Ever since the COVID-19 pandemic hit Hawaii, the state’s contact tracing program has relied on two fax machines to receive the thousands of new positive and suspected case reports pouring into its offices.

Recently, those machines have been overloaded with the new cases. Occasionally, they break down.

The decades-old technology, along with other IT inefficiencies, has consumed valuable time throughout the crisis and heaped duplicative data-entry work on an overburdened staff, according to Emily Roberson, who was recently leading the Department of Health’s Disease Investigation Branch.

“Picture running a printer from the beginning of the day to the end of the day, without a break,” she said.

Roberson was assigned to the branch chief role in July to help oversee the state’s struggling contact tracing efforts. On Wednesday, she asked for a leave of absence from DOH until the “significant confusion” over whose directives she should follow could be resolved.

Emily Roberson, DOH Disease Investigation Branch Chief and Governor David Ige in a large room at the Hawaii Convention Center with banks of computers and contact tracing personnel. August 19, 2020
Disease Investigation Branch Chief Emily Roberson shows Gov. David Ige contact tracing operations at the Hawaii Convention Center. Until recently, the branch relied solely on fax machines to receive new COVID-19 case reports, making data entry more difficult and time-consuming. Cory Lum/Civil Beat/2020

Prior to her leave request, Roberson told Civil Beat she’d been working to fix inefficiencies, including the faxes, that were hampering the DOH contact tracing operation. Even her division’s core group of six to eight primary investigators has been doing basic administrative work throughout the pandemic, she said.

DOH leaders have been roundly criticized for not hiring more contact tracers fast enough to keep up with the pandemic’s recent surge. The state has now seen 9,202 reported cases, including 211 new cases Thursday. Hawaii has also endured 79 reported COVID-19 deaths.

“You can’t address the personnel without addressing that we’re highly dependent on fax machines that keep breaking,” Roberson said Monday.

The faxed reports often have missing patient data, which University of Hawaii student interns and National Guard personnel have recently helped to clean up, she added. Dealing with obsolete IT adds time and labor, as staff moves spotty data from thousands of hard copies of paper into Maven, the software DOH uses to manage its contact tracing strategy, she said.

Before Roberson arrived, staff with the Disease Investigation Branch would manually scan the faxed sheets of paper even though the system was already automatically scanning most of the faxes and placing them in a digital folder, she said.

“I don’t think they realized it was being scanned the first time,” Roberson said. Only a couple of people had access to the folder, she said, adding that she didn’t know why that was.

The National Guard team assigned to help the branch now has access to the folder and the duplicative scanning has stopped, Roberson said.

Since Aug. 18, the team completed more than 12,000 data entry forms for the branch’s system, Roberson said. It also added nearly 2,200 missing data and corrected or cleaned up more than 6,200 existing data elements, she said.

“It’s still too labor intensive, but it’s better than the alternative,” she added.

On Sunday, the Disease Investigation Branch unveiled to health care providers across the state a new, fillable online PDF form to report cases. The branch hopes that hospitals, doctors and providers will use the digital form to report new COVID-19 cases instead of faxes.

It will still take work to upload the data from those forms into Maven, however. Roberson said it’s been hard recruiting workers who know how to code in “R,” a computer language to make that upload a less time-intensive process.

For now, the branch has relied on an entomologist on loan from the health department’s Vector Control Branch who knows how to code in that language to oversee that effort, she said.

‘No End In Sight’

The state government’s heavy reliance on antiquated IT — and how that affects the quality of service and transparency to the residents it serves — has been well-documented.

But Roberson and other health officials say it’s actually the health care providers and the nation’s healthcare system that are more to blame in this case for all the faxes.

“That’s how hospitals communicate these days” said Dr. Ryan Roth, a physician who works at hospitals on Oahu, Kauai and Hawaii island. “That’s what we do is we fax paper back and forth. It’s nuts. It’s 2020 and it boggles my mind.”

The problem, Roth explained, is that there’s no centralized database for hospitals in the U.S. to share patients’ records with one another. Hospital systems developed different electronic medical record systems, he said, “but they didn’t talk to each other.”

“The only way to do it is by fax,” he said. “There’s no end in sight. There’s no federal drive to do this.”

Nonetheless, she said she hoped local hospitals and doctors would report new COVID-19 cases with the new PDF form instead of faxes. But she said it’s “hard to get everyone to switch over at one time.”

Investigators Assigned To Write Letters

Beyond the fax and data problems, Roberson said she’s been trying to free the state’s limited team of disease investigators from administrative duties and responsibilities that land on their plate.

In recent weeks, as Hawaii’s COVID-19 case counts have spiked, those investigators have been getting phone calls at the branch from residents desperately trying to reach anyone within the health department for help with other social services, their plights exacerbated by the pandemic, she said.

When that happens, the disease investigators, who aren’t trained as case managers, nonetheless try and help those callers, Roberson said. In several instances, they’ve bought meals for the person on the other end of the phone, she added.

Department of Health employees take calls in April. More recently, as Hawaii’s COVID-19 cases have spiked, disease investigators have been receiving calls from residents desperate for help with social services. Cory Lum/Civil Beat/2020

“On the one hand, it’s very nice that you want to help people, but my investigators are burning out themselves. It’s very emotionally taxing,” she said Tuesday, hours before requesting her own leave of absence.

Roberson said earlier this week that DOH was working to route such calls to its behavioral health division. “This needs to happen yesterday,” she said.

Those investigators also drafted thousands of letters informing COVID-19 patients and those who had been exposed to the disease when their quarantine and isolation periods were set to start and end, Roberson said.

Those letters should have been assigned to other agency staff without investigations expertise so that the investigators could focus solely on contact tracing, she added.

The branch is also looking to use the Maven software more efficiently to better prioritize which cases to focus on, given the surge of new cases and the limited staff. For instance, if a patient’s home address matches the address of a care home or nursing home, the system will flag that patient as a top priority, Roberson said.

The branch has developed similar matches in Maven to flag especially vulnerable patients or those at risk of spreading the disease. They include those who work at hospitals or correctional facilities, and those who live at homeless shelters, she said.

Asked whether her branch is getting the resources it needs, Roberson said “there’s always limitations, and I’m just doing the best to push back against limitations.” She declined to specify further.

She did add that she was grateful to the numerous staff members from other departments on loan to her branch.

Less than two days later, she put in her request for a leave of absence.

It’s not clear whether DOH leadership addressed the fax situation prior to Roberson’s arrival. However, Roberson said that state Epidemiologist Sarah Park, who’s taking a leave of absence effective Friday, brought her on board to seek ways to improve the contact tracing operation.

COVID-19 patients who need support or their service providers can call 832-3100 to reach Department of Health staffers.

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