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National Information Center on Health Services Research and Health Care Technology (NICHSR)

Health Indicators in Action (Examples of Indicator Projects) Transcript

Event Started: 5/5/2010

Welcome to part four of the Health Indicators Webinar Series brought to you by the National Library of Medicine's National Information Center on Health Services Research and Health Care Technology. Before we begin, please maximize the meeting window by using your F11 key. You should see a title slide in the main part of your screen; directly below and to the left of the slide, you should see a little figure in a blue shirt. Please click on this icon and select agree if you can see the slide and can hear me well. Thank you. We will be monitoring your status throughout the webinar, so please use the options in this status indicator to communicate problems with us. To the right of the slides there's a section entitled Chat Q and A. Throughout the webinar please type any questions you would like the presenter to answer. The presenter will address the questions at the end of the session. The slides and a recording of the presentation will be available next week at the Web site where you registered.

We are delighted to introduce Cheryl Wold, our presenter today, who will provide an in-depth look at two examples of indicator projects focusing on health indicators in action. Cheryl has an MPH in epidemiology from Boston University School of Public Health, has extensive experience in public health evaluation in Los Angeles County and is a recognized expert in health indicators, including developing a compilation of indicator projects for the Institute of Medicine. Go ahead Cheryl.

Okay, thanks very much, Kate. This is Cheryl Wold. I'm pleased to be continuing our conversation about health indicators and I want to thank the National Library of Medicine for sponsoring this series on health indicator projects. Prior to today's presentation, modules in this series have provided both general and detailed information about health indicators including an overview of health indicators and an in-depth look at the Community Health Status Indicators resource and related case studies of librarian involvement in module three. We've seen many examples of how health indicators are applied in a variety of ways to drive improvement efforts. The 4th module today will look at two indicator sets, one national and one local, both of which I think you will find very interesting. I should also mention, as was stated in previous modules, we anticipated including the State of the U.S.A in this series but because the site is not yet launched it isn't possible.We hope to explore the State of the U.S.A. in the near future and are sure you will appreciate all that it has to offer.

The goals for today are to further your understanding of health indicator resources and their uses by focusing on two online examples of health indicator projects. My primary focus will be on the County Health Rankings, a tool that provides rankings, targets and comparative information for all states and counties on a set of health determinants. The second is the Boston Indicators Project which is an example of a comprehensive indicator system at the local level designed to track the overall quality of life in the Boston region across several domains in addition to health. At the end of today's presentation, you'll understand some of the similarities and differences in the approaches, key features, and content of both of these rich indicator resources.

First, I'd like to quickly highlight several points that have been made about health indicators in previous webinar discussions about what defines indicators and what makes them valid and useful. Health indicators individually and collectively as indicator sets share many qualities, for example, they are designed to provide standardized comparable measures of health over time between groups of people and across geographic areas in central domains of health. Good indicators alone or collectively are informed by models for what influences health, are based on high quality data, communicate well and are relevant to prevention opportunities. Today's discussion is intended to focus not so much on individual indicators, but how the whole indicator project is used to drive improvement. As we review our examples and their unique approaches, it is worth reflecting on some of the characteristics that will help librarians and other professionals as well as the general public in how best to define and use the information.

In addition to the qualities just mentioned, you might consider some of the following whether you're an information consumer or an intermediary; please note that this is not an official list, but rather food for thought. It may be useful as you navigate the variety of indicator resources available. The first quality is transparency - do the developers share information about the quality of the data sources and the methods? How frequently is the information updated? What are the stated purposes? Who is involved? Who are the intended audiences and what are the intended uses? How is the effort financed and what is the commitment to updating it and funding it in the future? Are indicators attached to an agenda or a set of measurable objectives or intended to broadly inform? Who is accountable to act?

The first module discussed data sources for indicators in some detail. Credible sources of information at the national, state and local level feed multiple indicator systems and are mostly from public sources. Certainly the federal government has a long term commitment to the collection and dissemination of data that supports indicators. Furthermore technology increases access to information and the demand for data driven planning and accountability are just two examples of trends that are bound to increase the uptake of such data dramatically. To make these data accessible and digestible, a great deal of secondary data analyses are required. Increasingly such analyses and dissemination is supported by public-private collaboration, and this is poised to grow. In fact, this is the subject of an exciting initiative called the Community Health Data Initiative. It's the intent to spur innovations in the dissemination and use of health indicator data and is part of Open Government. I will come back to this to discuss it at the end of the presentation and tell you more about the vision for increasing the public's interaction with health indicator data through the creation of health applications, games, reporting tools and other innovations.

Indicator sets, in particular those on the local level, are wide ranging and have a variety of purposes. They're generally compiled by organizations such as public health departments, non-profit agencies, foundations, businesses, civic groups and universities. Indicators are used to raise awareness about problems or trends, identify priorities, draw people and organizations together to take action, target or redirect resources toward priorities, and promote accountability. Now these uses hold true at both the national as well as the local level, although the implications for taking action at the two levels are quite different. Projects designed to raise awareness may look very different from those that are intended to improve performance and accountability for achieving results. On some level, however, all of these efforts want to motivate a broad base of support and push for innovation, and information is an important tool in that process.

There is a substantial literature and experience base for this work. Many sources discuss the community health improvement cycle. The graphic shown here was used by the Institute of Medicine in their 1997 report "Improving Health in the Community". It focused on the use of health indicators and two processes. The first is the problem identification and prioritization cycle shown at the top of the slide. And this is where, for example, the 240 indicators in the Community Health Status Indicators project, as well as the County Health Rankings which we will discuss today can be used in combination with local data to support that whole process. The second cycle is what happens once a specific health issue is identified as depicted by the smaller graphics across the bottom. And today's examples of indicator projects are also designed to provide resources to inform both parts of this cycle.

The County Health Rankings was released recently in February of 2010. This site was published by the Population Health Institute at the University of Wisconsin in collaboration with the Robert Wood Johnson Foundation. Extensive research went into developing this indicator resource. The leaders in this effort tapped the expertise of an impressive group of technical advisors and obtained high quality data for the indicators. Work that proceeded and shaped the County Rankings was done by the University of Wisconsin which first released it's statewide county health reports in 2003. In papers referenced in this slide, Wisconsin's evaluations tracked media stories to assess how much attention the reports garnered and surveyed local health officials to assess how information was being used. The rankings were found to be a useful approach and one that was subsequently taken with the nationwide County Health Rankings. In addition to the research findings, the leaders of this effort were inspired by the use of rankings by the popular media to compare places such as rankings as the best places to live, attend college, and so on, and by the America's Health Rankings report. I should note that rankings have some strength and limitations in their application, as do any comparative statistics, such as grades; we'll touch on that a bit later in the presentation. Suffice it to say that the main goal was to capture the attention of the media and decision makers and to increase access to health data in the county areas.

So here is a view of the home page of the County Health Rankings site. You can either click on your state using this flash animated map or type in your county or state in the area circled to the right to obtain rankings on health outcomes and health factors. If you click on a state, for example, I'll use California, a map of California will come up showing how all the counties in the state are ranked based on a composite measure for overall health. And this composite measure is primarily based on health outcomes. The lighter shaded counties are the healthiest, the lightest among them ranked first through 14th and the darker green counties are the least healthy, ranked number in this case for California, 43 through 56. There are two features on this page that I want to highlight, first is that you can easily navigate your way to both table listings of the rankings for all counties in the state or a similar map showing health factors by clicking on the descriptions in the upper left, circled in red. Or, you can zoom in on one county. For example, the arrow was pointing to Los Angeles County, and if I click on LA County, the site will give me a snapshot of the county with data for all of the indicators. Now, before we get into the details of the snapshot, the link circled on the left make it easy to navigate back to very quickly access the five or so report formats available for the rankings, and I'll show you examples of each. In addition you can find links to other facts about LA County as well as recent news stories. However, it is important to note that the related links, news and information shown in the two lower circles ideally would be selected by those states and counties, and the developers take suggested additions to their pages and you can do that via the Contact Us feature. I should also mention that the developers are beginning to investigate the possibility of allowing states to add their own data.

Let's look briefly at the other report formats. So for those who prefer tables, another format is a table showing the rankings for all counties for each of the four Health Factors. Or, I could click on the Health Factors map to access a graphic showing how all counties are ranked overall on Health Factors. It looks very simple, right? But as I'm a glutton for detail and I know you are, too, let's take a closer look at the snapshot for LA County and how the rankings are determined. You'll see across the top are column headings for the detailed indicators and running down the left hand side of the the screen are the first portions of the indicators. The first column provides the indicator result for the county, followed by the error margin, the target value, the comparison to the entire state and the ranking of LA County compared to the other counties on that composite indicator. You will see that there were over 6,000 years of life lost due to deaths that occurred prematurely, that is, before the age of 75 per hundred thousand residents in LA County. If the county were in the 90th percentile, in other words, if only ten percent of the counties in the state faired better than LA County on that ranking, the number of years lost would be closer to 5200. Similarly, let's look at the indicator under morbidity. The percentage of the adult population in poor or fair health is 22 percent with a target value of 11 percent. You'll note that the overall ranking for Morbidity, 49th out of 56 counties, is based on a composite of the four indicators listed, including Poor or Fair Health, the Average Number of Poor Physical and Mental Health Dys, and the Rate of Low Birth Weight Births. You can get more detail about any indicator. Let's say you wanted to know more about how Premature Mortality was calculated. If you click on Premature Death, circled in red, the blue link, you'll find summary information about how the indicator is measured, the data source, and how each indicator is used in the ranking methodology.

That same information can be obtained for the health factors circled here a bit further down the list below the indicators for Morbidity and Mortality.You'll see for the composite measure for Health Behaviors, LA County receives a more favorable rating, 20th out of 56 counties on Health Behaviors. This may be a good time to note some of the strengths and limitations in the use of rankings. It's worth pointing out that several of these caveats are openly stated on this web site. On one hand the counties ranked higher look good in these types of comparisons, however, I would think that anyone would argue that an adult smoking rate of ten percent in the best counties or an adult obesity value of 19 percent in the 90th percentile counties may still be too high. However, the target values are useful for showing the variation and for what may be a reasonable target to obtain. The second thing I'll point out is the error margin. The rankings are intended to provide a general guide for these Health Factors and may have limited precision. It is important that data and resources are available in the states and counties to assess whether interventions in place locally are having any impact. The data sources and measures here may not detect meaningful changes in local areas, for example, were a county to achieve great strides in reducing youth smoking, and may otherwise mask important trends. Another trend that may be masked is wide disparities in the population, because it states an average value, there could with be wide racial, ethic or other disparities.

So let's go back and look at the three main components of the site. Looking at the marquee across the top of the page inside the red oval, you'll see Health Outcomes, Health Factors, and Taking Action. If you click on the Health Outcomes, you'll be taken to a page, this page, that describes key, in lay terms, indicators that are used to create those health outcomes rankings. You'll see the same type of information for each of the Health Factors. The County Health Rankings does a really great job of explaining the rationale and details behind all of the indicator choices. Click on any of the indicators shown here in blue and you'll be taken to a page that provides a detailed description of each indicator. For example, if I follow the link about Tobacco Use, I would be taken to this page. Every health indicator gets a detailed description. The screen shot can't capture all the categories, so I'll show you what is described on the next slide. But, if I can just comment, one of the best things about this web site, other than the rankings themselves, is the transparency of the information. The detailed information provided for all the indicators includes a description of the indicator and why it was selected. They also describe why it's an important health indicator and evidence for specifically how it reflects or impacts the health of the population. The measurement strategies review the options for measuring a given indicator including how the measure itself is obtained as well as available data sources and their quality. The County Health Rankings measurement strategy explains which metric was selected among the choices previously outlined as well as the rationale for its selection. The measure's strengths and limitations are self explanatory, but it is an honest appraisal of what the indicator can and cannot tell you - the completeness of reporting, for example, and other information that is vital to the interpretation of the findings. The references cite peer reviewed publications and research, but they're presented in a very user friendly language. The literature provides technical information - whereas otherwise specific to the methods and applications of the indicator.

Now this graphic shows the model, the model for the weights used to come up with the rankings on Health Outcomes in the green box and the Health Factors in the blue box. You'll see running down the middle are the weights assigned to those composite indicators. Starting at the top, Morbidity and Mortality measures each contribute 50 percent to the overall ranking on Health Outcomes. The Health Behaviors contribute 30 percent to the Health Factors ranking, Clinical Care contributes 20 percent, Social and Economic indicators contribute 40 percent and Physical Environment indicators contribute ten percent to the overall ranking for the Health Factors. The red box shows the Policies and Programs at the local level that can have a huge impact on these Health Factors which in turn impact the Health Outcomes and I'll come back to that when we discuss the actions lengths in more detail. So, the detail of all these indicators, if you look down the right hand side of the slide are all provided on the site. And, I won't go into the detailed measures that contribute to all of the various indicators, but I will mention that for Morbidity or Mortality there are five specific measures. There are six specific measures rolling up into the Health Behaviors, the composite indicator for Health Behaviors. There are three specific measures that roll up into the composite indicator for Clinical Care. There are eight individual measures that roll up into the Social and Economic Factors and four that roll up into the Physical Environment composite indicator.

So, I'll go quickly through these next slides. I was going to go through these in detail, but in the interest of time and your attention, I think that we will go through them, but you can see that the composite indicators are quite a bit more detailed than their presentation, which really makes the information quite accessible. And, again, the detail of all those measures is provided on the web site. So now that we have seen the big picture as well as some of the indicator and measurement detail the most logical question concerns the next steps, and the other fantastic feature on this site and one that we could spend hours exploring is the Take Action link, circled in red at the top of the slide. This project is very directed toward providing relevant and actionable information as well as links to resources useful for taking action. I want to focus on three features, starting with the graphic that has Take Action at the top. Now, communities can be at different stages, so this is not strictly a sequential process but a cycle, and very similar to the Institute of Medicine model shown earlier in the presentation. For each of the steps shown in the outer part of the ring, the County Health Rankings site provides links to additional information and resources; for each of the bubbles shown in the inner part of the ring, which are the types of collaborators that play various roles in the health improvement process, the site also provides resources specific to those groups. For example, there are links to information from the Business Group on Health that may be of use to businesses looking to implement worksite wellness programs for example. I wanted to highlight the links and resources related to Working Together as well as Finding Programs and Policies that Work. Under Working Together, for example, you will find resources that are related to Leadership Development, Forming Partnerships and Building Community Capacity. Under Programs and Policies that Work, there are links to resources to assist with locating evidence based interventions. And the other process tools are so specific to local situations and too detailed to get into in this presentation, but it is very interesting that communities can really decide, depending on their specific needs and where they are, what resources are the most relevant. And one important caveat is that these compendiums are by no means complete and will always be a work in progress. Again, it is the developers' intention that various entities, such as the public health and even the librarian community, I hope, would contribute useful information and sources as these evolve. So, for example, these are some guides found under Find Programs and Policies that Work. Again, this is not an official listing, there's no single source for this data, rather there are rapidly evolving resources for locating evidence based interventions, however, these are certainly credible sources, for example, the Community Guide is a widely respected source on evidence based interventions. It comes from the CDC with task force members from various academic institutions. It conducts systematic reviews of the scientific studies on a particular topic assessing the quality of those studies and summarizing the findings and from my perspective it is a very high quality resource, thus I gave it a star there. However, it is similar to other data sources and it would be up to the customer to assess the quality of that information including the timeliness of the reports, how frequently the data are updated, its purpose, and the perspective of the compilers when looking at similar sites.

So, as we transition from our discussion of the County Health Rankings to our local example, I'd like to just point out some features that are common to both of the approaches. I know you haven't seen the Boston Indicators Project yet, but I think you'll see these commonalities as we go through them. Local indicator sets, oh, I'm sorry, both of these resources are rich for health improvement, they offer high quality and accessible information. They offer links to practical information, they seek to activate a base within local communities to take action and engage their users. They both push innovations and new ways of working - for example, using more informed approaches and tools, vehicles for collaboration and sharing. And how current these resources will stay and be maintained going forward is not known. However, Community Health Rankings is designed as a snapshot, but it is funded, I think through the year 2012, while the Boston Indicators Project is more trend-oriented and there's a commitment there to keep it updated through 2030.

Local indicator sets and uses vary so widely and have a number of different groups involved and interests at stake. Many areas such as Boston and other countries have created indicator systems to frame the civic agenda and create a forum for discourse. I'll briefly run through the history of the Boston Indicators Project and focus areas called sectors and highlight some of the features that makes this indicator system unique. The Boston Indicators Project is an example of a comprehensive indicator system. Many cities and counties across the U.S. use this type of indicator system. You'll see on the home page a marquee going across the top, highlighted in red on this slide with each of the ten sectors; I'll show you those ten on the next slide. The home page also features the most recent indicator report which is the result of a civic agenda that engages citizens and leaders throughout the region in addressing the issues identified and provides a continuous analytic and feedback process; we'll talk more about that in a minute. The website provides a means for locating information related to the overall conditions and quality of life in Boston. It is a selective clearinghouse for reports, contextual information and data. The site is led by the Boston Foundation in conjunction with the city of Boston and the Metropolitan Area Planning Council. And really for the past decade, I think the first publication was in the year 2000, it has provided several reports, annual, biannual and special reports; it plans to continue publishing these reports with updates and conducting outreach through the year 2030, which coincides with Boston's 400th anniversary. The most recent report for the project is highlighted prominently on the home page; this is circled in red. Let's zoom in so you can see the ten sectors more clearly. They include: Civic Vitality, Cultural Life and the Arts, the Economy, Education, Environment and Energy, Health, Housing, Public Safety, Technology, and Transportation. The Project relies on the expertise of hundreds of stakeholders gathered in multiple convenience to frame its conclusions and draws data from the wealth of information and research generated by the region's public agencies, civic institutions, think tanks and community-based organizations. The Civic Agenda is integral to the indicator project and has four components: Analysis, the first component, is analysis and interpretation of current trend data to create common ground and shared understanding; Agreement through dialogue, debate and discourse, on the nature of the key challenges, threats, opportunities and goals; Alignment on long term goals and short term targets; and Action, to leverage assets and achieve impact through collaborative strategies, partnerships, alliances, and public private initiatives as well as personal commitments. The goals for the current Civic Agenda areas shown on the outer edge of this frame are not unlike those you would find in examples around the country. The first is an Open Dynamic Civic Culture, the second is 21st Century Jobs and Economic Strategies, the third, World Class Human Resources and the fourth is 21st Century Infrastructure and Sustainability.

And going across the sectors across the top, if you click on the Health Sector, sector number seven, you'll see eight indicators, and these look similar to what you might see with health indicator reports. There are some notable differences, for example, they have indicators for Retaining the Region's Competitive Edge in Health and Funding for Public Health. Similarly, clicking on the Environment and Energy, you would see the ten indicators listed here, you'll note the inclusion of Clean Air, Accessible Green and Recreational Spaces, and Beautiful Walkable Communities, which are clearly related to health and may often be seen on other health indicator sets, in fact, environmental conditions, as you recall, were part of the MATCH system, the County Health Rankings system, as proven determinants of health. Similarly the sectors include Community Safety, Transportation and Education, all of which relate to health and well being. As we look in more depth at the Boston Indicators Project, I'll focus on these five key features. The first of those features is the framing of the indicators. There are eight indicators under Health, some very similar to other indicators as I have mentioned but some quite different. The two measures under this indicator shown here, which are Research Funding in the State and Boston Region as well as the city's Ranking in Child Outcomes Compared to Other Large U.S. Cities, this is a good example of how a nationwide indicator system, like the Community Health Status Indicators or County Health Rankings can be integrated nicely in conjunction with local indicator projects. The second feature is that you immediately see the most recent report of the Boston Indicators Project when you first visit the home page. The report provides current data on trends for each of the sectors through 2009 and is a crucial component of the Civic Agenda. The third feature is the incorporation of national and local data. As you link to local data, for example the national sources, the Youth Risk Behavioral Survey, available for approximately 30 states, 15 cities; Boston happens to be one of those cities that has local YRBS data. Although some of the graphics are not updated, you can easily spot the most recent information as noted by the green dot that says new and find, for example, recent Estimates for Smoking Among Teens.

Another feature is the Sector Cross Cuts, which can be found on the home page and throughout along with the People and Places tool and those are both circled in red on your screen. These are handy filters for looking at the indicators across sectors, for example, if you're interested in examining all the indicators for Boston's 24 neighborhoods, or if you're just interested in one of those neighbors, you can use the Sector Cross Cut tool. I'll show you an example - if I select the Boston Sector Cross Cut, I will be able to look across all sectors, one through ten that have indicators with data available for each of Boston's 24 neighborhoods. I've shown here the indicators for four sectors that come up using the filters, although there are many more. Another nice feature is that the indicators are numbered and those numbers are retained with the indicator wherever they appear, so using this tool, I can easily spot that Trust in Neighbors circled at the top is part of the Civic Vitality sector which is the number one sector. So if I click on that indicator, the Trust in Neighbors Among Boston Residents, you'll see data related to Trust in Neighbors, in this case, from the Boston Health Commission. In addition, you can see data from the Boston Police Department on a very similar indicator, so there are two local data sources related to the indicator for Trust in Neighbors that is analyzed for each of the particular neighborhoods. The last feature that I'd like to highlight related to the links that the project provides to assist community groups with planning and taking action. For each of the ten sectors, the Boston Indicators Project displays information about Innovative Strategies, Proven or Promising and those are featured with links for further information. And you can find this information by going directly from the home page following a graphic called the Hub of Innovation or by linking to the Hub of Innovation in any of the sector pages, you can easily read by scrolling through. And again, this is not a definitive source but put together to highlight innovations and engage people in the process of creating change and improving health.

The Boston Indicators Project is a valuable example of a different approach to health indicators using a comprehensive quality of life approach. It is unique in the offering of a broad range of social indicators not available in other comprehensive indicator sets. It also includes useful features and innovations in the presentation and framing of indicators and will continue to evolve through the use of open source software and other tools for engaging a broad audience.

So, I'd like to jump back quickly and tell you about the Community Health Data Initiative, which is a major new public-private effort that aims to help Americans understand health and health care performance in their communities and to help spark and facilitate action to improve performance on the part of decision makers and communities as a whole. I really encourage you the read about this initiative. The first phase is starting with the Department of Health and Human Services, and eventually with other federal agencies, will focus on making a wide range of indicators available through a web portal free of charge including measures produced for the 240 Community Health Status Indicators as well as the County Health Rankings and eventually the State of the U.S.A. datasets. The CHSI, as well as the County Health Rankings are currently available for download, following the second link down on the slide. The goal for this year is to also include measures from Medicare and Medicaid (from CMS), the data from measures tracked by Healthy People 2020, as well as information on evidence based programs and policies that have successfully improved community performance across many of these measures. The second phase of the Community Health Data Initiative will be to stimulate development of new technological applications - games, consumer applications, interactive health maps, dash boards, all designed to increase awareness of health indicators. They are also designed to pressure decision makers to act to improve those health indicators and to stimulate improvement in health and health care performance. Here is the design framework for the initiative and you will find this similar information in the links that I provided. Starting at the top with making raw data available from the government, eventually other data sources, making that data more openly available, the initiative will catalyze the uptake of the data by innovators who will work with the data eventually creating new applications, products, services, and tools to be used by end users. I really don't have time to do this incredible graphic justice today. This is not just a one-way process, the increase in use of health indicator data will likely provide feedbacks and provide new data back to the open system.

I have just a few other resources to mention. Health care reform has specified in several places the requirement to conduct surveillance community health assessments and to analyze and disseminate information. It also increases funding for disseminating information on evidence based practices in community health and clinical care. It funds prevention and wellness activities. The Kaiser Family Foundation has created a very nice synopsis of the legislation and the link is provided here. The National Library of Medicine would also like to notify you about two resources for locating funding opportunities: first is the Partners in Information Access for the Public Health Work Force and the second is HSR Information Central which has a section on grants. These are additional resources for designing and planning community interventions. Also we've listed resources for community health improvement models, so similar to the Institute of Medicine model that I showed earlier. I want to thank you for attending today. I think we are going to take some questions. And I want to in particular thank Ione Auston at the National Library of Medicine for working with me on this project.

Thank you, Cheryl, you should see a question appearing in your Q and A at the bottom of your screen. Do you see it?

Okay, I'll try it again. Oh, I see there's a question. Sorry, there's a terrible echo. Earlier modules covered the Community Health Status Indicators. The question pertains to the difference between the two. The Community Health Status Indicators feature about 240 different indicators and it provides comparisons to peer counties - so counties that are very similar to your own and it gives you some - it digests the indicators and will tell you ways that you're doing better than your peer counties and ways you might be doing worse. It really helps in that prioritization cycle that we talked a little bit about. It also just gives you, you know, this sort of raw data for how your county is doing. By contrast, the County Health Rankings is designed to be a snapshot. It's designed to provide the information on rankings to really grab people's attention with the rankings, and to provide more digested information, so quicker information that's more quickly accessed. And that's not to say that it's superficial, there's a lot of information that is provided on this site, but they really want you to take home several key points very quickly by looking at the data where Community Health Status Indicators is, I think, designed for more sophisticated users when they're investigating community health issues in more depth.

I see another question here. Okay, the second question is essentially asking why the rankings from the County Health Rankings data were older than the data that they had in their local county and that the measures used in County Health Rankings were not the best for their area. The questioner's pointing out that this is not a criticism, but just pointing out that such a site can only go so far to look at the local context without being on the ground and in the area. I agree that the best place to use the area, I mean, it's really up to the local area to frame the information and to complement that information with other valuable local data sources. And I did have, I cut it out of the presentation, but I was going to talk about what some of those complimentary data sources at the local level can be. You know, in LA County, we're fortunate to have the LA County Health Survey; I was intimately involved with this survey for many years. We have the California Health Interview Survey, that survey provides information for all the counties in the state. Places like New York City have local surveys and local areas also have administrative and services data, data from public agencies, like education departments, local police data, as well as other tools that can really enrich the information used in the health assessment and community health improvement process. So, I agree that the locals are really the experts. At the same time, the County Health Rankings, does make information accessible to those parts of the country, many counties that aren't fortunate to have those local resources or might not have had the chance to develop them yet. So, I do think it serves an important purpose and it is important to take some of the measures with a grain of salt or feature them on the local web site, but provide some interpretation. I also think I mentioned that the developers of the County Health Rankings site are exploring having the states in the local areas be able to add their data to the site. So, I think they're very interested in being very collaborative with this new tool.

Okay, thank you.

And thank you all for your participation. The slides and the recording of the presentation will be posted next week on the web site where you registered. When I close the meeting window you'll automatically be directed to our short evaluation form, the Medical Library Association will be conferring one hour of CE credit for viewing this webinar. Please complete the form and we'll arrange for you to receive your credits. Thank you.