Posted: Aug 17, 2020

The Scenario

Testing and contact tracing have become part of our daily vernacular.

And since the first positive COVID-19 case in North Dakota March 11, Team ND has had a singular focus: protect lives and livelihoods.

This is the story of how people, process and technology came together to transform the state’s approach to testing and contact tracing – key pieces to the overall equation – through a unified approach built on technology, automation and teamwork.

Staff Sgt. Ashley Laine, of the 119th Wing, right, gathers data from voluntary drive-through COVID-19 testing traffic in the parking lot of the FargoDome, Fargo, N.D., as people drive through the parking lot June 25, 2020. The testing site was open to anyone desiring a test. National Guard members partnered with the N.D. Department of Health, NDIT and other agencies in support of the whole community response to the COVID-19 pandemic, working together to help their neighbors in the communities where they also live and work. (U.S. Air National Guard photos by David H. Lipp)

 

 

The Back Story

Testing and contact tracing are integral to identifying and limiting the spread of contagious diseases, and traditional disease surveillance systems have been used around the world to fight contagious disease outbreaks for decades. Never has the awareness of those concepts been more in the spotlight than during the COVID-19 pandemic.

At the front end of the process in North Dakota, there is a system called Starlims that houses test results that come into the state lab. A system called MAVEN is the back-end work horse that houses data for dozens of communicable diseases, including data on close contacts of those who test positive for monitoring of potential infection.

As Department of Health officials and other state leaders began evaluating how to develop and scale solutions to build capacity around testing and contact tracing that would integrate with the systems and provide user-friendly, streamlined solutions, it became clear that the legacy infrastructure – along with labor-intensive, manual data entry processes – was ripe for improvement.

“Widespread, rapid testing capacity and robust contact testing infrastructure are key elements of our state’s ability to continue to reopen while protecting lives and livelihoods,” – Gov. Burgum outlining ND Smart Restart criteria April 15

A cross-cutting team of Department of Health, National Guard and Information Technology professionals immediately began testing the waters of various technology tools to help transform the process.

“We understood the Governor’s Direction from Day 1,” said North Dakota National Guard Team Leader Barbie Lowe. “We needed to get to 10x contact testing and tracing and build out infrastructure that would automate as much as possible. Our success as a state relied on it.”

Leveraging Artificial Intelligence and data analytics was also vital to understanding the data and being able to make more informed decisions, giving the ND Information Technology team multiple avenues to help enable the whole-of-government effort.

From Paper-based to Automated

The efforts initiated in mid-March were based almost entirely on a paper-based process involving three-page carbon copied forms that were submitted to the state’s seven field epidemiologists, the CDC and local public health officials.

“We had three forms we were doing with carbon paper – I didn’t know they still made that,” said Lowe. “That manual process was time consuming and compounded by people working from home and dealing with printing and scanning of the paper forms, as well as unnecessary data entry steps. We had a tremendous amount of support in the field, with National Guard, university students and public health officials helping manage the testing efforts – but the process was impossible to scale.”

Lowe went on to explain, “The reality was that during the testing interview, people jump from symptoms, to where they’ve been and whom they’ve been around – the contact tracing part of the continuum – so we needed to look at a holistic approach to automating the test registration, processing samples, and follow up with positives and close contacts. At the outset, there were 22 National Guard soldiers just doing data entry for CDC and the lab – that was just to get the limited demographic info in to run the specimen. We had to figure out how to help connect some of the front end with the back end.”

The challenge was clear: develop an end-to-end solution that made everything easier for everyone.

From paper forms to tedious data entry, communicating test results and tracking close contacts for positive cases – the pandemic was a Pandora’s Box of opportunity.

Enter Technology

Working with NDIT, the Department of Health and Unified Command teams began exploring automation solutions for the testing and contact tracing continuum. This included extensive process mapping to understand where the pain points and automation opportunities were.

Kristine Vollmer with NDIT’s Technology Division became the de facto program manager for the effort, and along with lead architect and developer Eli Cornell, dove into the fast-moving effort.

“I have been involved since March 17. The last day I had off, which I remember because it was St. Patrick’s Day and my husband’s birthday,” joked Vollmer.

Cornell, who has 22 years with state government, was one of only two NDIT architects who had participated in newly implemented Agile training, a software development approach based on two-week ‘sprints,’ and Microsoft Dynamics training, a low-code/no-code programming tool – two elements that were crucial to getting the effort off the ground quickly and in a scalable manner.

“This was about a lot of people working together, in an unusual circumstance, who don’t normally work together,” said Cornell. “Getting the solution iterated and reshaped to meet the lab’s needs and our healthcare needs was the goal. The Dynamics solution was originally developed for NY and our needs were different – their solution was shaped due to their system being overwhelmed, where ND was able to take a more proactive approach.”

Vollmer stepped in to help manage the business flows and help the development team and vendor partners understand the business needs.

“Our team understood the Governor’s goal of building capacity,” said Vollmer. “We knew we had to structure a foundation for the way the testing and tracing needed to be done to be able to dial up capacity and automate as much of the process as possible.”

In addition to automating the paper forms thanks to vendor support, and getting the contact tracing app up and running, the other key element  was TestReg, an online portal used by New York that enabled individuals to pre-register their demographic information, helping to facilitate the testing process, and remove an extra step of epidemiologists doing data entry after they received the paper forms from testing events.

The back end is the TestReg app, which essentially packages the individual’s information with the actual sample, facilitating the flow of that data into the lab’s system.

“We used TestReg for six people at the drive-through test in Bismarck in May. There were six lanes of traffic, it took 120 people to manage and they did 800 tests,” said Vollmer reflecting on the trajectory of the project. “Fast forward to late June: DoH did a testing event on the Capitol grounds. We did 1,500 tests with 80 people on the ground, and TestReg was used for 100%.”The second pieces utilized Microsoft Dynamics. The NDIT team took the Dynamics platform, tweaked it and began working with DoH to integrate it into the two ends of the spectrum: facilitating test info between test sites and the lab, and supporting contact tracing for positive cases through a self-service portal that enabled close contacts to enter any new symptoms online daily – eliminating the need for thousands of phone calls.

Login page for TestReg.ND.gov, a cornerstone of testing and contact tracing efforts.

Cornell and Co. had a prototype up and running within days of standing up the two pieces.

The Department of Transportation provided state surplus iPads for TestReg use, and NDIT was able to get additional devices for contact tracing from the emergency cache, Verizon and elsewhere, ultimately helping create a virtual, statewide network of connected users.

“Just the act of getting all of those accounts set up, the devices, provisioning, licenses, etc. was a huge lift,” added Cornell. “The logistics of getting them dialed in from a back-office support standpoint – especially considering all of the county, state and local health units, and stakeholders who had to be able to use the system as we a unified, collaborative team – was really a significant milestone.”

By late May, the new platform had been pushed out via iPads to soldiers and airmen in Fargo, Bismarck and the other mobile testing events.

“There is a certain timeline involved with monitoring cases and contacts. Infections are monitored for 10 days, close encounters for 14 up to 24 days. Traditionally, before Dynamics, people were called on a daily basis to check symptoms, temperature, remaining in isolation, etc. That was scanned in and attached to MAVEN. That data wasn’t captured in an electronic format that could be automated in any fashion,” said Michelle Dethloff, Disease Control expert with DoH.

“The vendor solutions really helped link the data entry with the back-end systems. Our developers are now helping with maintenance and enhancements to continue to drive improvements,” said Brandy Fagerland, NDIT team lead involved in the automation effort.

Testreg.nd.gov has played a significant role helping streamline the testing registration process.

Lowe added, “Having people go to TestReg.ND.gov enabled us to plan ahead and gather demographic data and gave participants a bar code that facilitated the process. The barcode helped eliminate 22 users entering data individually by simply importing a single electronic file.”

Cornell and Vollmer echoed the benefits: “We needed to provide an electronic package of information that could flow from the citizen, to the lab, to the tracing team. There is still integration we’re working on, but we’ve vastly improved the end-to-end process.”

The only challenge with the iPads? Having to put them in coolers to keep them from overheating!
 

Automation in Action

From three pages of paper in Amidon and Gladstone April 4, to iPads, self-service solutions and 5,000 tests/day the end of July – the cross-cutting team transformed the entire system.

“The pandemic accelerated the opportunities for North Dakota to enhance service delivery, perhaps most importantly in the testing and contact tracing arena,” said Vern Dosch, retired NISC CEO who was brought in by Gov. Burgum to lead contact tracing efforts.

The use of low-code/no-code solutions like Dynamics, and integration with front and back-end systems resulted in a rapidly accelerated implementation timeline that helped position North Dakota to be more proactive than many other states.

CIO Shawn Riley added, “We implemented in two or four weeks what would normally have taken six months or a year. This is a clear example of how business process improvement, combined with enabling technologies and a singular team focus, have helped Empower People, Improve Lives and Inspire Success as part of North Dakota’s COVID response.”

“We were able to do roughly 37 cases per hour using the original paper-based process,” explained Lowe. “Now, during testing events we’re able to do ~6,000/day – a huge step towards reaching the goal of 10,000 tests a day Gov. Burgum has stated as key to the state’s continued #NDSmartRestart efforts.”

The team also identified additional areas of opportunity. For instance, they were only capturing employer data for positives. The healthcare analytics needed more data on negatives, so they realized that capturing additional data up front would help benefit the down-stream process.
 

Next Steps

While further integration and automation are underway, the impact of Working as One is evident. Mike Benz, Disease Control expert with DoH, is also working closely with the NDIT team to further integrate the new systems.

“On the flip side of the testing process, the benefit for the contact tracers is that instead of going back and capturing signs and symptoms, they could now access that information based on TestReg and front end of the system – that’s what we’re working towards,” said Benz on the continued iterative nature of the effort.

There are numerous data points that, once they are part of a ‘data lake,’ can be used to glean insights,” said Dethloff. “Age, underlying health conditions, where they were, tribal affiliation, etc. A future state is definitely to enable a more complete snapshot with the data to better target testing, help quarantine more quickly and stay on top of potential spread.”

There was an additional side benefit for National Guard and health officials running test events.

“Soldiers never want to go back – the writer’s bump on their fingers is finally diminishing from having to write so hard on the 3-part carbon version of the form.” said Lowe.

There have been hurdles and areas for opportunity remain. All of the information gathered at test events goes to the Cloud; however, the contact tracers aren’t yet able to pull that info out of TestReg, so the team is looking at further integration.

From the NDIT team’s perspective, the use of Dynamics, including recent projects with Department of Financial Institutions and Labor, also represents a growth mindset. “There have been a lot of hours put in to make this work,” said programmer Matthew Lengenfelder. “This is definitely different than the C++ programming I’ve done previously but represents a huge opportunity for how we get things off the ground.”

The longer-term public health benefits are also appealing. Replacing paper forms and clipboards with iPads and an online system will be helpful when local public health officials do vaccinations or have similar testing needs. It puts control of the testing events, schedules and data input right in their hands.

“We want to get to the point where we have a person-centric, seamless system,” added Vollmer. “Where all of the tests you may have had, along with your case management and demographic information, are readily available to citizens and public health officials. It’s a work in progress but we’re proud of what we have achieved.”

As Lowe explained, “It’s incredible to think that April 1, we were talking about a CRM (Customer Relationship Management) tool and how we were going to tackle this challenge. To be able to take something off the shelf and get it implemented and functioning in such a short amount of time was a huge win.”

“We have people who have worked 80+ hour weeks for months on end,” said Riley. “I’ve never seen any team at any job I have had implement solutions this transformative, this fast. From building dashboards used by state leaders, the media and the public on a daily basis, to website development, programming, the architects and database administrators, security and Service Desk teams, Teams support – the list goes on. Virtually every member of NDIT has played a critical role in North Dakota’s response to COVID-19. This is a world-class team and their commitment to serving citizens and our state is second-to-none.”