1. Examining Front-Line Decision Making in State and Local Communicable Disease Control Programs – A qualitative analysis of semi-structured interviews.
Laverne Snow, MPA1; Heidi Kramer2; Frank Drews, PhD2; Matthew Samore, MD1,3
University of Utah Departments of Biomedical Informatics1, Psychology2, and Internal Medicine3, Salt Lake City, Utah
Introduction
Front-line professionals in state and local public health agencies make important decisions for communicable disease control, under complex and challenging conditions. While front-line decisions are often routine, many have significant impact on the control or spread of serious and highly infectious diseases.
Examining human factors and understanding the underlying cognition of decision makers is essential for developing useful and accepted decision support tools.
Aims
Examine decision-making of front-line governmental communicable disease control professionals to identify decision making processes under condition of ambiguity, uncertainty, high risk and time pressure.
Develop recommendations for decision support tools.
Problem: Reportable diseases affect millions of Americans million illnesses, 325,000 hospitalizations and 5,000 deaths from foodborne illnesses alone.
Discussion
Trust in protocols as a substitute for expertise may be creating a fragile foundation for disease investigations.
Reliance on protocols comes from technical systems, like aviation, where conditions are controlled and predictable. Public health interface with a natural system, like disease evolution, are not controllable or predictable.
Reasons protocols break down in public health include: * Infrequent and unfamiliar diseases
* Unpredictable time delays
* Missing and uncertain information
* Information overload
* Appropriate lab tests not taken
* Inconsistent judgment to resolve ambiguity
Findings
Commonly believed among public health disease investigators:
Public health agencies rely on protocols as an important strategy for outbreak investigations.
Disease cases are significantly under-reported.
Many individuals do not seek health care treatment when ill.
Public health agencies rely heavily on lab tests for case confirmation before taking intervening actions.
Physicians under report disease cases and frequently rely on laboratories to report lab results.
Physicians do not always order appropriate lab tests needed for case confirmation.
Case situations vary; therefore, protocols are underspecified by necessity.
Staffing, resources and training for communicable disease control are often under-funded.
Less understood:
Protocols are perceived to be a substitute for experience and expertise.
Front-line public health workers are gate-keepers for disease case consideration and investigation.
Individual judgment is frequently required to navigate uncertainty of information and ambiguity in protocols.
Disease reporting often occurs because of personal and professional relationships.
Appropriateness of tests ordered, specimen handling, timing of taking tests, delays in receiving lab results, adherence to test procedures and test specificity and sensitivity create additional uncertainty about laboratory data factors not consistently considered.
Vision for Future Research
Enhanced Decision Support Tools for Disease Reporting and Investigations
Electronic physician reporting using their electronic medical records.
Patient and school web portals for reporting to local public health agencies.
Automated case investigation forms populated by electronic disease reports.
Central knowledge base on PH grid with reference information, case definitions, community specific data, and directories.
Automated line lists populated by electronic case investigation forms.
Algorithms to help identify common risks.
Outbreak simulator for exploring “what-if” scenarios.
Special thanks to those in Utah and Nevada Public Health agencies for participating in this study.
Materials and Methods
Semi-structured interviews
11 pre-pilot, 8 pilot and 42 formal interviews
State or local health departments
Epidemiologists, nurses, environmental health scientists and infectious disease investigators
Utah and Nevada
Interview protocol
Two part interview to examine decision making:
Semi-structure questions on use of protocols and ambiguity, focus on work and school exclusions.
Enteric disease cluster scenario with multiple causal pathways.
Data collection and analysis
Two interviewers in each interview
Interviews recorded, transcribed and individually coded
Qualitative research methods - modified grounded theory
Atlas.ti Knowledge Workbench software
This research was conducted under the leadership of the Utah Center for Excellence in Public Health Informatics, Decision Support for Infectious Disease Epidemiology (DSIDE) Project
CDC Grant # 8P01HK000030
excluding someone from work or school
collecting and using data
using protocols or guidelines
Examples of protocol use:
when protocols worked
when protocols didn’t apply
Responses to enteric disease cluster scenario with multiple possible causes
This research was conducted as part of the Utah Center of Excellence in Public Health Informatics: Decision Support for Infectious Disease Epidemiology (DSIDE Project)
Protocol challenges for making decisions on exclusions from work or school
Protocol Ambiguity
“So I think what I have found with communicable disease is there are always exceptions to the rules and there is generally no black and white.”
“ You have to make your best scientific judgment based on what you know about the situation… it is almost never exactly what the guideline says.”
Information Availability and Changing Conditions
“…this day we may make this decision and then as we get new and more and updated information then within an hour or two we may make another decision.”
Information Overload
“Well you walk into a situation and there is a pile of 50,000 pieces of data… is very difficult to make sure that you identify the pertinent data out of that.”
Substituting protocols for experience and expertise
“I would need to read protocols on that because I don't have personal experience.”
“ I need to understand what that disease looks like and at least have something written that helps guide you in that….”
Unpredictability
“… with epidemiology you can't say that exactly it's always going to go this way, things change.”
Time Delays
“One of the more troublesome parts of doing disease investigations is that … by the time you find out, the people who were contagious are no longer contagious.”
RWJF/ National Library of Medicine
Training grant # LM007124
Laverne Alves Snow, MPA