Data Modernization Strategies from Island Public Health Leaders
August 10, 2026 | Luigi Leblanc
Public health leaders across the United States are working to improve public health decision-making through data modernization efforts. However, the U.S. territories and freely associated states (T/FAS) face significant geographic, fiscal, and infrastructure challenges that distinguish their data modernization efforts from those of their mainland counterparts, including:
- Extreme geographic isolation.
- Underdeveloped telecoms infrastructure for remote populations.
- High broadband costs and instability.
- Ongoing workforce recruitment and retention challenges.
Despite these constraints, T/FAS data modernization (DM) leaders are making measurable progress by modernizing technical systems, expanding data exchange capabilities, and bolstering cyber resiliency. In the process, they continue to demonstrate remarkable innovation, resilience, and adaptive leadership approaches. During a conversation at ASTHO’s 2025 Spring Leadership Forum, territorial public health leaders examined the complex interdependencies between technical infrastructure and connectivity, data exchange, and cybersecurity. This discussion emphasized three key takeaways:
- Infrastructure modernization requires integrated strategic planning and collaborative approaches, not just technology acquisition.
- Prioritize data interoperability and exchange to improve patient care across fragmented health systems and nationally.
- Cybersecurity is both a technical and governance challenge — invest early to avoid costly downtime.
Integrate Strategic Planning and Collaboration
Infrastructure constraints represent a foundational challenge for T/FAS health systems. These challenges impact every aspect of DM implementation, including core technical systems, data access and exchange, cybersecurity, and broader technological capacity. Territorial leaders consistently stressed that trusted, reliable infrastructure is especially critical in island contexts, where public health systems play a direct role in ensuring patient safety during environmental crises, cyberattacks, and other emergencies.
T/FAS public health leadership also acknowledged that these challenges are both technical and systemic. To address these challenges, leaders must take a holistic view that goes beyond installing new technologies or upgrading legacy hardware — they need a people-centered approach that integrates change management. Through active strategic planning and systems thinking, territorial leaders can equip their teams with the skills and tools they need to maintain an agile, readiness-focused posture while also strengthening resilience and facilitating long-term change.
Prioritize Interoperability and Data Exchange
In T/FAS, where health systems are historically underfunded and health systems are fragmented across a wide geography, data exchange and interoperability is critical. However, implementing it is difficult in the best of circumstances, and T/FAS have long relied on a health system that extends beyond their borders. With limited specialty care available in region, T/FAS patients get transferred to Hawaii, the Philippines, or Florida for tertiary care — and it has always been a challenge to ensure patient information travels alongside them during those off-island referrals.
T/FAS health leaders highlighted several hurdles impacting their data exchange attempts. For example, there is often tension between theoretical data ownership and practical data access, particularly when systems depend on third-party vendors and expensive data stewardship or hosting services. In addition, legacy Public Health Information Systems constrain data exchange goals and hinder participation in national health data exchange frameworks — with cyber threats and service disruptions creating delays in systems integration and modernization.
When data modernization efforts prioritize interoperability and data exchange, leaders are more able to limit cost overruns, maximize impact of data collection/sharing, and minimize reliance on outdated legacy systems that cannot be easily upgraded or migrated to modern platforms. Within their jurisdictions, T/FAS leader participants also recognized the importance of data exchange and interoperability to effectively serve a small population
“Integrated data sharing between government health agencies, public health clinics, hospitals and behavioral health clinics… in a small community, they [community members] will all get to one and two or all three in their lifetime. So shared data will make a better patient experience.”
Invest in Cybersecurity
Data exchange and cybersecurity present both significant opportunities and substantial risks. In recent years, several cybersecurity incidents have significantly undermined public health and health care systems in T/FAS. For example, the Federated States of Micronesia (FSM) suffered a ransomware attack in March 2025 that disrupted health operations for more than six months
“Many hospitals have been hit by ransomware attacks, which have had huge impacts on downtime and recovery costs. Palau and FSM have both experienced massive cyberattacks.”
Territorial technology leaders emphasize that protecting territorial data is a top priority, given their unique geopolitical context and related national security considerations. As highlighted at the start of this blog, data modernization requires both technical solutions and people solutions. This remains true for cybersecurity, where sustained investments in workforce training, governance, and inter-island collaboration are essential to strengthening cybersecurity defenses and enhancing overall resiliency in T/FAS.
Conclusion
T/FAS health leaders are committed to strengthening their public health infrastructure and services through data modernization. Their experiences offer lessons learned for all jurisdictions: Embrace strategic planning and collaboration, prioritize data interoperability and exchange, and acknowledge the importance of cybersecurity. With these tips, progress toward secure, resilient, responsive health systems is possible
