An Epidemiologist Helps an Indiana Health Department Prepare for Emergencies

    • October 30, 2012

Joseph Gibson, MPH, PhD, is director of epidemiology for the Health and Hospital Corporation of Marian County, which operates the Marion County Health Department, the largest in Indiana. The health department employs some 690 staff members and serves the Indianapolis metropolitan region (population 903,000).

In 2006, Marion County was one of six health departments around the country to receive a public health preparedness grant under a Robert Wood Johnson Foundation (RWJF) national program, Common Ground: Transforming Public Health Information Systems (ID# 59734). 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.

From Cowboy to a Career in Public Health: A New Jersey boy who wanted to "do something different," Gibson was intrigued when a friend told him about a college "in the middle of the California desert." At Deep Springs College, Gibson was one of 24 students who combined rigorous academics with work on a cattle ranch. While learning to ride a horse and herd cattle, Gibson also absorbed lessons on how to be a responsible member of a community. "We learned that what anyone does affects the community."

Gibson took that knowledge with him when he transferred to Brown University in Providence (R.I.) after two years at Deep Springs. At Brown, he designed an independent major in sociology and psychology to examine how communities may foster individuals' development.

After college, Gibson joined the Peace Corps where his education in community health continued. Teaching nutrition and gardening in remote areas of Costa Rica, he became interested in the country's national health system and its use of the community health worker model. He was impressed with a system that had a nurse visit every house in the country every few months, even in very remote areas.

Back in the United States, Gibson spent a year in the Public Health Service's Commissioned Officer Student Training and Extern Program (COSTEP). His mentor, an officer in the federal Maternal and Child Health Bureau, encouraged him to pursue a career in public health and specifically recommended that he look at epidemiology. Public health needed statistical expertise, according to his mentor, and Gibson had shown an aptitude for computer work.

In graduate school at the University of Washington, Gibson began the data-intensive work that would lead him to a career in health informatics. He focused on primary care utilization and preventable hospitalizations for his master's thesis. His PhD dissertation was on the impact of Medicaid fee-for-service versus capitation on access to health care.

While in graduate school, he worked for the Seattle/King County Department of Public Health as a data analyst and epidemiologist. From 1992 to 1995, he was involved in a project to determine modifiable factors contributing to infant deaths. He created data-entry systems and a database for tracing subjects and integrating data from medical records, birth certificates, and other sources.

After earning his PhD in 1996, he was hired as a research scientist in Scottsdale, Ariz., for a company owned by Eli Lilly that processed pharmaceutical claims for 20 percent of the insured people in country. Gibson did outcomes research, looking for patterns of suboptimal care.

In 1998, he moved to the Eli Lilly headquarters in Indianapolis where he focused on mental health. Gibson initiated, conducted, and published health services research on schizophrenia and bipolar disease, and the effects of various antipsychotics on health care costs, utilization, and patient quality of life.

The human element of research was always important to him. "It was great to be able to work with folks with schizophrenia and talk to them about their lives and how medications affected them. They were such an impressive group, able to self-manage and advocate for themselves and others. They cared so much about each other," said Gibson.

Working with top-flight researchers from around the country was exciting, but Gibson said "I wanted to get back to a mission-driven organization, where everyone is trying to get to the same spot." That opportunity came in 2003, when he became Marion County's director of epidemiology.

The Project:

From InformationLinks to Common Ground. In 2005, the Indiana State Department of Health received a grant through InformationLinks, a national RWJF program designed to give public health departments a "place at the table" in the development of health information exchanges—electronic data networks that make it possible to share health-related information among organizations.

InformationLinks allowed Gibson to work closely with state-level colleagues who were also "pushing informatics. We set up regular meetings, which moved things from a now-and-then conversation to a consistent effort. We developed stronger relationships and a better understanding of each other." When the Common Ground call for proposals came out, the director of the Marion County Health Department urged Gibson to apply.

Gibson sees the two programs as complementary. "Through InformationLinks, I became very well attuned to the technical side of informatics through the opportunity to develop better databases and data systems. In Common Ground I was attuned to the importance of the user side of informatics."

"I've seen the failure of big systems that build solutions without looking at what was needed by users. With Common Ground, we started with defining business processes at the department level rather than the system-level. We also developed stronger relationships and a better understanding of each other's needs as we tried to define common processes among departments."

Preparing for emergencies and improving everyday operations at the local level. Marion County's Common Ground project built on a fairly unified information system that the health department had recently implemented. "We wanted to make changes in how that system was used, not build a new one," said Gibson. "We looked at our business processes and asked how we could improve them to enhance not only our response to emergencies but also everyday operations."

To launch the project, Gibson got department chiefs and key managers together and had them develop a "long list of processes. We organized the list and then asked department chiefs to prioritize them. We stressed we wanted the processes to be ones we would use both during an emergency response and also day-to-day, like case management and case investigations."

Department heads got the message quickly. The chief of the population health bureau pointed out problems moving clients through the system at the county's two new tuberculosis and refugee care clinics. Visits were taking three hours, creating barriers to access.

With help from a business analyst hired with grant funds, Gibson's team applied the Common Ground process-improvement methodology, supplemented by other quality improvement tools. The changes that resulted-targeted completion times for each step in the workflow, alterations in clinic staff roles and responsibilities, and improvements in communication-reduced the time it took a patient to move through the system from two hours and 52 minutes in January 2008 to 65 minutes in February 2008.

Helping the state develop a disease surveillance system. At the time of the Common Ground grant, the Indiana State Department of Health was in the process of developing a web-based system for collecting, integrating, and sharing data between local health departments and the state. The goal was to automate and streamline the paper-based processes of reporting laboratory results, communicable diseases, and disease investigations.

But, said Gibson, the state had a "history of building systems without getting enough user input. They were aware that was not good practice, but did not have enough resources to document business processes and improve them." In order to automate, the state needed to better understand how diseases were reported at the local level. With Common Ground, the timing was right for Marion County to collaborate with other local health departments in Indiana to inform the development of the new electronic system. The system has been one of the state health department's most successful information systems.

Training other health departments in Common Ground tools. Marion County staff conducted one-day workshops with nine local health departments to train them in business-process analysis and to define information system requirements for disease investigation. The team followed the same approach as they had in their Marion County project, blending the Common Ground methodology with other quality improvement strategies.

Each agency brought its own experiences and perspectives on disease reporting to the table, but most workshop participants were unfamiliar with business-process analysis. To meet their needs, the Common Ground team conducted the training in phases, teaching a new concept and then giving participants, most of whom were nurses, an opportunity to apply it to their own work.

Participants discussed the current workflow for disease investigation within their agencies, what worked well, which diseases were easiest or more difficult to investigate, and where the barriers to reporting occurred. They also discussed data and reporting needs and other "wish-list" items for an information system that would support the disease-investigation process.

From these workshops, Gibson's team and a Common Ground business analyst learned that all of the local health departments conducted disease investigations in slightly different ways. As a result, their needs for a statewide disease surveillance system were slightly different. For example, nurses in some counties wanted a template to generate patient reminder letters, while in others, nurses wanted reminders in the system to flag a case when no contact has been made.

Gibson's team documented what they learned and passed that information along to the state. "It was a win-win for both of us. Giving the state good user information helped them build a web-based system for case reporting and case management and we formed good relationships as a result."

"Networking, networking, networking," said Gibson, who identified it as the greatest value of Common Ground for him. "It gets back to the importance of a shared mission in public health—all the good things that happen when people with common interests and goals can move things along, connecting with each other."

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."