Established In 1872, the El Paso County Public Health (EPCPH) serves the residents of El Paso County. Located in the central part of the state, it is the second most populous county. The 2020 population projections from the Colorado Department of Local Affairs have El Paso County’s population estimated at 735,176. Encompassing 2,158 square miles, El Paso County Public Health (EPCPH) serves all residents of El Paso County with 158 full-time equivalent employees.

 The U.S., Colorado, and El Paso County are becoming more culturally diverse. At least two-thirds, 68.6% of El Paso County residents identify as either White or Non-Hispanic White, 17.7% identify as Hispanic or Latino and 6.9% identify as Black or African American. Population growth by age group indicates that adults ages 60 years and older and adults ages 20-29 are the two fastest growing age groups, each growing their population since 2012 by 17.3 percent and 16.7 percent respectively. Additionally, there is a significant military presence with five military installations including Ft. Carson, the Air Force Academy, Schriever and Peterson Air Force bases and Cheyenne Mountain Airforce Station. Data from 2015 – 2019 indicate there are 84,343 Veterans.

El Paso County experienced significant growth over the last decade with a 15.8% increase between 2010 and 2019. As the population continues to grow, the need was identified to expand Public Health’s capacity to collect, analyze and disseminate data in real time, the agency established a new office of data and analytics to harness the power of data for informed, proactive decision making. This office is designed to lead strategic agency and community efforts that are upstream, using data, evidence-based best practices, and innovative approaches to create efficiencies and further community health improvement measurements. This initiative solidified EPCPH as the leading local data expert with the purpose of establishing a central repository to provide accurate, credible, relevant and timely information.

In 2020, this office was instrumental in launching an innovative COVID-19 data dashboard which greatly expanded access data for public and community partners. Data visualizations and information regarding incidence and prevalence with interactive features made it easier for users to visualize and breakdown complex data to better understand the disease spread within the community.

The data office is the result of a partnership with leadership of all county agencies, and it is anticipated its full capability will continue to be maximized well beyond COVID-19. Through community-specific data collection, EPCPH will be more proactive in understanding the challenges facing EPCPH partners and El Paso County residents. Using technology and comprehensive data analysis, resources can be prioritized and directed more efficiently to meet those challenges collectively. Data analysis and visualizations assist all community members to deepen their understanding of the relationship between health risks and disease outcomes. By sharing results of data analysis with the public and the partners of EPCPH, this information will assist community entities to prioritize their own efforts and enable EPCPH to work collaboratively and more efficiently through aligning resources to better serve the community. 

Public health has a history of leveraging data to gauge the needs of their communities, determine aligned strategic initiatives, and identify and mitigate the impact of health inequities.  (DeSalvo & Wang, 2016) Innovations in the health informatics realm empower health departments to strategically foster critical partnerships, forecast emergent needs and respond in agile and comprehensive ways. Public Health 3.0 acknowledges the critical role of informatics in actualizing the redefinition of the pubic health care worker into a Community Health Strategist. Relevant, timely, and accessible data sets not only ensure local agencies are able to forecast need but also assist in developing the vital cross-sector partnerships required to fully address identified health inequities. Integral to this work is extending access to health informatics to the public domain in ways that encourage informed discussion, allowing healthcare workers and the community to share equal footing in the conversation. It is this parallel lens, both inward and public facing interfaces, that enable the core purpose of Public 3.0 to take hold, and it is here where innovation lives.

EPCPH proposed the formation of a Public Health Data and Analytics Division in 2018 to enhance the agency’s capacity to achieve significant progress in the goals and targets outlined in the Community Health Improvement Plan.  The data analysis conducted in the development of the CHIP highlighted economic and health disparities and indicated residents in these areas are faced with many health inequities including a lack of access to care, lack of adequate public transportation, and higher rates of unemployment. The current pandemic has had a disproportionate impact within these communities as demonstrated by some of the highest number of recorded cases and serious illness. (Health, 2017)

The Public Health Data and Analytics Division consists of four full time positions including a Data Scientist who is the leader of the division, two epidemiologists, and one informaticist. In January of 2020 the team initiated the development of a data informatics system specifically designed for El Paso County and aligned to the health equity goals and strategic measures detailed through visual dashboards in the El Paso County Community Health Improvement Plan (CHIP). A dashboard provides a visual representation of complex, multi-layered information “…and, for some (but not all) tasks, it is clear that a visual presentation – such as a map or photograph – is dramatically easier to use than is a textual description or a spoken report.” (Schneiderman, 1996) Data dashboards live at the intersection of health and technology and are a catalyst for promoting rich, data-driven dialogue between public health and the general public. The public facing interface of this endeavor is a data dashboard integrated into the EPCPH website. The information display was intended to replace the existing practice of sharing data primarily through periodic PDF updates, and instead redirect information inquiries to an interactive and user-friendly dashboard.

The first case of COVID-19 was detected in El Paso County in early March and the focus of the dashboard quickly pivoted to address the community needs driven by the COVID-19 pandemic. COVID-19 underscored the demand for timely data that is transparent, accessible and serves the purpose to inform the public about the issue, support mitigation efforts, and provide constituents with information relevant to their individualized needs. In July of 2020, ESRI reported the Center for Disease Control and Prevention (CDC) was providing support for states to develop COVID-19 dashboards and maps for the public. CDC provided guidelines and best practices for developing a state dashboard based upon information gathered from the type of questions it was fielding.  (Geraghty, 2020) Basic data points initially included case incidence, prevalence, rolling averages, deaths, hospitalizations, and testing.

The state of Colorado has a data dashboard with representative data from each county, yet it was quickly understood by EPCPH the imperative to tell the evolving story of COVID at the local level. At that time there was no history at the agency of publicly tracking a disease in flight. The initial version of the dashboard was launched in a matter of weeks through focused partnerships with the County IT department to obtain the necessary analytics and reporting software, the Communicable Diseases team managing the COVID-19 case to understand available data, and the Public Health Communications team to coordinate presentation. Internally, a cultural shift occurred as it became a collective priority to leverage the dashboard to provide radical transparency in the sharing of COVID-19 related information. It was understood that if the agency did not respond to the need, the public would seek out other sources which may not represent accurate or vetted information. Throughout this process, a high standard was set for data integrity, accuracy and validity of the information.

Indicators of an effective dashboard designed for the public health sector often include the following attributes:  an overview representing the key objectives, a map interface, explanatory variables, comparative visualizations and the ability for the user to drill down by data set to discrete subsets. (Concannon, Herbst, & Manley, 2019)  Currently, it is common for a state public health agency to support a statewide COVID-19 dashboard, yet it is rare for a local health department to create and manage a dashboard with the attributes of a statewide system. A survey of 47 local health agencies in Colorado revealed 17 with a COVID-19 data dashboard and of the 17, seven displayed data through a dynamic, interactive interface. Overlaying 10 attributes detailed in the report to analyze the current iteration of the EPCPH dashboard it is noted nine of the 10 features reviewed in the study are integrated into the interface.

El Paso County has experienced spikes in cases and is currently in a heightened response level, raisng the anxiety of the community. The dashboard provides a lens for the individual to understand what as is happening now, chart a decrease in data and understand clearly the potential impact.

The purpose in establishing the Public Health and Data Analytics Division was to strategically expand the capability of EPCPH to operationalize the Public Health 3.0 model through creating a data hub for public health information. The strategic objectives of the office included developing capacity to study and influence systems that impact health and promote healthy communities and use information and information technology to support evidence-based practice and research.

The community played an integral role in identifying the need for a data analytics division during the process of developing the Community Health Improvement Plan (CHIP). EPCPH facilitated the development of the El Paso County Community Health Improvement Plan (CHIP) as part of the Healthy Communities Collaborative (HCC), a stakeholder group of more than 60 community partners. The community members are representatives from schools, hospitals, health systems, non-profit organizations, city and county government agencies, public health, medical providers, businesses, and interested citizens.

The five-year plan implemented in 2017 is the result of an intensive 18-month community health assessment to identify the top health priorities for El Paso County. Framing the information through a lens of equity, demographic and socioeconomic data were presented, including race/ethnicity, gender, age, income, and education. The HCC used a ranking process to determine the areas of highest need based on the level (high or low) of impact on health inequity. The Winnable Battles ranked as the highest priority and highest burden were selected for further consideration.

Working with community partners, the HCC identified the top priorities of 1) mental health and substance abuse, 2) healthy eating and active living, and 3) tobacco use as the highest burden and highest priority based on health inequity severity. The Colorado Department of Health has identified both mental health and substance abuse, as well as healthy eating, active living and obesity prevention, as flagship priorities.

In 2017, EPCPH worked with Thriving Colorado to turn data into action for statewide collective impact for communities in Colorado. The Thriving Colorado dashboard is a statewide community health dashboard that provides an online gateway to data, information and strategies as a means to share and track the progress of Health in the key priority areas. The Thriving Colorado dashboard supports the development of shared goals; alignment of efforts and strategies; sharing and leveraging resources; reducing duplication; improving communication; support for evidence-based strategies; and achieving collective impact. The dashboard consists of two components – strategy maps and scorecards.

EPCPH was one of the first public health agencies to adopt the dashboard model as a mechanism for collecting and presenting data in a transparent manner to partner organizations and the community. Through the community health assessment process, the HCC identified the priority areas featured on the Thriving Colorado website. Data for these priority areas are updated on an annual basis through input from local, state and national data sources as well as partner agencies implementing specific strategies.

The dashboard was created to serve as a communication tool for objectives and measures identified, showing trends, targets and current data values with color bands ranging from red to yellow to green, providing a summary of the magnitude and directional change for that particular measure. Objectives can be process or outcome based, displayed as a target in a blue square of the scorecard and used to describe the desired change of the priority area. EPCPH serves as the convener and facilitator of the HCC and will maintain and track the progress of key strategies and outcomes. Updates to the dashboard are provided at the quarterly HCC meetings.

The opening of a new El Paso County Health Department building located in an area hit hardest by the pandemic is a working example of how data analytics fueled a vital, Public 3.0 endeavor. Data related to health disparities in the area informed the collaborative effort between the City of Fountain, multiple agencies, and EPCPH to develop a proposal to open a new, innovative public health space. The new El Paso County Public Health South just opened in December and is providing multiple services to the community. It is designed as a central location where multiple partnering agencies provide support for food insecurity, access to behavioral health services, a Women’s Infant and Children’s program (WIC) and health services including vaccinations for the flu and COVID. The site currently provides COVID testing to meet the increased need of the community.

Community partners continue to inform the evolution of the dashboard. Data sharing among partners, like local hospitals, has expanded the depth of available and timely data and multiplied potential options to mine the data for relevant and informative trends. The level of data sharing is a development driven by the COVID-19 response and the associated urgent need to provide this information in support of the relief effort. In the future, it is the hope of the team to have increased flexibility with data sharing as these collaboratives move into the recovery phase.

Data continues to drive the response and relief effort of EPCPH. As of December 27, 2020, the COVID-19 Summary included 39,831 cases, 1803 hospitalizations, and 526 deaths. The impact of COVID-19 upon the El Paso Community is pronounced and far reaching. At the close of December 2020, the county remains in Level Red: Severe Risk and the “5 Star” certified business program providing parameters for businesses to expand operations was introduced at the state level.

These two current realities drive many decisions within both the private and public sectors and impact all residents. Discussion within the community is focused on the mental health and well being of our youth, the sustainability of local businesses, and the impact to on-going initiatives addressing the many underlying health issues impacting our most vulnerable residents.

The numbers; stark and vivid, speak to the effect of the pandemic. Each lens of information communicates the complex story through text, visualization, and historical information and represents multiple streams of data shared across various sectors of the county. Amid a constantly shifting landscape, the Public Health Data and Analytics COVID-19 page is understood by the community to be a place to find reliable, trustworthy and immediate information. The information is presented and explained through multiple conduits; the site, public forums, city council meetings and in the media.

Yet, challenges exist in keeping pace with the demand for information and the incoming stream of data. Over the last two months, cases reached the highest levels in the County resulting in an explosion of COVID-19 related data. This presents a challenge in maintaining a high level of resolution in providing details, most notably specifics related to health disparities. To address this issue the office is looking into tools for data management which will maintain the granular level of data necessary to examine the specific impact of COVID within population subsets.

Initiated mid-April, the dashboard is now in its 9^th configuration and is evolving and adapting based upon the changing landscape of COVID-19 and its impact on our residents. Each phase of the pandemic; response, relief and recovery inform the adaptation of the dashboard to best convey vital information. When the dashboard initially launched in April of 2020, it consisted of five pages, it now includes over 100 pages of layered information.  The site is responsive and expands according to the needs of the community and is directly shaped through their data requests and inquiries. Stephen Goodwin, the Director of the Public Health Data and Analytics division states their role is to “find, curate, drive, develop, and maintain information in a way that makes it actionable.” This operating definition exemplifies the key principles of excellent data visualization described by Edward Tufte which include (1) design for your audience, (2) accurately represent the data, and (3) keep it clear. (Tufte, 1997)

The overarching goal driving this work is to elevate the conversation through interactive information visualizations. For example, internally, staff have a two-dimensional view of information allowing them to slice information to analyze multiple variables; like zip codes and deaths. Externally, the public is also gaining access to information allowing them to analyze different factors. The COVID-19 Demographics page provides the user the ability to view four case study variables side-by-side. One can slice the data by age, sex, race and ethnicity and form their own assumptions, as well as questions.   Varied depictions of information provide the user with options to explore and dig into each area, in this way they are driving their own investigation of the statistics.

As the agency moves into the next phase, vaccination data will shape the next data visualizations. The intended outcome is that the site is a trusted location to find the most relevant information about the response effort, to serve as a communication arm and a centralized source of validated data. An important outcome of this effort is that by building trust in the information, the data is then able to inform data-based discussions, and ultimately decisions.

In order to respond effectively in a crisis, it is imperative to have standard data sets that are responsive and reflective. Prior to COVID-19, the intent was to create a platform that can foster and support partnerships vital to addressing large scale issues impacting the health of the community. The pandemic accelerated this work and emphasized how cross-sector collaboration is highly dependent upon the sharing and communication of health information and how these partnerships are sustained through trust.

Data continues to shine a light on the specific zip codes and demographics which have the highest case counts and sustained, upward trend data in positivity and morbidity. Community partners and EPCPH leverage these statistics to support current initiatives and develop new strategies to provide resources for our hardest hit areas.  Part of this work entails lifting out the story to be told and discussing connections and correlations in public forums. A recent observation mapped a cluster of distress calls for mental health services in specific zip code to the same zip codes with disproportionately high COVID-19 data. In this way, multiple agencies can respond in a concerted way to the urgent need.

The information displays will continue to adapt to the community drivers post COVID. Multiple projects are in the planning phases and members of the team work directly with agency divisions to explore and explain health disparity data. While it is acknowledged by the team that there are limitations to the data, it is also noted that it is at the edges of data where the discussion happens. Assumptions made around information sets and the resultant discourse highlight the areas where additional sets of data are required. The maturation process involves making people aware of the limitations of data and will create the pressure to have better, more improved conversations by sharing and contributing information. In this manner, the dashboard becomes a catalyst for Public Health 3.0.