The New York State Department of Health was one of six health departments around the country to receive a public health preparedness grant in 2006 under the Robert Wood Johnson Foundation (RWJF) program Common Ground: Transforming Public Health Information Systems. The three-year, $15 million national initiative awarded 31 grants to state and local public health agencies to develop information system requirements and designs and begin the process of implementing these systems in order to meet the challenge of preparedness for bio terrorism, emerging infections, and potential pandemics-and the burgeoning rates of chronic disease.
Public health preparedness grantees analyzed their agency's business processes related to emergency preparedness, redesigned them, and then described, in words and graphics, the requirements for an information system that would support the redesigned tasks and improve the health department's response to emergencies. This three-step approach is known as the Collaborative Requirements Development Methodology (CRDM).
Always Learning: Geraldine S. (Gerry) Johnson is a lifelong resident of New York State. She received her undergraduate degree in mathematics from the College of St. Rose in Albany. From there she went on to a career in public health of more than 20 years, working at all levels of local, regional, and state government.
Over the years, Johnson gained expertise in infectious and non-infectious disease epidemiology, public health informatics, and program management. The idea of combining epidemiology and informatics solidified for her while she was at the Wadsworth Center for Laboratories and Research, the state's public health laboratory. With her math background she was naturally interested in understanding how information systems are designed and developed within public health.
In 2006, when the Common Ground grant (ID# 59735) was received by the New York State Department of Health, Johnson was serving as director of regional epidemiology and infection control programs. Her duties included conducting statewide communicable disease and sexually-transmitted disease surveillance, outbreak investigations, and epidemiologic studies for healthcare—associated and community-acquired diseases. It was about this time, Johnson recalls, that she and other state epidemiologists became more aware of the growing importance of electronic health records.
"Part of life is going back to school," she says, explaining why she returned to St. Rose College for a master of science degree, focusing on public health and computer information systems. "It was a good approach for preparing for what was coming down the road."
This preparation made Johnson a natural choice for the Common Ground project team. Principal investigator for the New York project was Dale L. Morse, MD, MS, assistant commissioner in the Office of Science, New York State Department of Health (now retired). Morse tapped Johnson in 2006 to serve on the diverse eight-member team because of her background and experience in epidemiology and informatics.
The Project: New York State saw Common Ground as an opportunity to improve public health preparedness by developing sophisticated and interoperable information systems. Key to this goal was ensuring that critical tools were available to support an all-hazards approach to emergencies. This approach recognizes that certain activities and procedures-an emergency warning system or mass evacuation plan-are critical components of the response to any type of disaster, whether it is natural, accidental, or intentional in origin.
Training local health departments to "do business." Staff of the Public Health Informatics Institute, the national program office for Common Ground, trained grantee organizations to apply the components of its CDRM. At these national trainings, Johnson and other members of the New York health department became expert in the use of business-process analysis and redesign.
To transfer this expertise, New York's Common Ground project team conducted quality improvement trainings for local health departments across New York State, training some 215 staff from 54 of New York's 58 local health departments. Approximately 46 percent of local health departments in the state had at least one representative attend all three sessions. Additional training sessions were held for 55 state health department staff.
The growing enthusiasm for Common Ground didn't surprise Johnson, who had become a "convert" to the methodology, despite some initial skepticism. Before participating in Common Ground, she confessed, "I always would joke around that I was a public health practitioner and would be the first to tell you I 'didn't do business,' but I fell in love with what Common Ground was doing, demonstrating that public health can be defined as business and you need to do that to design the information system."
Like many grantee agencies, New York hired a consultant to help with the trainings. Nancy Schultz, an expert in business-process engineering, worked with the Common Ground team to develop content and facilitate the trainings. Schultz, who had worked for the state health department for many years (and had supervised Johnson in the 1980s), had an extensive background in quality improvement, including 17 years with General Electric customer service.
Improvements in local health departments. After the training, staff members from local health departments used Common Ground tools to improve processes in their agencies and to share their skills and experience with others in their counties. At least 15 local health departments initiated a process improvement project in the areas of intake, inventory control, purchasing, billing, and contracts.
In addition, Clinton County incorporated quality improvement training as part of its standard training curriculum. Twenty-two members of that county's health department participated in the training sessions.
Johnson recalled anecdotes from Common Ground team members that illustrated the impact of training. A commissioner from a large county saw a swim lane map (a visual depiction of process steps, laid out either vertically or horizontally) on the wall of a conference room and commented that he wanted additional processes to be mapped out in that way. Local health departments said, "This was amazing. We never understood what we did and how we did it before."
In another instance, a public health nurse from a small county recalled how an extremely cynical member of her process improvement team became a convert to the Common Ground approach. After the team concluded its work, the skeptical team member sent an e-mail to the county health director stating that the project was the best thing he had worked on in his 20 years with the department.
Spreading the methodology within the state. At the state level, Common Ground guided analysis and design for emergency preparedness projects. These included a volunteer management system and development of information systems requirements for outbreak management. The business-process analysis tools and techniques were also used to assist in a redesign of the Health Emergency Response Data System, a system to gather hospital data in emergency situations.
As Johnson described it, "We were 'cross-fertilizing' projects with Common Ground, bringing to public health new ways of looking at problems as well as new tools and techniques. Having people see the results helped them understand the importance of gathering information system requirements.
"The idea was not to build a new information system based on current problems or get bogged down trying to make up for inefficiencies that can be changed. The idea was to look at what are you doing now, understand your work flow, and redesign it. The redesign piece is important. How do you change to bring more efficiencies?"
In 2010, Johnson became the director of a new state Public Health Informatics and Project Management Office. She is responsible for oversight, implementation, and integration of complex public health information system projects in the state, including Public Health Preparedness, New York Early Intervention System, and Child Health Integrated Information. "Now," Johnson said, "when we look at informatics projects, we ensure that we have business analysts who focus on business rule gathering, documentation, and methodology testing as well."
New York is also sustaining the spread of Common Ground tools by integrating the curriculum into a 12-module online training for local health department quality improvement.
Grantee Perspective: "Building on Common Ground methodology, we are looking at quality improvement more broadly, beyond emergency preparedness, to other offices within the department of health," said Johnson. Reflecting back on the project, she added, "I really understood how critical it was to articulate the practice of public health, to explain it using business-process analysis. There's definitely some resistance, even if people are receptive, because of the time it takes."
Johnson continues to use tools and lessons learned from Common Ground. She is managing a Centers for Disease Control and Prevention grant to implement a statewide syndromic surveillance system.(Syndromic surveillance is a method of detecting symptoms, signs, or behavior patterns indicative of disease in individuals and populations before a confirmed laboratory diagnosis is made.) She was also instrumental in developing the International Society for Disease Surveillance's 2010 recommendations for syndromic surveillance using emergency department and urgent care centers.
RWJF Perspective: In funding Common Ground, RWJF wanted to strengthen state and local public health departments so that they could perform better in the face of the increasing challenges of bioterrorism, emerging infections and potential pandemics, and burgeoning rates of chronic disease. Meeting these challenges required health departments to develop and use more sophisticated information systems than they currently had.
Many state and local health department leaders ultimately found that the Common Ground tools—business-process analysis and redesign—could be used not only to design information systems, but in quality improvement as well. "That was a benefit that we weren't anticipating." said RWJF Senior Program Officer Pamela G. Russo, MD, MPH. "The application of business-process mapping to process improvement was a huge step toward quality improvement in public health."
Former RWJF Senior Program Officer Terry Bazzarre, PhD, MS, agrees. "Over time, it became clear that the Common Ground approach was an alternative way of doing quality improvement in public health, focusing specifically on how the work gets done and the business processes that contribute to it."