So, I want to remind you again of the outline that we talked about. We've already reviewed that even if you find a high level of disease, it's hard to tease out the cause. We've talked about cancer and how common it is and the fact that it's not one disease but many disease, and that it can take decades to develop. I've given you a couple of examples of cancer cluster investigations, where we were successful in finding environmental factors that likely played a role in the cancer development. But most studies are not that successful and there really is a need for a national state-based environmental health surveillance system to be developed. Why is that? Because as we've discussed, these types of cluster investigations usually involve small numbers of people with disease and that limits our ability to statistically associate environmental factors and disease occurrence. Generally speaking, there's lack of adequate exposure data. I mentioned these two studies where we had pretty good exposure data, but some of that was by luck. So, let's talk about something that begin to change the picture of trying to look at disease and environmental factors today. In 2000, the Pew Environmental Health Commission detailed an "environmental health gap" in a book that described a lack of basic information needed to document links between environmental hazards and chronic disease. The commission had several recommendations that came out of that report that they wrote. First, there was a need for a national baseline tracking network for diseases and exposures. Second, that there was a need for an early warning system for critical environmental health threats. That there was also a need to develop pilot tracking programs in state and local health departments to test diseases, exposures, and approaches for national tracking, and that there had to be links to the communities and research. What is the need to really involve everybody in what we are going to do if we were going to move environmental health foreign? So, in 2002, the US Centers for Disease Control and Prevention initiated the National Environmental Public Health Tracking Program. Congress provided funding for the development and implementation of a nationwide environmental health tracking network and capacity development in environmental health at state and local health department. CDC established a structure that distributed funds to states and local health departments to establish portals. At national levels, they establish state content working groups, they provided IT infrastructure, and more as guidance for these local partners, and in state, there was a need to develop data sharing agreements with agencies, both environmental and other agencies to collect and provide health data while working to ensure patient confidentiality. Today, CDC's program has 26 grantees. So, 25 states and the city of New York are funded through CDC's tracking program. They've trained over 200 state and local practitioners in how to use the tracking network data to look for potential associations. CDC and ASTHO, The Association for State and Territorial Health Officials had some 34 tracking fellowships. I was fortunate to serve as guidance for a couple of states that did those fellowships during my tenure at the Mass Department of Public Health. CDC has also developed partnerships with other federal agencies and national organizations to promote the tracking network. This is an array of data, both health data and environmental exposure data that are currently contained within the tracking network at CDC. Even though only 25 states are funded presently, 73 percent of the measures on the national portal cover more states than simply those states and the city of New York alone. This is just meant to give you the website if you want to go on this website to take a look at CDC's tracking network. I would encourage you to do that, it's a pretty impressive site. So, let's talk a little bit about enhancing the current systems to address environmental health in more real time measures. That is specifically trying to evaluate the utility of electronic health records in trying to investigate health and environmental exposures. So, some of you may be familiar with what's often referred to as ARRA or the American Recovery and Reinvestment Act, that was passed a number of years ago when the economic decline was at an all time low. But, among the many things that ARRA did to spur the economy and to address significant problems that were happening across all of government, it was a requirement for all public and private health care providers and other eligible health professionals to adopt and demonstrate meaningful use of electronic health records and they were supposed to have done that by January of 2014 in order to maintain Medicare and Medicaid funding. ARRA also called for the use of certified electronic health record technology to improve quality and improve care coordination in population and public health. Clearly, the intent of this was for us to be able to improve public health. That gives us thought about how these records might be better used in the world of environmental health. In an electronic health record, this is just the patient profile generally. The electronic health record contains various patient characteristics. So, gender, age, and for example, if a woman was pregnant. Exposure data, where were you and when were you there. So, it won't necessarily have exposure information itself, but it will give address information such that we can as an environmental health practitioners, look at the environmental factors that are important and trace it back to where people live. It describes symptoms and that's not just what the diagnosis is, but it's what the patient says. For example, "I've had the worst headache ever". So, headaches that might be related to other types of exposures that wouldn't be contained in a typical disease registry. It has physical findings. What does the provider measure such as the patient's temperature and then what the provider observes such as, the patient appears sensitive to light. Then assessments and plans. So, very important, tests that are ordered that might be an indicator of whether or not an exposure has taken place. So, one thought that is very important is to try to consider whether electronic health records could be used to better address public concerns over perfluorinated compounds that have been showing up in drinking water supplies across the country. So, how might we go about using electronic health records to try to understand the impacts of drinking water contamination? Well, the United States Environmental Protection Agency already require states to do perfluorinated compound monitoring under the unregulated contaminant monitoring rule for public water supplies that serve more than 10,000 individuals. So, we have pretty good environmental data. Many of the health outcomes of interest are routinely collected at provider office visits, so that if you go back and think about that patient profile. So, for example, lipid profiles such as total cholesterol, low density lipid, high density lipids, triglycerides, thyroid function and thyroid disease, cardiovascular disease, and hypertension are all thought to be impacted by exposure to these perfluorinated compounds. These are the types of information that are included in that patient profile. So, if the US CDC's tracking program could gain access to electronic health records, it may allow for more ready preliminary assessment and addressing public health concerns not just as it relates to these perfluorinated compounds, but for a whole range of different environmental exposures of interest. So, in summary, when we're conducting these cluster investigations, keep in mind that even if you find a high level of disease, it's often hard to tease out that cause. Cancer is not one disease, but yet a term that describes more than a 100 different diseases. It usually takes a long time to develop, sometimes 15-20 years or more between exposure to a cancer causing agent and symptoms, and identifying possible associations is difficult. But with optimal exposure information, some studies had been successful such as those that we've discussed in Woburn and Ashland, Massachusetts. But there really is a need for better nationally state-based surveillance systems to be in place, like those that we have through the CDC's tracking program, and that along with a maturity of electronic health records provides incredible promise in better understanding impacts of environmental exposures on disease outcomes. Thank you so much for your interest in this lecture, I appreciate your time.