Johnson County Public Health is an accredited local health department located in Iowa City, Iowa, an UNESCO City of Literature, the county seat of Johnson County, and home to the University of Iowa. Johnson County has a population of approximately 151,000 residents, a rural urban mix that contains the Iowa City metropolitan statistical area. The county is home to three large healthcare systems, the University of Iowa Hospitals and Clinics, Mercy Iowa City, and Veterans Affairs Hospital.

Due to the volume of COVID-19 cases, the department sought an ability to decrease the amount of time investigations required that tyipcally occured by phone. This practice was implemented in late April early May, roughly a month after the pandemic had been declared in Iowa. The goal was to acquire the ability to capture personal health information online in an appropriate manner and decrease the time that an investigation would require as it was anticipated that the department would see surges of cases throughout the rest of the pandemic.

Initially, the purchase was beyond the department's purchasing policy without Board of Health approval, but after review of the need of this ability, the Director conferred with the Chair and allowed the department to initiate the purchase and begin planning the process of information flow, design of the investigation form, and implementation. The disease investigation team met on several occasions to map the process and several iterations of survey design before implementation. After implementaion, the time saved from the majority of disease investigations was calculated to cover the cost after a month of implementation, roughly $8,000.00 and this was reported to the Board of Health during its monthly COVID-19 updates. The department has utilized this software and specifically process for disease investigations for over 10,000 cases with the process having gone through multiple changes to meet the volume of cases and specific investigation needs. As of January 2021, Johnson County Public Health is one of thirty-three counties that have continued to investigate cases locally and have not had to relinquish its investigations to the state health department.

The success of this project was largely driven by the skill and innovation of staff and was a staff-driven project that incorporated quality improvement tools. The online investigation form has been altered on several occasions on what is described as rapid PDSA cycles. After implementation of the final product, the time saved is able to be redistributed to case investigations that require prioritization due to risk of severe outcomes or those who have additional barriers to utlizing the online investigation form or those who refuse. The survey has also been translated into Spanish and French.

The impact of having the ability to collect personal health information through a online survey tool that provides design control has major implications for public health practice for COVID-19 investigations and other public health programs.

The public health problem that was addressed was the burden of disease investigation for COVID-19. The current state disease surveillance system for communicable disease investigations was not built to scale for this many cases and disease investigations by phone requires a considerable amount of time. Given both of those staples of the department's disease response and the sizable population, the department sought a tool and process to decrease the amount of time COVID-19 disease investigations required for the entire county. At this point in time, no other county in the state of Iowa utilized Qualtrics or online survey tool for disease investigation. While there were concerns that an online tool would alienate or cause the amount of 'loss to follow up' cases to occur, the process was created in a manner to make 'first contact' with a person who tested positive to determine their willingness and ability to perform their disease investigation online. The process ensured that those who could not or refuse to perform online were still able to be investigated timely. The use of an online survey tool is not new to the field of public health, but to our knowledge the use of the online survey tool to collect personal health information for the purpose of completing one's own diseaes investigation is.

The state health department also utilizes qualtrics for their screening tool for statewide COVID-19 testing, but this information is not part of the disease investigation. Initially, the department had plans to implement a substantially similar online screening tool as a form of syndromic surveillance, but declined to do so as it would capture persons who have not tested positive rather symptomatic and would require action.

Due to the department's COVID-19 response, it has several staff who hold Incident Command System positions. Specifically, the Operations Section Chief and the Planning Section Chief long with other Disease Prevention Specialist staff have met as needed to build and design the online investigation form.

The online investigation form and process has been altered on several occasions to meet the needs of the department to rapidly respond to the increased amount of cases throughout several surges. The online investigation form has had several different forms for positive persons who are adults or positive persons who are children and their guardian fills out. At one time there was a serology test specific investigation form as well, but the state health department no longer requires investigation or follow-up. Currently the department is utilizing the survey software to evaluate the effectiveness of the state's quarantine negating mask protocol, that if both parties are wearing a mask, the close contact would not have to quarantine. 

The online investigation form and process assited the department to address several surges of cases throughout the past year of the pandemic, primarily where staff contact can be made within 24-48 hours and the online investigation form may be initiated to collect further information beyond what is reported through the disease surveillance system. This provides information for the disease investigation and contact tracing team to prioritize and organize cases. The county is home to the University of Iowa and given the return to school during the fall semester, the department had over 1,000 cases reported in the first week of school. The ability to address this surge of cases was due to the use of this online investigation form and process and its partnership with the University. The department has since seen another surge of cases that also saw over 1,000 cases reported within a weeks time and spurred the department to create an iteration of the online investigation form to focus on close contact information to stop transmission.

The goal of implementing Qualtrics survey software was initially to decrease the time for staff and patients that a normal COVID-19 investigation takes via phone. The initial steps were to create a public facing survey that can be sent to persons who test positive to capture the appropriate amount of information that staff would be able to review to determine other probing questions or if further action was warranted. Initially, planning and implementation was internal to the department and minor changes were implemented as responses were reviewed for accuracy. Disease investigation team members and contact tracing team members have also offered input.

Eventually, as the local university semester would commence, a planning team with the university COVID-19 campus health officer, student health director, and chief information officer would offer input and ways to implement the department’s process and use of the online disease investigation form  within the university’s self-reporting system.

Several other workgroups have also been initiated and those planning meetings discuss the online investigation form and process along with other disease investigation tools such as line lists and isolation and quarantine protocol with the various caveats to essential workers and health care staff. Those other workgroups include: the quality long-term care committee (established pre-pandemic), school nurse workgroup (an enhanced workgroup to the existing partnership), the Johnson County licensed day care workgroup (newly formed during the pandemic), adult day care provider workgroup (newly formed during the pandemic), University of Iowa COVID-19 safety committee (formed specifically for the pandemic), and a health equity workgroup (recently formed and in its initial stages). Primarily, the school nurse workgroup that includes the K-12 population and the University workgroup provided feedback and insight into the process. The University of Iowa created a public health password protected system for notification of ‘unable to contact’ based on the department’s online investigation form results. The school nurse workgroup were trained as ad hoc disease investigators that assist the department in school related cases and outbreaks.

The ability to send the investigation form electronically to persons who test positive or those who are close contacts provides the ability to collect disease investigation information much more quickly than the standard phone interview and more efficiently than on site interviews. The department had initially calculated that it shortens investigations by at least two-thirds in most cases.

Since fully utilizing Qualtrics for disease investigations, that is, having the ability to collect personal health information that meets requirements ISO 27001 and HITRUST and having the ability to alter the form as necessary, the disease investigation process and investigation form collection tool has been altered several times to meet the departments needs which include: collect disease investigation information and direct specific persons to specific guidance autonomously, inform person of their positive COVID-19 result and provide immediate guidance by simply entering in the patient's contact information (referred to as the first contact form), investigate the effectiveness of face masks (the department is currently investigating the effectiveness of the state's mask quarantine protocol which would negative the need to quarantine if both parties are wearing a mask), and to address a rapid onset of cases (surge protocol to prioritize contacting positive cases and collecting close contact information).

The majority of cases have been able to receive text or email and utilize the investigation form online leaving more time for the disease investigation team and contact tracing team to spend on cases that have various barriers to participating in their disease investigation. Given the volume of cases at several points throughout the pandemic, this entire process also allows the disease investigation team the ability to prioritize cases for investigation by utilizing the online investigation form information. Typically, upon receiving test results and prompt notification, initial case information can be received within 24-48 hours to prioritize. Without an ability to prioritize cases, the sheer volume at times of peak surges could leave some cases uncontacted and uninvestigated for several days.

Two main resources were allocated for this practice: 1) the investment in Qualtircs and the version that is able to appropriately house person health information which was not incluced in the department's budget and 2) the disease investigation team meets daily to discuss trends, concerns with the contact tracing team, and issues with the investigation process. The department has utilized its Incident Command System structure since the beginning of the pandemic in Iowa and improvement meetings occur as needed with the Operations Section Chief and the Planning Section Chief along with other staff who are directly involved in disease investigations.

Everyday, including weekends and most holidays, cases information is exported from the state's disease registry and initial contact is made with each positive patient and their information is input into the process to receive the option to perform their disease investigation throuhgh the online form. This initial process maintains the process for COVID-19 disease investigations.

The department is very new to utilizing qualtrics, but several staff have made this integration a reality. Investing in staff who have the skills and the desire to learn to utilize new tools effectively and rapidly have made this ability possibly. Having staff assigned as 'super-users' of Qualtrics may be a possiblity and establishing internal workgroups to integrate the softwware into other programs have already occurred. The ability to have design control and to collect sensitive inforamtion provides local public health the ability to exercise its skill and ability to collect primary data, analyze local results, and provide their jurisdiction with local analysis.