Reimagining Tracking and Surveillance of Diseases in the Cloud

As a large federal health agency embarked on an initiative to modernize its complex public health database system, the team leading the charge was met with a disheartening warning from stakeholders on the project: “You’re never going to change the way public health operates.” End users who had used this system for years could not see how real change could occur inside the aging infrastructure. As the agency contemplated changing the database, they ran up against several issues:

• Only certain jurisdictions within the 60+ state, territorial, local and tribal (STLT) public health departments in the country were actually using the database. 
• This low adoption rate was due to many reasons outside of the agency’s control, but those in the field noted that one factor was the aging technology and user experience/user interface (UX/UI). The database was too difficult and time consuming for to use on a daily basis, a problem that was exacerbated during the COVID-19 pandemic. The lag times and nonstandard workflows made conducting investigations and merging data time consuming and burdensome. 
• The complexity of the database system led to a third problem: many users had deployed customizations to the system with unique workarounds that made it difficult for the governing agency to deploy updates and changes to all instances of the database.

How could the agency improve the database system while expanding its adoption and usership? And was there a way to build trust with overburdened and skeptical users? To answer these questions, they partnered with CDW Government.

HCD is a methodology that enables problem-solvers to learn directly from real people to create solutions that are desirable, feasible and viable. While the HCD process can be used by anyone, in the case of this agency’s database, a diverse group of stakeholders ideated on new creative possibilities to drive efforts toward the right solution for users. Have you ever used an app that was confusing and had too many extra steps? That’s a sign that HCD practices were not deployed during the creation of the app.

Here are five steps that CDW Government used to transform the database system and improve the working lives of the end users:

The ability to analyze and share disease-related health information across STLT health departments is critical to this federal agency’s mission. To do so, they rely on STLT departments to update their database, as much of the necessary work of tracking and surveilling public health is conducted by epidemiologists and case agents at health departments scattered across the nation. Many of these end users were asking for an improved user experience with modern technologies, a modern interface and a platform that had a better extracting, transforming and loading (ETL) process.

Although the federal health agency recognized the problem, lack of standardized implementation across the country had prevented the agency from implementing system-wide UX and security improvements. Additionally, as STLT health departments made customizations, they inadvertently created variations to their instance of the database, making it virtually impossible to have a seamless upgrading process for important changes and improvements to the system.

The CDW Government team observed that building trust and buy-in with stakeholders would be the critical first step to digital and cultural transformation. This discovery led us to recommend adopting the human-centered design methodology, ensuring that concerns of the key stakeholders were heard, addressed and incorporated into plans for rebuilding the database system. The process of soliciting feedback from public-health stakeholders would engender confidence in the new system, while the user input would improve the new solution.

CDW Government’s first step probably felt familiar to epidemiologists and public health professionals: going into the field to understand the issues firsthand. To understand the obstacles epidemiologists faced as they used the database system, the CDW Government team engaged in fly-on-the-wall observations, HCD understanding workshops, a heuristic evaluation, cocreation workshops, user focus groups, user testing and usability testing.

Through their work, the team identified four major obstacles:

• Cost and maintenance: The existing database system required significant maintenance costs and specialized IT talent to maintain the system within their state. Most local jurisdictions lack the resources to host a large database themselves, requiring IT specialists or third-party companies to maintain the database — hired at significant cost.  
  
  
• ETL performance and lag time: The process of extracting, transforming and loading (ETL) data into the system resulted in significant downtime for local health departments. A typical data upload required 12-24 hours, rendering the system unusable by users during this time. This downtime impeded public health departments’ ability to respond to urgent crises and limited the federal agency’s ability to provide truly up-to-date data. 
  
  
• Nonstandard workflows impact productivity: Each jurisdiction had its own way of investigating and closing a case, and significant manual labor was required to enter patient data and complete an investigation. Some STLTs only collected the total number of cases for certain diseases, for example, other STLTs investigated each positive case. Meanwhile, not being able to share cases and files across state lines made it difficult to track patients across different jurisdictions.
  
  During the pandemic, this resulted in an extra burden on public health departments, who received many duplicate lab reports for the same patient. STLTs are also very private about their data and do not want their data leaked — which was preventing other jurisdictional public health professionals from identifying emerging patterns and trends across the country.
  
  
• Maintaining individual and local privacy: While STLT public health officials recognize the need for a central system, they also have a responsibility to maintain the privacy of their citizens. Officials worried about ensuring that the federal agency only had access to the data necessary to meet its mission.

To ensure that users were not taking a backseat to technology as the solution was being created, CDW Government added two epidemiologists straight from public health departments onto its HCD team. These staff experts shared their invaluable experience as public health experts during the workshopping and ideation process. With their assistance and ability to validate assumptions, CDW Government has been able to verify the user journey’s accuracy and ideate while receiving field-informed and user centric feedback. The ability to immediately validate any assumptions expedited CDW Government’s ability to pilot a solution.

Rome couldn’t be built in a day — and neither can a complex, multi-jurisdictional public health system. For this reason, CDW Government recommended that this federal agency take an iterative approach to transform their database system bit-by-bit, using Agile methodology. Making small, actionable steps demonstrates real progress to stakeholders who expressed skepticism that public health can improve. Additionally, the Agile process helps CDW Government continue to collect real time, tested feedback from users throughout the project — even as pilots are launched and used.

CDW Government identified patient search, data entry and nonstandard workflows as the best place to start to make a positive change — the “low-hanging fruit.” From user research, the team knew that when presented with a new lab or case report, epidemiologists first look for existing patient records within the national database or go to the queue of labs to review.

Standardizing the process for recording these patients’ data would make it easier for epidemiologists to find, create or update existing patient data within the system, almost automating the whole ingestion process through standardization. Ultimately, this will significantly reduce time to close and complete a case, easing the burden of public health workers and shortening the time it takes for relevant data points to reach the federal health agency.

As CDW Government overhauls and transforms the database system bit by bit, they are also migrating those pieces to the cloud. The federal agency’s goal is for the entire system to live in the cloud by the end of the project. Centrally governing the system from the cloud will allow the agency to deploy and standardize database processes to improve the user experience — and any upgrades can be pushed out across the entire system with the click of a mouse.

Centralizing deployment also removes the burden from public health jurisdictions, reducing or eliminating the need to use critical resources to hire IT staff. As a final benefit, the cloud-based system can be built with the privacy concerns of local public health departments in mind. Cloud providers enable users to set access management policies that will empower health departments nationally to keep their local data private — even from the federal agency. Additionally, the built-in compliance provided by most cloud computing services ensures patient data will remain in a HIPAA-compliant and secure environment.

It’s a bit of a Catch-22: a public-health database is only effective if it is widely used, but it requires popularity for people to want to use it. By committing to a human-centered process as it modernized its database — asking for feedback, holding focus groups and surveys, and checking in with users along the way — this federal health agency was able to build both buy-in and trust as the project unfolded.

As new features and solutions are introduced and piloted, the agency and CDW Government will continue to proactively solicit feedback from public health departments, changing course as needed to meet the needs of the epidemiologists who use complex system every day. As momentum continues to build, the database will become an easy-to-use, simple-to-search app that supports public health workers as they work to do what they do best: prevent the spread of disease and keep us safe.