1. Contextual Inquiry of Enteric Disease Outbreak Investigation Processes to Improve Visualization Capacity for Public Health Surveillance Jonathan Anderson, MPH Bureau of Epidemiology Utah Department of Health

2. INTRODUCTION Inform visualization tool (Epinome) development & implementation 1 - Describe existing work processes (user stories) 2 - Identify: - decision making milestones - intervention steps - wish-list items - limitations

3. METHODS Data collection: Contextual inquiry Participants: Domain expert – UDOH Enteric Diseases Epi Interviewer – UDOH Epi UDOH Deputy State Epi CoE Project Manager Computer Scientist Other CoE members

4. C ONTEXTUAL INQUIRY APPROACH  Semi- structured Interview & Observation Steps in work process drafted Collection of artifacts Group review session Add’l questions & refinement

5. RESULTS 61-Step “Work Process” Document : Steps in enteric disease investigation. Wish list items Limitations Possible Intervention Steps Q & A Appendices (Artifacts)

6. Work process steps Links to Appendices Wish list item

7. RESULTS 61-step Work Process Document LHD Involvement22 steps (36%) UPHL Involvement12 steps (20%) UT-NEDSS data used13 steps (21%) Non-NEDSS data used 26 steps (43%) Manual data entry 15 steps (25%) Data analysis & visualization 10 steps (16%)

8. Example NEDSS Database Use : 38. The Enteric Disease Epidemiologist uses NEDSS as a record keeping tool, a place to enter/record: a) lab results, b) outbreak names/codes, and c) case status (e.g. Confirmed, Not a Case, Suspect, Probable, etc). The Enteric Disease Epidemiologist enters information into a spreadsheet (Appendix H) from NEDSS. However, NEDSS is typically not updated with information on risk factors & exposures in the spreadsheet. Therefore, as the investigation progresses the spreadsheet becomes the most current source of data.

9. Example Data analysis & visualization : 36. The Enteric Disease Epidemiologist uses the spreadsheet (Appendix H) to analyze the outbreaks.Appendix H “Analysis” is an ongoing process, beginning as soon as two cases with matching PFGE patterns are identified. Analysis in this sense involves searching the spreadsheet (Appendix H) for commonalities.Appendix H Variables that are commonly analyzed include: Age, Exposures, Date of onset, Location.

10. IMPACT Enhanced communication of ideas among participants Unique approach/model: “This approach to design provides an important model for other researchers and practitioners to design usable systems that fit with and expand on existing practice.” “Academic informatics does not have a good insight into how departments of health function so this paper nicely addresses this gap.” Created map for development team Able to compare & validate with other epis

11. Poster Submission Summary

12. Key Points: Analysis of PH work processes Contextual inquiry Collaborative effort Detailed (61 step) work process document Guide software dev to support PH practice Mapping of additional diseases?

13. Contextual inquiry of enteric disease outbreak investigation processes to improve visualization capacity for public health surveillance Jonathan Anderson, MPH 1 ; Wu Xu, PhD 1 ; Warren Pettey, MPH, CPH 2 ; Yarden Livnat, PhD 2 ; Julia Hall, MPH 1 ; Rachel Herlihy, MD, MPH 1 ; Matthew Samore, MD 2 1 Utah Department of Health, 2 University of Utah, Salt Lake City, UT Intro Mapping business processes to guide development of new IT applications has become a recommended practice in public health informatics development 1, 2. Rocky Mountain Center (RMC) * for Translational Research in Public Health Informatics’ Visualization Application Project used contextual inquiry to document work processes of disease outbreak investigations to guide development of a user-centric integrated visual analytics and decision support tool for state and local disease control programs. This poster presents development of the first use case: Mapping the foodborne outbreak investigation process at the Utah Department of Health (UDOH). Methods We deployed contextual design methods to document the enteric disease investigation process from the state level perspective. The Enteric Disease Epidemiologist for the state of Utah was identified as a domain expert and an interviewer was assigned to document the epidemiologist’s work processes for an outbreak investigation. Data collection methods included semi- structured interviews with the domain expert, artifacts collection, and iterative group review. Interviews included sessions where the expert described tasks, workflow, collaboration, and analysis process. The expert also demonstrated performance of regular routines. The interviews and data collection took place at on-site at UDOH. The artifacts collected included documents, manuals, charts, communications, and notes that are used or created during the investigation process. Notes and artifacts from the interviews were developed into a work process document. Through an iterative process feedback was solicited from the project team, including the domain expert, to refine the document. References 1. Pina J, Turner A, Kwan-Gett T, Duchin J. Task analysis in action: the role of information systems in communicable disease reporting. AMIA Annu Symp Proc. 2009; 2009: 531–535. 2. Public Health Informatics Institute. Taking care of business: a collaboration to define local health department business processes. 2006; Decatur, GA: Public Health Informatics Institute. Conclusion The document and artifacts are now used as a base and guide for the design and development of new informatics software. It helped highlight potential inefficiency, redundancy, and areas for improvement. Another valuable outcome of this project was the collaboration and sharing of information among public health, informaticians, and academic computer scientists. This collaboration will enhance the performance and outcomes of each of the collaborating entities. Results The Enteric Disease Outbreak Investigation Work Process document provides a rich source of information, including a detailed 61-step narrative workflow, and artifacts such as charts, tables, and email communications with CDC and local health departments. The workflow document also provides a common vocabulary for the various members of the team. Acknowledgement Acknowledgement to the CDC funded RMC, University of Utah (Grant #1PO1HK000069- 01).