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Health Emergency Assistance Line and Triage Hub (HEALTH) Model

Chapter 5. Model Requirements

Using the research on lessons learned for emergency response and best practices for call center management, we derived a set of requirements for the model. These requirements achieve the goal of delivering a public health emergency contact center that is highly integrated with public health agencies and can minimize surges to the health-care delivery system during a bioterrorist event or other public health emergency.

We produced a Requirements Document, which is available as a companion to this report (Appendix O). It lays out the technical specifications or functionality required to support the business needs associated with developing the Health Emergency Assistance Line and Triage Hub (HEALTH). This document is a technical document used to guide purveyors of information and communications technology in submitting proposals for systems upgrades that would meet our objectives. It should be kept in mind that this document, as well as its followup document, HEALTH Multi-Channel Contact Center Specifications Concept Plan and Report, are specific to DHMIC and are included as examples of the steps in acquiring appropriate technology upgrades.

Process Requirements

Data collection should attempt to identify the public's risk perceptions, particularly around issues of trust, control over the risk, equity, and dread.
The process should effectively handle surges of up to 1,000 contacts per hour.
The process should include maintenance of a library of Centers for Disease Control and Prevention (CDC)-approved Frequently Asked Questions (FAQs) on agents of concern for bioterrorism.

Privacy and Security

The model must include a privacy policy statement and updates of privacy and confidentiality policies as they relate to various technology channels.
Notice and consent verbiage that advises patients of confidentiality and security issues must be developed.
A security structure must be developed.

Data

Data collected must give feedback to public health agencies on the public's concerns.
Data fields must meet public health agencies' needs.
Database content must be consistent with State and CDC disease reporting programs.
Call metrics must be collected for continuous quality improvement, including the costs per call, hang-up rates, wait times, call length, FAQs shared, etc.

Personnel Requirements

The model should maintain readiness for surge capacity staffing without additional cost.
The model should minimize training times.

Volunteers

The model should include a volunteer management plan that addresses recruitment, management, training, activation, evaluation, and security.
Staff and volunteers must be trained specifically to deal with callers in a disaster event by adjusting for the public's lessened ability to process information under stress. This can be accomplished by tailoring the message and the method of delivery accordingly and frequently repeating the message.

Technology Requirements

The public's preferred communication modes should be offered (E-mail, fax, etc.).
The technology must be cost-effective and able to keep up with future technology advances.
The model should offer alternatives to traditional telephony if telephone systems are down, especially during the first hours of an event.
The systems must accommodate a call volume of 1,000 calls per hour without detracting from other essential service provisions of DHMIC.
The systems should include plans for remote access or alternative site staffing.
The system should allow high priority calls to get through in time in spite of surges.

Incident Command System

Incident Command System (ICS) is an organizational tool that can be thought of both as a requirement of public health and disaster response agencies and as an internal requirement for good emergency response management. Disaster events may involve huge numbers of personnel whose activities must be carefully coordinated, and multiple agencies that must quickly establish effective ways of interfacing with each other and, in a unified fashion, with the public.

The ICS is an organizational tool, used by emergency response agencies to maximize the effectiveness of their response. Law enforcement, fire departments, and the military have long used this system. Public health agencies have come to realize the necessity of identifying how to fit into the larger ICS and how to apply it internally to make their emergency response more effective. The same challenge—identifying how to fit into the larger incident command structure and how to apply it internally—exists for the HEALTH model. To be prepared for emergency mobilization, the call center must establish its own internal incident command structure and activation procedures. This framework must be established prior to any event and frequently tested and evaluated.

ICS provides the following key management functions:

Minimizes the span of control.
Maintains unity of command.
Keep decisions and resource allocations prioritized and objective-driven.
Uses common terminology.
Creates and follows an action plan.

ICS begins with establishing lines of authority and communication to be followed when an event occurs (Figure 1). Roles and responsibilities are pre-assigned and are based on job title. The Command staff consists of the Incident Commander and the Liaison, Information, Safety, Operations, Planning, Logistics, and Finance and Administration Offices.

The Incident Commander has the ultimate responsibility for determining event objectives and strategies. The Information Officer coordinates all information dissemination and clears all information releases. If an information point person is not made readily available to the media or is not prepared to provide accurate information that addresses the public's concerns, the media will conduct its own risk interpretation and will disseminate its own conclusions to the public. In the case of a possible bioterrorist event, information control can be a more sensitive issue if, for example, a criminal investigation is concurrent with the event management. In the case of an event involving human patients, there are additional concerns for privacy of victims and sensitivity to victims' families.

The Safety Officer anticipates, detects, and corrects unsafe situations. The Liaison Officer serves as a contact point for representatives of assisting and cooperating agencies. The Operations Section develops the strategy portion of the Incident Action Plan, participates in the planning process, and accomplishes the incident objectives. The Planning Section maintains resource status, gathers and analyzes data, provides displays of situations, estimates future probabilities, and prepares alternative strategies. The Logistics section manages the allocation of personnel, equipment, services, and support. This section is responsible for management of internal communications equipment and strategies. The section also is responsible for procurement and for servicing equipment. The Finance and Administration Section will provide financial management and accountability. They will authorize expenditures, maintain disaster records, maintain injury and damage documentation, negotiate vendor contracts, and establish any formal agreements with other agencies.

ICS is flexible, allowing for a systematic approach that can be expanded or collapsed as needed, depending on the level of response required for a specific incident. ICS allows for multiple emergency response agencies to effectively coordinate to maximize resource utilization and improve communication while minimizing confusion, proliferation of misinformation, and duplication of efforts.

Effective Risk Communication

Risk communication is the science of communicating critical information to the public in situations of high concern. The objectives in emergency communications are to identify and respond to the barriers of fear, panic, distrust, and anger; build or re-establish trust; resolve conflicts; and coordinate between stakeholders so that the necessary messages can be received, understood, accepted, and acted on.

Risk communication includes using both one-way (mass broadcast) and two-way (including one-on-one) communication strategies to identify and overcome barriers to effective communication. The goal is to assist people at risk in identifying their risk status and making choices that will protect their health and safety.

Principles of Risk Communication

Identify the public's risk perceptions. Collect information about the public's perceptions about the risk, particularly around issues of trust, control of the risk, equity, and dread.
Establish two-way communication. Listen to the public's concerns. The public must feel that their concerns are heard and are being addressed. Accept and involve the public as a legitimate partner. Sustain interaction with the public regarding their concerns.
Avoid unnecessary negative language. Adjust for the public's tendency to focus on negative messages by countering negative messages with positive or solution-oriented messages.
Develop trust. Be honest, frank, and open. Trust will be erased by public disagreement among experts, denial of risk, insensitivity, irresponsibility, or lack of coordination.
Coordinate and collaborate with other credible sources. While trust is best established ahead of time, "trust transference" can occur when a highly trusted source concurs with the message delivered by a less-trusted source.
Cut through the mental noise. Speak clearly and with compassion. Adjust for the public's ability to process information under stress. Tailor the message and the method of delivery accordingly. Make sure the message is repeated frequently.
Provide one-on-one communication. Television and radio broadcasts will provide information that is adequate for most of the public; however, there will always be concerned citizens who, for whatever reason, need personal communication.

Strengths of DHMIC in Providing Effective Risk Communication

Our medical information centers (Poison Center, Drug Center, and NurseLine) are already trusted sources of information used by more than 250,000 people each year; the public currently confers a high level of trust on medical information centers. Our staff is trained to listen and to provide critical information to callers who may be in distress. They are experienced in conferring respect and confidentiality to their callers. Poison centers and nurse advice lines hold the position of trusted information service providers, making them appropriate vehicles for risk communication in a bioterrorism event. When the communication is delivered in a compassionate, informed, and consistent manner, it will foster trust and reduce anxiety. The DHMIC is exploring remote triage capabilities to provide services in high-demand situations. Remote triage may take on great importance in the event of an outbreak of infectious disease that creates a need for mass quarantine, causes hospital closures, and necessitates home-based care.

The Importance of Two-way Communications

The importance of establishing one-on-one communication or two-way mechanisms as early as possible has been identified as a need in the evaluation of response to several disasters, including the WTC bombings. This necessity is dual: it is essential to have the capacity to collect information on both symptoms and the community's concerns. This allows the public health agencies to respond to the public's concerns and symptoms, building critical trust and credibility.

Exportability Requirements

We determined that there are three key requirements for a truly exportable model of an emergency contact center. These requirements deal with the ability to provide medical triage, offer preferred communication formats, and assess capacity for providing services.

The HEALTH model should address medical licensing requirements for serving States other than Colorado with medically licensed call center staff.
The HEALTH model should offer different communication modalities to reflect the differing needs of agencies that serve populations with different preferences.
The model should offer a "tool set" that can aid other organizations in assessing their capacity and needs for developing this sort of service.

The first issue is outside the scope of this project and depends on legislative bodies and their decisions. The second issue depends on the specific characteristics of the population to be served, which are addressed in Chapter 5, and the potential technological solutions, which are addressed in Chapter 7. To address the last issue, we have developed a "tool set," which is included in this report and discussed in Chapter 6.

HEALTH Contact Center Assessment Tool Set

In the fall of 2001, the intentional release of anthrax in the eastern United States caused much fear and panic. The Denver Health Medical Information Centers (Rocky Mountain Poison & Drug Center and the Denver Health NurseLine) experienced a 10 percent increase in call volume without an actual incident in our five-State service region (Colorado, Hawaii, Idaho, Montana, and Nevada).

What would your agency do to accommodate a surge in contacts from a public trying to get information?
Could you adequately predict the potential volume?
How would you begin to identify staff and other resource needs?

Understanding the potential information demands related to a health emergency and developing strategies to handle these surges is important for all public health and health care agencies.

A tool set was developed in conjunction with the HEALTH model to assist public health agencies in understanding the potential magnitude of public information needs related to bioterrorism or other emergency events. The tool set allows for minimal and fine-tuning input to help public health agencies assess their current operational and technological infrastructure and their capability to field public inquiries. The user will enter data into the tools or view sample calculations to determine resources needed to meet potential risk communication demands related to public health emergencies. The user will review different options and strategies for handling these risk communication demands and better understand the requirements and resources for each option.

The tool set contains six tools or components:

Instructions—Provides basic directions for using the tool set and allows you to enter a target population. Each of the subsequent components contains further instructions on how to use them. In case there is any question about the tool or its use, contact information has been provided.
Contact Surge Calculator—Provides a simple way for a public health agency to estimate the number of contacts (telephone, Web site, E-mail, fax) that may be generated from a bioterrorism or emergency event.
Staffing-Resource Calculator—Provides a simple way for a public health agency to determine personnel and basic resources (telephone lines) needed to handle an expected number of contacts (based on call center industry standards) with an internal contact center or hotline. This component uses Erlang-B and Erlang-C modeling calculations (long used as a standard for call center planning and forecasting). By entering basic parameters, such as service level required, call volume numbers, and duration of calls, the user can calculate staffing requirements.
Capital Expense Calculator—Provides a means for a public health agency to assess the facilities and equipment needed to handle an expected number of contacts. This component calculates the potential investment needed for resources not currently available so agencies understand potential costs associated with an internal contact center or hotline.
Technology Expense Calculator—Provides a means for a public health agency to assess the technology infrastructure needed to handle an expected number of contacts. This component calculates the potential investment needed for resources not currently available so agencies understand potential costs associated with an internal contact center or hotline.
Surge Options Matrix—Provides a simple way for a public health agency to assess its capabilities for implementing an emergency contact center or hotline and suggests other potential options.

A functional copy of the HEALTH Contact Center Assessment Tool Set can be downloaded as an Excel File (228 KB) or accessed as a Web Version.

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