TCPH LIMSSelection AsIsWorkflows

PUBLIC HEALTH

RFP NUMBER 2017-090 APPENDIX A CURRENT OPERATIONS (AS-IS) LIMS SELECTION – PUBLIC HEALTH TARRANT COUNTY

LIMS Selection – Public Health As-Is Workflows

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Table of Contents INTRODUCTION........................................................................................................................................................ 4 1.

GLOSSARY AND ACRONYMS .................................................................................................................................... 4 2.

OVERVIEW ............................................................................................................................................................... 8 3.

BUSINESS OFFICE ..................................................................................................................................................... 9 4.

DEPOSIT PREPARATION AND HANDOVER .......................................................................................................................... 9 4.1. INSURANCE PAYMENTS ............................................................................................................................................... 11 4.2.

ADULT HEALTH SERVICES ........................................................................................................................................12 5.

CLINICAL SAMPLE RECEIPT ........................................................................................................................................... 12 5.1. STD PREVENTION AND INTERVENTION ........................................................................................................................... 14 5.2.

BIOTERRORISM RESPONSE AND EMERGING AGENTS ..............................................................................................16 6.

MOSQUITO SURVEILLANCE .......................................................................................................................................... 16 6.1. INFLUENZA AND RESPIRATORY VIRUS TESTING ................................................................................................................. 18 6.2. BIOTERRORISM SAMPLE TESTING - REDACTED SECTION – PROCESS IS FAIRLY STANDARD FOR BIOTERRORISM RESPONSE. NO 6.3.

EXTRAORDINARY WORKFLOWS. .................................................................................................................................................. 19

CLINICAL MICROBIOLOGY .......................................................................................................................................19 7.

SEROLOGY AND STD MICROBIOLOGY TESTING ................................................................................................................ 19 7.1. STD STAT TESTING ................................................................................................................................................... 20 7.2.

CONSUMER MICROBIOLOGY ...................................................................................................................................21 8.

WATER TESTING ........................................................................................................................................................ 22 8.1. MILK AND DAIRY TESTING ........................................................................................................................................... 24 8.2.

EPIDEMIOLOGY DIVISION .......................................................................................................................................27 9.

ARBOVIRUS STATISTICS ............................................................................................................................................... 27 9.1. INFLUENZA AND RESPIRATORY ILLNESS SURVEILLANCE ....................................................................................................... 28 9.2. COMMUNICABLE DISEASE LAB SUBMISSION .................................................................................................................... 29 9.3. BIOTERRORISM AGENT TRACKING ................................................................................................................................. 29 9.4.

ENVIRONMENTAL HEALTH DIVISION ..................................................................................................................30 10.

MOSQUITO SURVEILLANCE .......................................................................................................................................... 30 10.1.

PREVENTIVE MEDICINE CLINIC ............................................................................................................................32 11.

PATIENT CONTACT & VISITS ......................................................................................................................................... 32 11.1. PATIENT BILLING ........................................................................................................................................................ 34 11.2.

TB ELIMINATION .................................................................................................................................................35 12.

PATIENT INTAKE ........................................................................................................................................................ 35 12.1. TB TESTING .............................................................................................................................................................. 37 12.2. TB REPORTING .......................................................................................................................................................... 37 12.3.

LABORATORY SUPPORT ......................................................................................................................................39 13.

SAMPLE RECEIPT/COLLECTION ..................................................................................................................................... 39 13.1. INVENTORY MANAGEMENT .......................................................................................................................................... 40 13.2. ACCOUNTING ............................................................................................................................................................ 41 13.3. ELECTRONIC SUBMISSION TO TEXAS COMMISSION ON ENVIRONMENTAL QUALITY (TCEQ) ...................................................... 41 13.4.

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END OF THE MONTH REPORTING .................................................................................................................................. 42 13.5.

Table of Figures Figure 1 Business Office – Deposit Processing .................................................................................................................10

Figure 2 Business Office - Insurance Payments ................................................................................................................11

Figure 3 Adult Health Services - Clinical Sample Receipt ..................................................................................................13

Figure 4 Adult Health Services - STD Prevention and Intervention ..................................................................................15

Figure 5 BREA - Mosquito Surveillance ............................................................................................................................17

Figure 6 BREA - Influenza & Respiratory Virus Testing .....................................................................................................18

Figure 7 BREA - Bioterrorism Response Testing - REDACTED DIAGRAM – Process is fairly standard for Bioterrorism response. No extraordinary workflows. .................................................................................................................19

Figure 8 Clinical Microbiology - Serology & STD Testing ..................................................................................................20

Figure 9 Clinical Microbiology - STAT Testing...................................................................................................................21

Figure 10 Consumer Microbiology - Water Chemistry Testing .........................................................................................22

Figure 11 Consumer Microbiology - Water Bacteriology Testing .....................................................................................23

Figure 12 Consumer Microbiology - Dairy Water Testing .................................................................................................25

Figure 13 Consumer Microbiology - Dairy Product Testing ..............................................................................................26

Figure 14 Epidemiology - West Nile/Arbovirus Statistics Reporting .................................................................................27

Figure 15 Epidemiology - Influenza and Respiratory Illness Surveillance Reporting .........................................................28

Figure 16 Epidemiology - Bioterrorism Agent Tracking ....................................................................................................29

Figure 17 Environmental Health Division - Mosquito Surveillance ...................................................................................31

Figure 18 Preventive Medicine Clinic - Patient Intake & Contact .....................................................................................33

Figure 19 Preventive Medicine Clinic - Billing Uninsured Patients ...................................................................................34

Figure 20 TB Elimination - Refugee Group .......................................................................................................................36

Figure 21 TB Elimination - Clinical Screening ...................................................................................................................38

Figure 22 Lab Support - Sample Receipt ..........................................................................................................................39

Figure 23 Lab Support - Inventory Management .............................................................................................................40

Figure 24 Lab Support – Accounting ................................................................................................................................41

Figure 25 Lab Support - Electronic Submission to TCEQ ...................................................................................................42

Figure 26 Lab Support - End of Month Reporting .............................................................................................................43


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INTRODUCTION 1.This document provides graphical representation and description of the key activities of the Tarrant County Public Health (TCPH) Laboratory with respect to 1) receiving, processing, testing and reporting results; 2) receiving and processing payments for services rendered; and 3) submitting surveillance reports to public health agencies. Workflow diagrams include who performs the tasks, the relative order of the tasks, how the tasks are synchronized, how information flows to support the tasks, and how tasks are tracked. The workflow documents demonstrate how the laboratory uses its current paper-based processes to support its operations. This document also includes a descriptive summation of the laboratory’s routine activities.

The intent of this document is to capture the elements of current processes (As-Is) that are beneficial with the anticipation of incorporating those elements into one integrated LIMS. At the same time, this document will assist in discovering elements of processes that are lacking and could be provided by the revised informatics architecture.

GLOSSARY AND ACRONYMS 2.The following table provides a list of acronyms relevant to this document:

Acronym Definition

AAIV Administrative Assistant IV

ARIES AIDS Regional Information and Evaluation System

BREA Bioterrorism Response and Emerging Agents

BT Bioterrorism

CDC Centers for Disease Control and Prevention

COC Chain of Custody

CSV Comma Separated Value

DSHS Texas Department of State Health Services

DIS Disease Intervention Specialist

EHD Environmental Health Division

EHR Electronic Health Record

FDA Food and Drug Administration

HIPAA Health Insurance Portability and Accountability Act

HIV Human Immunodeficiency Virus

HSV Herpes Simplex virus

JPS John Peter Smith Hospital

LIMS Laboratory Information Management System

NELAP National Environmental Laboratory Accreditation Program

NREVSS National Respiratory and Enteric Virus Surveillance System

NTRL North Texas Regional Laboratory


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Acronym Definition

PCR Polymerase Chain Reaction

PMC Preventive Medicine Clinic

PO Purchase Order

QA Quality Assurance

QC Quality Control

RNA Ribonucleic Acid

RPR Rapid Plasma Reagin

RSV Respiratory Synctial virus

RT-PCR Real-Time Polymerase Chain Reaction

SAP System Application & Products

SLEV St. Louis Encephalitis virus

SPSS Statistical Package for the Social Sciences

SQL Structured Query Language

STD Sexually Transmitted Disease

TB Tuberculosis

TCEQ Texas Commission on Environmental Quality

TCPH Tarrant County Public Health

WNV West Nile Virus


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The following four tables define the workflow shapes used within this document:

Visio Workflow Shapes

Microsoft Symbols

Outlook (E-mail)

Excel

Word

Notepad

Electronic Shapes

PDF Document

Flash Drive

QuickBooks

Generic Process

Process Detailed in

AnotherWorkflow

Document

Data Entry into an Electronic

Application such as LIMS or Excel

Stored Data New Data

Decision? Preparation Start, EndTo…, From...


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Other Shapes

Manual Record Manual Log

Binder

Handwritten Label

Handwritten Label

on Test Tube Pre-printed Labels

US Mail

Telephone Call

Open Package

Face to Face

Meeting Transport Items Package

Open Package

Fax Print

Scan Document

Photograph

Copy Document

Hand Calculator

96-well Plate

Stereo or Light

Microscopy

Verification

Physical Storage of Optical Media Travel by Car

The following terms are used interchangeably in this document:

• Sample, specimen • Laboratory, Lab • Lab Tech, Analyst


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OVERVIEW 3.

Tarrant County Public Health (TCPH) provides essential public health services in a diverse urban county of 1.8 million residents. TCPH’s vision is a community where there are healthy choices enhancing healthy lifestyles and creating a healthy environment for all Tarrant County residents and the mission is working with community partners to create healthy communities. TCPH employs 394 persons and occupies a 40,000 square foot two-story administrative building with 23 additional satellite clinic locations throughout Tarrant County.

TCPH’s North Texas Regional Laboratory (NTRL) provides clinical diagnostic support for TCPH clinics; provides communicable disease testing and infectious disease surveillance testing; provides milk and dairy product testing to support the Texas Department of State Health Services’ milk quality assurance program; provides water bacteriology testing for public drinking water systems, private well water customers, and bottled/vended water customers in a 49-county North Texas region with over six million residents; provides bioterrorism response by participating in the Laboratory Response Network (LRN) of Texas with an assigned 33 county jurisdiction, and actively participates in a number of public health surveillance programs by testing for infectious diseases and emerging agents.

The TCPH system consists of support teams, clinics and laboratory sections and divisions listed in the following table:

Laboratory Groups

Business Office

Adult Health Services

Bioterrorism Response and Emerging Agents

Clinical Microbiology

Consumer Microbiology

Epidemiology Division

Environmental Health Division

Preventive Medicine Clinic

TB Elimination Clinic

Laboratory Support


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BUSINESS OFFICE 4.The Business Office is responsible for the day-to-day management of the business aspects of the TCPH. The Business Office is composed of a Business Manager and additional staff, who provide support for the financial aspects of the TCPH including: financial reporting, accounts payable and accounts receivable.

DEPOSIT PREPARATION AND HANDOVER 4.1.The Business Office has provided the Laboratory division with its own banking deposit book and as a means to capture daily accumulation of cash and checks obtained through the collection of funds for the payment of services. A Daily Deposit Summary in Excel accompanies each deposit submitted to the Business Office by Lab Support.

In order to track the movement of funds from the Business Office to the bank, the Business Office relies on the three-part deposit slip copies that are maintained by the following groups:

• Laboratory Section • Business Office • Bank


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The following figure demonstrates the workflow for the processing of deposits from the Business Office:

Figure 1 Business Office – Deposit Processing


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INSURANCE PAYMENTS 4.2.Payments for services covered by insurance are processed through Medisoft. Lab Support utilizes paper forms provided by various laboratory areas and clinics to for insurance payment request. All information from paper forms are entered into Medisoft for payment request submissions. Payments come back to the Business Office as in the form of ACH items from the insurance companies. Any discrepancies noted with payment remittance are corrected within Medisoft and resubmitted.

The following figure demonstrates the workflow for the processing of insurance payments within the Business Office through Medisoft billing:

Figure 2 Business Office - Insurance Payments


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ADULT HEALTH SERVICES5.

The Tarrant County Public Health (TCPH), Adult Health Services (AHS) division, serves the county through the support of STD and HIV Intervention and Prevention, STD community education and outreach activities. AHS makes the diagnosis, treatment and prevention of Syphilis and HIV its highest priority. AHS has responsibility for sexually transmitted diseases reportable under Texas Health and Safety Code.

Adult Health Services' personnel conduct field investigations to ensure that any person exposed to an infection is aware of their possible exposure and has the opportunity to be examined and treated. Counseling and information are provided for anyone diagnosed with an STD. One of the program's goals is to ensure that anyone who is treated for an infection has knowledge about their infection and is able to take the appropriate precautions to ensure that they are not re-infected or exposed to another STD.

CLINICAL SAMPLE RECEIPT 5.1.The clinic has various means of obtaining patient samples for testing, including the following:

1. Outreach workers in the field complete screening testing; patient is referred to clinic2. Positive patient results from private testing are routed to the clinic for additional testing and

counseling3. Patients come into the clinic for treatment as a walk-in for syphilis and HIV testing4. Samples are routed from Arlington Clinic

Most commonly patients arrive at the clinic for an exam at which time the patient sees a physician. The physician conducts a symptoms assessment, requests labs to be drawn and determines the appropriate testing. Results are provided to the clinic provider. The AHS staff enters positive results into the STD*MIS system used as the state/Centers for Disease Control and Prevention (CDC) reporting mechanism. STD*MIS is a free database application provided by CDC to state and local STD control programs for use in managing their disease control protocols and results. Only HIV discordant or early detection samples are routed to Dallas County Laboratory for confirmatory (NAAT) testing. Positive results for all STD’s are reported to Texas Department of State Health Services (DSHS).


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The following figure demonstrates the workflow for Adult Health Services Clinical Sample Receipt:

Figure 3 Adult Health Services - Clinical Sample Receipt


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STD PREVENTION AND INTERVENTION 5.2.An important role of Adult Health Services is the control and prevention of HIV through comprehensive evaluation, diagnosis and treatment of more common STDs. Preventing reinfection and disease complications are important goals, involving individual and community education. When someone develops an STD infection, they are at a high risk of acquiring HIV. STD treatment reduces the ability of an HIV-positive individual to transmit an STD/HIV to others in the community. By targeting the identification and treatment of STDs, Adult Health Services works to reduce the HIV transmission rates in Tarrant County.

The AHS DIS is the first point of contact for patient counseling, after positive test results are provided. The AHS DIS are responsible for locating and tracking of STD positive patients and potentially exposed partners. The investigative network covers the entire country and can extend to other countries around the world. Similar programs are in place to locate individuals exposed to an STD in all 50 states. AHS DIS workers will follow a case for a maximum of 45 days insuring all patients who were identified in the investigation were notified and treated before case closure. Case management and Supervisory case review are part of the requirements set forth in annual grant applications and contracts, supporting prevention and/or reduction of new STD cases.


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The following figure demonstrates the workflow for Adult Health Services STD Prevention and Intervention:

Figure 4 Adult Health Services - STD Prevention and Intervention


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BIOTERRORISM RESPONSE AND EMERGING AGENTS 6.The mission of the Tarrant County Public Health (TCPH) Bioterrorism Response and Emerging Agents (BREA) Laboratory Section is to provide culture-based and rapid molecular testing for suspected bioterrorism agents, emerging agents, as well as perform routine surveillance for respiratory viruses to support the Epidemiology Division, and for mosquito-borne viruses to support the Environmental Health Division. In addition, other pathogens can be detected to support epidemiologists in outbreak investigations. Bioterrorism agents are living organisms, such as bacteria, viruses, and fungi, or toxins that are deliberately used to harm the public at large. The laboratory conducts its mission through BT testing for hospitals and law enforcement, and surveillance testing and assay development for the detection of emerging agents such as influenza, other respiratory viruses, and mosquito-borne diseases. The BREA laboratory section receives and conducts testing for six types of samples:

1. Bioterrorism Clinical (BC) samples 2. Bioterrorism Environmental (BE) samples 3. Epidemiological samples: Respiratory surveillance (FLU) samples, Norovirus (NOR) samples, Bordetella

(BOR) samples, Dengue virus (DENV) samples, and Chikungunya virus (CHIKV) samples 4. Environmental Health mosquito surveillance: West Nile and St. Louis encephalitis virus (WS) samples 5. Proficiency Testing (BP) samples: done for BC, BE, FLU, and BOR samples 6. Accuracy testing: samples are provided by supervisors for all diagnostic assays; FLU, BOR, NOR, DENV,

CHIKV, which are tested on a semiannual basis by all testing personnel

MOSQUITO SURVEILLANCE 6.1.The TCPH BREA Section receives mosquitoes from the county’s Environmental Health Division (EHD) after sorting and speciation. The Mosquito Surveillance Form is utilized by the submitter and BREA to capture sample information, identification and laboratory results. BREA is responsible for testing of the samples to determine which samples are positive for West Nile and St. Louis Encephalitis (SLE) virus. Positive results are traced back to the pools of origin by the EHD. The EHD utilizes information from BREA to effectively track and control mosquito programs and community procedures. The BREA laboratory section utilizes Polymerase Chain Reaction (PCR) testing as the method by which positive and negative test results are determined. The section primarily uses Excel and thumb drives as a means of collecting and transitioning data from applicable PCR instrumentation. Excel-based forms are used to capture the following:

1. Sample Processing and Extraction 2. Presumptive PCR Setup and Analysis 3. Confirmatory Testing

The following figure demonstrates the workflow for BREA Mosquito Surveillance:


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Figure 5 BREA - Mosquito Surveillance


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INFLUENZA AND RESPIRATORY VIRUS TESTING 6.2.The Tarrant County Public Health Division of Epidemiology collects samples requiring testing for respiratory viruses and delivers them once a week to the BREA Laboratory Section. PCR testing is performed with the intent of determining the qualitative (Positive/Negative) result of each patient sample. PCR results are reported to Epidemiology as individual reports for each patient. In addition, an aggregate report is submitted weekly to the State Health Department.

The following figure demonstrates the workflow for BREA Influenza and Respiratory Virus Testing:

Figure 6 BREA - Influenza & Respiratory Virus Testing


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BIOTERRORISM SAMPLE TESTING - REDACTED SECTION – PROCESS IS FAIRLY STANDARD FOR BIOTERRORISM 6.3.RESPONSE. NO EXTRAORDINARY WORKFLOWS.

The following figure demonstrates the workflow for BREA Bioterrorism Response:

Figure 7 BREA - Bioterrorism Response Testing - REDACTED DIAGRAM – Process is fairly standard for Bioterrorism response. No extraordinary workflows.

CLINICAL MICROBIOLOGY 7.The mission of the Tarrant County (TC) Clinical Microbiology laboratory section is to provide laboratory support for TCPH divisions and our regional partners that primarily includes Sexually Transmitted Disease (STD) testing for syphilis, gonorrhea, chlamydia, Human Immunodeficiency Virus (HIV), Herpes simplex virus (HSV), and various other infectious agents. Results are utilized by our submitters to provide treatment and counseling, STD diagnosis, and/or follow-up of all possible infections.

SEROLOGY AND STD MICROBIOLOGY TESTING 7.1.The majority of the routine samples are received by the microbiologists through pick-up at locations at various TCPH divisions. The Laboratory Support team receives a few incoming samples from couriers or through the mail; they are delivered directly to the appropriate testing laboratory. Samples are routed to the appropriate laboratory and requested testing is completed. Final results are handwritten on the submission form and input on patient logs, peer reviewed and then routed back to the submitter and required state surveillance entities using the three-part submission form.


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The following figure demonstrates the Serology and STD Routine Testing Workflow:

Figure 8 Clinical Microbiology - Serology & STD Testing

STD STAT TESTING 7.2.Samples requiring immediate testing are submitted by internal TCPH submitters with a STAT request form and delivered directly to the STAT laboratory and received by the microbiologist. Testing is performed per SOP. Test results are handwritten onto the submission form and log, then the duplicate copy is given back to the submitter immediately after testing is complete. Stat testing results are provided to the submitter to aid in preliminary diagnosis and treatment decisions while the client is still in the clinic.

The following figure demonstrates the workflow for Clinical STAT testing:


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Figure 9 Clinical Microbiology - STAT Testing

CONSUMER MICROBIOLOGY 8.

The mission of the Tarrant County Consumer Microbiology laboratory section is to provide comprehensive testing of water and milk and dairy samples, both private and commercial. Laboratory testing is provided as a paid service for which billing and invoicing is facilitated through the Laboratory Support department. Tarrant County Public Health (TCPH) Laboratory conducts two types of tests on drinking water: bacteriological analysis and chemical analysis. Heterotrophic bacterial counts and limited chemical analyses are available for screening purposes, but not regulatory compliance. The laboratory also conducts regulatory testing on milk and dairy products for the DSHS Milk Group and noncompliance testing for private Milk and Dairy producers and plants.


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WATER TESTING 8.1.TCPH conducts water bacteriology and water chemistry testing within the Consumer Microbiology laboratory section. The Laboratory Support team receives incoming water samples from various submitters along with a submission form. Samples are retrieved by the Micro staff and analysis initiated. After incubation and reading, results are handwritten on the submission form and log. Results are internally peer reviewed and further tracked if discrepancies are noted. Positive test results are reported to Texas Commission of Environmental Quality (TCEQ) with the appropriate forms completed. The final test results are sent to the submitter via the submission form by fax, email, or regular mail per customer request.

The following figure demonstrates the workflow for Consumer Microbiology Water Chemistry Testing:

Figure 10 Consumer Microbiology - Water Chemistry Testing The following figures demonstrate the workflow for Consumer Microbiology Water Bacteriology Testing:


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Figure 11 Consumer Microbiology - Water Bacteriology Testing


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MILK AND DAIRY TESTING 8.2.State sanitarians collect monthly samples from regional dairies and retail milk plants for analysis. DSHS mandates the monitoring of the milk and dairy industry. Samples are taken monthly to ensure adherence to DSHS and the Food and Drug Administration (FDA) regulations. The Consumer Micro group receives the incoming samples and associated submission forms required for testing from the DSHS sanitarians. Sample information and temperature are recorded on the submission form prior to testing. Product types tested include raw bulk milk, raw for retail products, pasteurized milk products, milk containers, and plant/ farm water used in the processing of dairy products.

Three procedures are used in the testing of dairy waters to ensure the quality of the water:

• The Coliform P/A procedure is used to detect coliform organisms in the source water used by the dairy farm/plant.

• Multiple Tube Fermentation technique is used to detect coliform organisms from dairy plant cooling systems which contain additives.

• Water Heterotropic Plate Count is used to further analyze the quality of the dairy water through a culture technique as a reflex test when required.

Nine procedures are used in the testing of dairy products to ensure the quality of the product:

• Petrifilm Aerobic Plate counts are used to enumerate the heterotrophic bacteria in a sample. • Petrifilm Coliform Counts and High Sensitivity Coliform Counts are used to enumerate the total coliform

organisms in a sample. • Inhibitor Testing is used to detect the presence or absence of any inhibitors to heterotrophic bacterial

growth in a sample. • Beta Lactam Testing is used to quantitate the amount, if any, of the beta lactam family of antibiotics in a

sample. • Aflatoxin Testing is used to quantitate the amount, if any, of this mycotoxin in a sample. • A Direct Somatic Cell Count is a microscopic manual method of enumerating somatic cells in a sample. • An Electronic Somatic Cell Count is an automated electronic method of enumerating somatic cells in a

sample. • The Alkaline Phosphatase Pasteurization test is used determine whether a sample has been properly

pasteurized or possibly contaminated with raw milk. • The Freeze Point Determination test is used to see if the milk product has been adulterated with an

outside source of added water.

All samples are tested according to each products testing protocol. Results are handwritten onto the submission form for return to submitter. Some testing requires documentation on a test log. Violative results are called in to the DSHS Milk Group as soon as they are read. Final reports for regulatory milk and dairy products are emailed to the DSHS Milk Group and also sent in the format requested to the submitting sanitarian. Private samples are reported to the submitter only in the format requested.


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The following figure demonstrates the workflow for Consumer Microbiology Dairy Water testing:

Figure 12 Consumer Microbiology - Dairy Water Testing


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The following figure demonstrates the workflow for Consumer Microbiology Milk & Dairy testing:

Figure 13 Consumer Microbiology - Dairy Product Testing


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EPIDEMIOLOGY DIVISION 9.

The Tarrant County Public Health Division of Epidemiology and Health Information coordinates the consistent generation, analysis and dissemination of health-related data from various internal and external sources. The goal is to provide the Tarrant County community with health data and information in a usable and relevant format for monitoring health conditions and for planning and evaluating health services. This division maintains records and tracks the prevalence of diseases in Tarrant County. The data gathered from this effort is vital in predicting and preparing for seasonal disease incidence, as well as recognizing new or ongoing threats.

ARBOVIRUS STATISTICS 9.1.The Epidemiology Division obtains laboratory results of area mosquito monitoring performed from April to November. The Epi biostatistician downloads data weekly from a web-based data repository. Data is used to track human and mosquito West Nile virus results. The biostatistician creates an Excel spreadsheet with results and performs analytical reviews using SPSS. Aggregate reports are created for exposure to the Tarrant County website and other public agencies. Positive mosquito and human West Nile statistics are reported to leadership and local environmental agencies. Positive reports for human cases are submitted to the state.

The following figure demonstrates the workflow for Epidemiology West Nile Statistics Reporting:

Figure 14 Epidemiology - West Nile/Arbovirus Statistics Reporting


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INFLUENZA AND RESPIRATORY ILLNESS SURVEILLANCE 9.2.Tarrant County Public Health has developed a respiratory virus surveillance program with enhanced laboratory technology, which supports the year-round detection of influenza and other significant sources of respiratory disease. Specimens collected by this surveillance program are tested for:

• Adenovirus • Human Metapneumovirus • Influenza A H1, A H3 and B • Parainfluenza (Types 1, 2 and 3) • Respiratory Synctial virus (RSV) • Rhinovirus

Influenza kits are provided to client clinics and hospitals. Samples from patients with flu-like symptoms and respiratory illnesses are collected by client clinics and hospitals and prepared for submission to TCPH. Submission forms are received with quadrant information filled out by submitter. Select couriers pick up samples from client clinics and hospitals every Tuesday for delivery to TCPH Epidemiology. Samples are inventoried, signed off, and then delivered from Epidemiology to the laboratory for testing.

When samples are resulted, Epidemiology receives patient results via email and a paper submission form. Results are saved, hand entered and aggregated into an Excel spreadsheet for submission to the weekly flu findings reports and shared with local and state health departments. Data is manually input into the National Respiratory and Enteric Virus Surveillance System (NREVSS) to be used by CDC for the monitoring of virus patterns. Flu reports are made available to Tarrant County, public health professionals, health care providers, and the public.

The following figure demonstrates the workflow for Epidemiology Influenza and Respiratory Illness Surveillance and Reporting:

Figure 15 Epidemiology - Influenza and Respiratory Illness Surveillance Reporting


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COMMUNICABLE DISEASE LAB SUBMISSION 9.3.When epidemiology identifies an individual who is a suspect case of a communicable disease they may collect specimens from that patient and deliver them to the laboratory. The lab will run tests on the specimen where possible or will send the specimen on to the state or CDC for testing

BIOTERRORISM AGENT TRACKING 9.4.

Sentinel laboratories or first responders will make a call to the Bioterrorism Coordinator within the BT lab about preliminary positive results of suspected agents. The laboratory receives the sample directly with appropriate submission form. A hard copy of the submission form is scanned as the sample record and becomes part of the BT investigation. The laboratory tests the sample(s) using real-time Polymerase Chain Reaction (PCR) methodology. The results are hand written on the original submission form. Epidemiology and TCPH leadership are notified of sample results.

The results include patient results, demographics and hospital name where the patient’s specimen was collected. Medical records are collected and interviews with the patient and others are done by Epidemiology investigators in an attempt to determine where exposure could have taken place and find other possible cases. The Epi investigative report is scanned and filed in RACK2 as a Portable Document Format (PDF) document. A hard copy of results are kept in office for 2 years then archived to an offsite location.

The following figure demonstrates the workflow for Epidemiology Bioterrorism Agent Tracking:

Figure 16 Epidemiology - Bioterrorism Agent Tracking


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ENVIRONMENTAL HEALTH DIVISION 10.The Tarrant County Public Health (TCPH) Environmental Health Division (EHD) functions in a regulatory capacity regarding health issues linked to the environment and provides a variety of related services. Environmental Health provides education and information on local environmental issues such as vector-borne diseases, storm water, air quality and ozone; permits on-site sewage facilities; and inspects and permits public swimming pools.

Currently, the main focus of EHD surveillance includes mosquito and West Nile virus surveillance. EHD instructs city workers to effectively utilize different types of equipment including gravid traps for mosquito collection. TCPH EHD maintains programs to not only control mosquitoes, but also prevent the spread of the West Nile Virus through the education of public and city personnel. EHD helps guide cities/municipalities within Tarrant County on how to manage effective disease surveillance and control.

MOSQUITO SURVEILLANCE 10.1.Mosquito surveillance begins with the setting of traps in various locations within a city in Tarrant County. Mosquitoes are collected from traps, placed in containers and submitted to EHD using on Mosquito Surveillance Form. Containers are received and assigned a number by EHD to indicate the Trap ID, Trap Sampling number and the Sample Tube number which is handwritten on the Mosquito Surveillance Form. Data collected on the Mosquito Surveillance is hand entered into a SQL database for analysis and review.

Samples are frozen in a -20 degrees Celsius freezer until they are ready for processing. Processing of samples includes the sorting and speciation of the mosquitoes. The species identification and gender number of mosquitoes from the trap is written on the Mosquito Surveillance Form. Up to 50 individual female mosquitoes of the same species are placed into one sample tube by EHD. Each tube is labelled and prepared for testing. EHD provides sample tubes to laboratory in batches of 30 tubes along with the Mosquito Surveillance Cover Sheet. This Cover Sheet acts as a Chain of Custody (COC) between EHD and the testing laboratory. The COC form captures the following information:

• Number of samples sent to lab • Lab ID Range – numbering system to capture start and finish of samples • EHD Tube ID Start • Submitted by (Name, date and time) • Received by (Name, date and time)

The samples are tested within the TCPH laboratory via Reverse Transcriptase – Polymerase Chain Reaction (RT-PCR). The laboratory enters test results in an Excel spreadsheet and forwards to EHD via email. Upon receipt of results, EHD sorts results by city by utilizing a lookup function and enters all result information into SQL. The data consists of geographical information and the results positive for West Nile Virus (WNV) and St. Louis encephalitis virus (SLEV). EHD personnel calls city and emails a report to inform them of positive results and recommend corrective action. EHD documents all reported information within its SQL database. The data within SQL is aggregated and matched for upload to the Tarrant County website for public viewing. The data is analyzed to calculate a Minimum Infection Rate and Vector Index per vector species and provided to the Morbidity and Mortality Weekly Report (MMWR). EHD also reports all positive results to the State via email on a weekly basis.

The Epidemiology Division analyst reviews the date within the EHD SQL database for additional surveillance reporting. Any inventory utilized by EHD is tracked through SAP.


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The following figure demonstrates the workflow for Environmental Health Division Mosquito Surveillance:

Figure 17 Environmental Health Division - Mosquito Surveillance


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PREVENTIVE MEDICINE CLINIC 11.

The Tarrant County Public Health (TCPH) Preventive Medicine Clinic (PMC) serves the county through the provision of services within an outpatient ambulatory clinic. The clinic serves Human Immunodeficiency Virus (HIV) positive patients and provides medical care, immunizations, laboratory testing, case management, prescriptions and medication management, counseling, medical transportation and referrals to social services and other healthcare providers. Services are provided on a sliding fee scale in accordance with the Federal Poverty Level Guidelines. The PMC accepts Medicare, Medicaid, and other private insurance plans. Private insurance is billed by the laboratory testing provider for those patients with insurance. Laboratory testing for patients without insurance is billed to the Preventive Medicine Clinic.

PATIENT CONTACT & VISITS 11.1.Patients (new and existing) come into the Preventive Medicine Clinic to obtain services.

The following figure demonstrates the workflow for Preventive Medicine Clinic patient visits:


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Figure 18 Preventive Medicine Clinic - Patient Intake & Contact


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PATIENT BILLING 11.2.The PMC Administrative Assistant retrieves the patient Encounter Forms from the clinic nurse’s file. Laboratory Support creates a monthly billing invoice using QuickBooks used by the Billing Department to track billing activities. The Admin Assistant maintains Excel spreadsheets to track the billing invoices. The Admin Asst. determines which funding can be used to cover patient expenses. A purchase order (PO) is already in place prior to services for invoice processing. The PMC has blanket PO’s kept for each vendor and grant to track billed amounts and verify grant funding. These grant accounts are billed until a zero balance is reached and then supplemental PO’s are created for future expenses

Post-billing, the original invoice is sent inter-office to the Accounts Payable Office. The Accounts Payable Office enters the invoice information and dollar amounts into Systems Applications & Products (SAP) and processes the checks. A check is mailed to Lab Support to clear the invoice balance. The Admin Asst. verifies that each invoice has been posted correctly into SAP and that the invoice has been paid. Quest and other laboratory providers directly bill the private insurance companies for patients with insurance.

Lab Support updates the billing invoice in Accounts Receivable QuickBooks via manual entry. Any payment discrepancies are reported via email to the Downtown Office for correction.

ARIES can also be used as a means to pull billing information metrics. All services paid for by the grant must be entered as service dollar amounts in the ARIES system. These entries are completed or organized for data entry by the Admin Assistant.

The following figure demonstrates the workflow for Preventive Medicine Clinic Billing:

Figure 19 Preventive Medicine Clinic - Billing Uninsured Patients


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TB ELIMINATION 12.

The mission of the TCPH Tuberculosis Elimination (TB) Division is to prevent, control and eliminate tuberculosis (TB) among the Tarrant County community. The TB Elimination Clinic consists of a Clinical Screening clinic which also supports a Refugee Screening program for legal immigrants moving to Tarrant County. General health screening includes testing for HIV, blood pressure checks, vision testing and parasite testing as well as screening for pre-existing conditions, medication usage and pregnancy. Blood tests, weights and heights are evaluated for nutrition. Skin testing, immigration medical evaluation and chest x-rays are done as needed to evaluate for tuberculosis. Immunizations for immigration requirements are done in TB/Refugee for people that are newly arrived, or are older arrivals with certain eligibilities. Adults as well as children are serviced in the TB/Refugee program. The goals of the TB Elimination Division Clinic (Clinical and Refugee) is to identify persons with active TB, provide laboratory and diagnostic services and manage positive patients through follow-up care and referrals.

PATIENT INTAKE 12.1.

When an individual arrives at the Tarrant County TB Clinic as a scheduled patient or walk-in, he/she will complete the applicable Health Insurance Portability and Accountability Act (HIPAA) and patient release forms for consent to treatment. Pre-printed labels are generated for usage on patient charts and sample tubes. The initial visit within the TB clinic consists of the following interactions with the patient:

1. TB testing 2. HIV and STD screening 3. Medical Assessment 4. Additional testing based on patient demographics

Patients are given presumptive oral medication based on symptoms patients present with upon arrival at the TB clinic. Subsequent visits are scheduled within the ClearHealth system to ensure patients maintain the treatment regimen and receive additional testing as needed.


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The following figure demonstrates the workflow for TB Elimination Refugee:

Figure 20 TB Elimination - Refugee Group


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TB TESTING 12.2.Testing is determined for refugees by the patient’s demographics and country of origin. Testing for clinical patients is determined by the clinic physician. Samples are routed according to the required testing. Samples are sent to the following laboratories per required testing:

• Quest – to perform testing not conducted within Tarrant County or the Austin State Laboratory • TCPH – to perform in-house testing • Austin State Laboratory – to perform testing not conducted at TCPH and Quest

Positive patients are scheduled for additional appointments within ClearHealth for continued treatment and required follow-up.

TB REPORTING 12.3.Results are received by the TB clinic on paper via printer and fax from the various testing laboratories. Test results are reviewed and loaded manually into the Tarrant Country ClearHealth Electronic Health Record (EHR) system. Positive results are reported to Adult Health Services to allow for patient counseling and referral to agencies that support continued treatment and support. Results are also documented on the patient Encounter Form to maintain traceability within TCPH. Support agencies such as John Peter Smith hospital (JPS) serves the refugee community by tracking patient activity and results using a referral form that originates in the TB Clinic. Testing results on sputum and QuantiFERON assays are stored on the TB server.


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The following figure demonstrates the workflow for TB Clinical Screening:

Figure 21 TB Elimination - Clinical Screening


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LABORATORY SUPPORT 13.The mission of the Tarrant County (TC) Laboratory Support department is to provide peripheral support to the various laboratory divisions and sections through sample collection and receipt, inventory management, and accounting for services rendered by the Tarrant County Public Health (TCPH) laboratories.

SAMPLE RECEIPT/COLLECTION 13.1.The Laboratory Support team is the first point of contact for Water and Milk and Dairy (M&D) (private) individuals, agencies and organizations to submit samples. The Lab Support front desk is responsible for the receipt and handling of incoming samples and accepting payment for services to be rendered. Lab Support has the responsibility of labeling samples with pre-printed labels and accepting the associated submission form(s) for Presence/Absence (P/A) coliform samples. Upon receipt or collection of other types of samples, Lab Support will contact the responsible section of the laboratory to arrange appropriate sample storage and subsequent pickup.

The following figure demonstrates the workflow for Lab Support Sample Collection and Receipt:

Figure 22 Lab Support - Sample Receipt


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INVENTORY MANAGEMENT 13.2.The Lab Support group support the TCPH’s inventory management by compiling each section and division supply requests. The team coordinates the ordering of supplies in Systems Application Products (SAP), Share Point and with warehouse staff.

The following figure demonstrates the workflow for Lab Support Inventory Management:

Figure 23 Lab Support - Inventory Management


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ACCOUNTING 13.3.Lab Support compiles daily deposits from payments received from submitters. Using QuickBooks, Lab Support conducts financial transactions and completes Accounts Receivable reports from cash register transactions. Lab Support also completes deposit slips for various laboratory sections and divisions to support the banking activities of the Business Office. The following figure demonstrates the workflow for Lab Support Accounting:

Figure 24 Lab Support – Accounting

ELECTRONIC SUBMISSION TO TEXAS COMMISSION ON ENVIRONMENTAL QUALITY (TCEQ) 13.4.Before the 10th of each month, the monthly water logs are consolidated, checked for consistency and correctness, and then copied into the TCEQ Electronic Submission spreadsheet in order to create a Comma Separated Value (CSV) output file. This file is then migrated and assigned a LTS number and emailed to TCEQ.

The following figure demonstrates the workflow for Lab Support Electronic Submission to TCEQ:


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Figure 25 Lab Support - Electronic Submission to TCEQ

END OF THE MONTH REPORTING 13.5.At the end of each month all Lab groups give the Administrative Assistant IV (AAIV) monthly workload reports. The AAIV consolidates the reports into four reports: Billable, Workload Measures, Revenue and Activity reports.

The following figure demonstrates the workflow for Lab Support End of Month Reporting:


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Figure 26 Lab Support - End of Month Reporting

TCPH LIMSSelection AsIsWorkflows

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