimated 14 percent of the U.S. population was uninsured; border States had much higher rates of uninsurance, ranging from a low of 18 percent (Arizona) to a high of 24 percent (New Mexico). Texas border counties had the highest rates of uninsured populations, with nearly 1 in 3 residents lacking health insurance; 13 of its 32 border counties had uninsured populations greater than 30 percent. Aggregation masked large variations between counties. Among the three California border counties, Imperial County had the highest rates of uninsured, but is dwarfed in the aggregate by the size of San Diego County’s population. Similarly, Arizona had two large counties (Maricopa, Pima) below the State average for uninsured; the other five counties had an uninsured rate of 24 percent.

Figure 1. Data Source: U.S. Census Bureau Small Area Health Insurance Estimates: Experimental estimates of health insurance coverage, 2000 (release date: July 2005).

C. Organization of Border Health Activities

In addition to the usual array of State and local government health departments, private providers, and non-profit providers, border health activities involve a broad spectrum of international, Federal, and regional programs. In the international arena, the Pan American Health Organization, U.S. Agency for International Development, and World Health Organization (WHO) work at the border. At the Federal level, the U.S. Department of Health and Human Services Border Health Initiative is managed by the HRSA Office of Rural Health Policy. Each of the four U.S. border States has a State Office of Border Health, and some municipalities (e.g. San Diego) have their own border health initiatives.

United States-México Border Health Commission. The United States-México Border Health Commission (USMBHC) was formed as a binational commission in 2000, and designated a Public International Organization in 2004, to provide the leadership for “coordinated and binational actions that will improve the health and quality of life on the border” (United States-México Border Health Commission 2003-2005). Commission membership consists of 26 members, with 13 members forming 2 sections, 1 from each country led by a Commissioner, the Secretary of Health. Other statutory members of the commission are the chief health officers from the 10 border States, with the remaining 14 members appointed by the Federal governments of each nation.

• Eagle Pass, TX/Piedras Negras, Mexico/Kickapoo Nation (Trinational)
• Del Rio, TX/Ciudad Acuña, Mexico
• Brownsville, TX/Matamoros, Mexico/Cameron, TX
• San Diego, CA/Tijuana, Mexico
• Columbus, NM/Luna County, NM/Palomas, Mexico
• El Paso, TX/Ciudad Juarez, Mexico/Las Cruces, NM
• Laredo, TX/Nuevo Laredo, Mexico
• Mc Allen, TX/Reynosa, Mexico/Condado Hidalgo, TX
• Nogales, AZ/Nogales (“Ambos Nogales”), Mexico
• Noreste de Sonora, Mexico/Cochise County, AZ
• Presidio, TX/Ojinaga, Mexico
• Yuma, AZ/San Luis Rio Colorado, Mexico
• Imperial, CA/Mexicali, Mexicali (recognized by the State of California)

As the health system in Mexico has more public medicine (sponsored at the Federal level), and is more centralized and hierarchical, it is often difficult for U.S. health officers to meet directly with their Mexican counterparts, who are typically not authorized to communicate directly with their U.S. counterparts. The role of binational councils may vary depending on local needs, but they provide a forum for public health managers and providers from both countries to speak with each other and understand each others’ perspectives. As U.S. and Mexican public health officers typically do not speak each others’ language, translators play an important role at the meetings.

Institutional barriers to cross-border collaboration. Some border health experts note that while much attention is currently being paid to border health issues, few of the problems are new and they are already well documented. From an intervention perspective, despite extensive research there has not been enough action to make a difference.

The International Community Foundation, working in the San Diego-Baja California border region, cites two major types of institutional impediments to improving the health of the border population, and subsequently the health security of all Americans (Bach & Kiy 2006) . The first is a failure of leadership to make necessary policy changes to enable effective action. The second is the fragmentation of health services and programs that “focus exclusively on one disease, treatment, or subgroup.” This fragmentation is self-reproducing in an environment of chronic shortage of resources and in the absence of leadership for a more comprehensive, coordinated effort. In turn, “fragmentation reproduces limited capacity, even when a program is successful within its own objectives.”

Where programs are funded on the U.S. side, for example, they may not be funded on the Mexican side of the border, and U.S. Federal funding agencies may not permit expenditures on the Mexican side of the border. This undercuts the ability of individuals and organizations in Mexico to work with their American colleagues. In addition, a donor emphasis on “sustainability” may inadvertently contribute to the demise of once-funded HIT initiatives. The implementation of HIT may increase operational costs, and if support is made available only for new projects over the short-term, non-profits will face increasing difficulty raising funds to sustain ongoing operations.

D. Information and Communications Technology Infrastructure in the United States

Health information technology remains a vision of the possible rather than an everyday reality for public health and health care programs, particularly in remote rural areas. Compared with other developed nations, the United States lags behind in the development and deployment of HIT (The Economist 2005) . One reason is the difference in health systems – a country with a national health system will face fewer hurdles to the development and deployment of HIT. It is perhaps not surprising that many are skeptical of the possibility of a national health information system, given the characteristics of the U.S. health care system: a chaotic mix of providers and payers; a blend of public and private enterprise; tensions between cooperation and competition in a quasi-market-based health system; layers of administration; and a mosaic of legal regulations. The United States also lags behind other developed nations in the deployment of essential telecommunications infrastructure.

1. Lack of infrastructure on the United States-Mexico border

 Lack of access to essential telecommunications infrastructure remains a major bottleneck for HIT in many parts of the United States, as well as in Mexico. Most HIT applications require high-speed Internet connections, and some require the strength of T1 connections. Yet rural residents are more likely to rely on slow dial-up connections than their urban counterparts, and many places lack any service provider. However, data on the extent of broadband deployment in the United States are limited and difficult to assess (United States Government Accountability Office 2006) .

Although a recent national survey of local health departments showed that only 1 percent lack a computer, 2 percent lack Internet access, and only 7 percent lack high-speed Internet access, the survey also shows a consistent pattern of lower access to information and communication technologies among health departments that serve a population of less than 25,000 (Leep 2006) . Data on the populations served by local health departments for the entire border region are not available. However, in the 2000 Census, 27 of the 48 U.S. counties in the border region had populations of less than 25,000. (Some counties have more than one local health department, and some local health departments in Texas cover more than one county.)

2. The National Health Information Technology (HIT) Strategy

“Fewer Mistakes, Lower Costs, Less Hassle, Better Care.” The importance of HIT is summarized in this way by the U.S. Department of Health and Human Services (U.S. Department of Health and Human Services 2005) . Evidence of the benefits of health information technology to improve quality of care, increase efficiency of service delivery, and reduce costs over time are now well established (RAND Health 2005; Shekelle et al 2006) . HIT also can increase access to care through applications such as telemedicine. Widespread use of HIT may also improve public health initiatives through the automated collection and transmission of data for improved surveillance and monitoring of population health indicators.

National Health IT Strategy. The vision of HIT received an important boost in 2004 with the establishment of the Office of the National Coordinator for Health Information Technology (ONCHIT) within the U.S. Department of Health and Human Services. The Office provides the leadership for the development of a national HIT platform and promotes the widespread adoption of HIT in health care (U.S. Department of Health and Human Services) . Under the National Health IT Strategy, various divisions within HHS now coordinate IT initiatives (see Appendix D for a list of HHS IT initiatives).