Improving Emergency Response and Efficiency by Developing an Electronic 213 (e213) System

State: TX Type: Model Practice Year: 2021

Harris County, Texas, the third largest county in the country, is located along the Gulf Coast where human health and well-being are continuously impacted by intricately intertwined, man-made and natural events. Harris County Public Health (HCPH) is the local health department for the county's unincorporated areas and 33 municipalities located outside the City of Houston. HCPH provides comprehensive health services and programs with dedication to improving the health and well-being of Harris County residents and the communities in which they live, learn, work, worship and play. The HCPH jurisdiction serves approximately 2.3 million people within Harris County, not including the City of Houston. For certain public health services, such as mosquito control, Ryan White/Part A HIV funding, and refugee health screening, the HCPH jurisdiction encompasses the entirety of the county, including the City of Houston, thus providing services to 4.7 million people in total. 

In 2017, as a part of the disaster response to Hurricane Harvey, it became evident to HCPH leadership that a centralized process for creating, approving, and fulfilling resource requests using the Incident Command System (ICS) 213 form was needed. While activated staff were dispersed across the county at various county offices, emergency shelters, and remote locations, the paper-based system being used proved to be outdated and inefficient. As a quick fix, emails and spreadsheets were utilized in communicating across divisions and tracking resources, but this was not a long-term, sustainable solution. The FEMA ICS-213 form is used in disaster response to track resource requests and follow approvals through the chain of command. It is also used to track the status of requests and assist with documenting incident expenditures.

The idea for the electronic 213 (e213) web-based application was developed by activated Environmental Public Health (EPH) staff and was built and implemented in partnership with the Office of Public Health Preparedness and Response (OPHPR), Project and Business Technology (PBT) department, and HCPH divisional leadership over a span of 2-3 weeks. The e213 application needed to be developed quickly because of the rapid nature of the Hurricane Harvey response. The initial e213 application development was a first step in making the ICS-213 form and approval process digital, but would later be significantly enhanced for, and beneficial to, the COVID-19 response. What was ultimately needed during the extended COVID-19 response was a centralized system available to multiple users, with the ability to track the progress of requests, and maintain a historical record of response-related information.

HCPH sent out its first official notice to regional healthcare partners about COVID-19 on January 9th, 2020 with the first cases of COVID-19 in the county following in late February. On March 4th, Harris County activated the Incident Command System and on March 11th, a Local State of Disaster was declared for the County. The department quickly assembled its COVID-19 response team, ramped up staffing, tightened alliances with local government and community partners, facilitated mass testing logistics, increased surveillance of COVID-19 cases and data, and strengthened community outreach and communications. Within HCPH's expansive and ongoing COVID-19 response, the e213 program has served as a useful tool for employees at all levels of the response and ultimately allows the Administrative/Finance Section to efficiently track and document expenditures for reimbursements.

Through lessons learned during the COVID-19 response, HCPH has been able to advance the health department's capacity to respond to future disasters by standardizing the communication and documentation of ICS-213 resource requests and ensuring that HCPH maximizes reimbursements for disaster-related expenses. Public health is one of the most underfunded programs in the country, and HCPH must ensure they're reimbursed for expenses during the COVID-19 response. These reimbursement protocols not only protect HCPH but help the department to continue providing valuable services for all members of the Harris County community.  

The FEMA ICS-213 document is a paper form used to approve and track (through the chain of command)  a variety of resource requests that each contain a financial element. The form documents incident expenditures for all requests including those for supplies, equipment, activation and hiring of staff or contractors, as well as many more crucial tasks. Ultimately, the ICS-213 form is included in the reimbursement package sent to FEMA with all associated invoices and expenses. Without proper documentation, HCPH risks not being reimbursed for disaster-related response.  Often experienced in various types of disaster responses, activated staff are not located in the same room or building, making paper-based communication and tracking especially difficult. The paper-based 213 system of tracking requests is an antiquated format that provides many opportunities for errors, missed protocols, lack of proper documentation, and gaps in communication.

The 213 form's shortcomings became even more evident to leadership during Hurricane Harvey as activated staff were working across the county in different buildings, assisting with shelter operations, or working remotely. Activated staff that had prior experience in developing web-based applications, like the HCPH Timesheet program, quickly crafted a solution to the problem by proposing an electronic 213 application that could contain all the fields included in the form and follow a workflow for approvals. The intensity and rapid nature of the response posed another challenge as the staff creating the program needed to provide a viable solution to the problem as quickly as possible.

When the application was initially created in 2017, it contained basic fields listed on the ICS-213 form. The components included what was being requested and for what activity, the reason for the request, delivery or reporting location, and who to report to. Though the application served its purpose for the Hurricane Harvey response, during the after-action review (AAR), it was determined that some enhancements were needed. The fields on the e213 form were open text fields, none of which were required for submission or approval, and thus had a high susceptibility for user errors and incomplete information. When the application was revisited in early 2020 as the COVID-19 response was ramping up, it was apparent that the application would need updates for improving functionality and efficiency.

Under the Quality Assurance and Data Unit, the e213 Group was created in compliance with ICS organizational structure and was comprised of the same activated staff that initially created the application, as well as additional staff from the EPH Division and contracted application developers. The e213 Group led and managed the enhancement and development of the e213 application by convening staff from all functional areas of the ICS organizational response (command, operations, logistics, planning, and administration/finance) in order to capture requirements and feedback from all facets of the response. The e213 group met daily to discuss updates with the team and address any roadblocks or issues that users were facing in the process of submitting requests, approving requests, receiving all required data, and ensuring staff were appropriately notified. The e213 group also communicated daily with the developers to discuss the vision and functionality of the application and to test enhancements and bugs. The e213 group made sure that all application code, protocols, and workflows were properly documented. Trainings were also led by the team for all users after major updates were applied to confirm that new users were able to navigate the program.

Users with access to the application are assigned a role based on where they are positioned in the ICS structure to obtain the appropriate manager's approval. Based on the type of request (equipment, personnel, supplies, services, and communication), approvals are routed to the appropriate section for additional approval and fulfillment. The platform makes it easy for users, even those new to ICS or COVID-19 response, to put in a request. Certain fields are marked as required” which helps users identify the details necessary for completing a request. When a request is completed, the program generates a pre-filled 213 form that contains request details and includes the approval history. This form is later printed along with any associated invoices or service contracts as part of the FEMA reimbursement package. All requests are maintained in the application, thus providing a backup historical record should any physical documents go missing. Lastly, reports can be downloaded into Excel for additional reporting needs.

With long-term use in mind, Incident Commanders are given the ability to create new incidents within the e213 application for both real world events and practice exercises. The e213 application is also linked to the HCPH Timesheet application, which was further enhanced to automate the ICS-214 Activity Log form. Any incidents created in e213 are available for selection in the Timesheet program, thus creating the foundation for a fully dynamic emergency response application.

As a result of the application, field test site staff are able to receive supply requests in a timely manner; personnel and staffing requests are communicated appropriately between the Planning Section, Finance Section and requested division or office; and purchases and expenditures are tracked efficiently. Overall, HCPH's response to COVID-19 is now better able to meet the needs of county residents because of the digitalization of the 213 form.

In a time when face-to-face interactions are limited and response personnel are working from home or in different offices across the county, the e213 application has helped improve the flow of request communications, approvals, and tracking for all activated staff. Over the course of the COVID-19 response, the response team has grown significantly from 30 activated staff members to over 900 full-time employees and contractors. From the start of the response in early March to mid-December 2020, the Logistics and Planning Sections have processed over 2800 requests due to the improved efficiency and capacity provided by the e213 application.

The e213 application has transformed the ICS-213 document into an innovative, digital process for streamlining protocols, obtaining approvals, and properly documenting all resource requests while maximizing the potential for FEMA reimbursements. The application successfully eases efficiency of operations for all users and captures all necessary information across each of the ICS Sections and HCPH Departments.

Although the effort to create the e213 application was initially led by response personnel from the EPH division, the greater work of customizing it for all areas of the COVID-19 response was a collaborative effort with representation and input from personnel across the response. The newly-formed e213 Group, which was part of the Quality Assurance and Data Unit within the Planning Section, began meeting daily in March 2020 with 22 representatives from all five ICS functional areas (Command, Operations, Logistics, Planning, and Administration/Finance) to review and prioritize needed enhancements for the application. There was also significant involvement from PBT staff who would assist with pushing code changes, pulling user reports, and troubleshooting issues. Funding to create and update the e213 application was made available through approved reimbursed emergency relief funds.

Major updates of the application were completed by the end of September 2020, and the entire process was a collaborative effort among activated HCPH staff and contractors. Collaboration among involved staff was pertinent in order to meet all the section needs of the response and to have an open dialogue around processes, needed information, divisional requirements, and improvements.

The project began by walking through each section's business processes to ensure all aspects were accounted for. This was done multiple times throughout the lifecycle of the project to adjust for the growing and fluid nature of the response. The e213 group compiled data from the individual business processes to develop detailed workflows based on the user submitting the request and the type of resource being requested. These detailed workflows were converted to a workflow matrix which was used to guide the flow of approval that a request follows. As the project progressed, the e213 group developed standard operating procedures (SOPs), a user-friendly help guide, and periodically held trainings with e213 users as they were given access and as major updates were made. All documentation created as part of the project was saved and provided to OPHPR and PBT for future use. 

As meetings were held and feedback was received from participating staff, the e213 group would compile all feedback and coordinate with contracted application developers to devise solutions. This could be a result of a bug where a feature was not working properly or simply the result of users inputting requests without all necessary information. The developer would modify the code to fix a bug, add informational fields, or require specific information and then push to a stage environment where the e213 group would test the updates to verify proper functionality. Once it was determined the code worked as designed, the live e213 application would be updated.

The functionality of the e213 application is unique to disaster response and has the ability to be scaled up or down based on the nature and degree of the response. Users are assigned a role that aligns with ICS organizational structure and each type of request is routed to the appropriate ICS section for approval and fulfillment. For example, if a purchase order (PO) is necessary to purchase equipment or supplies, secure a service contract, or hire personnel, the request is routed to the Administration/Finance section for proper approval and procurement processes. Requests often depend on the cooperation or collaboration of multiple sections, therefore the revised e213 workflow helps to significantly reduce the hand-off process and prevent miscommunications between teams. As a request moves through the workflow, requests are assigned a status to indicate to the user when the request may be fulfilled and completed. Requests may also be rejected by managers and Section Chiefs. The e213 application facilitates communication between sections and roles by allowing messages or comments to be sent to the requestor, or other identified personnel, which can provide status updates, reasons for rejection, or request modifications. Additionally, a request can be delegated to a separate team member who will then be responsible for fulfilling and tracking the request. This is especially important for Logistics staff that are delivering equipment and supplies to various testing sites and offices across the county, as well as for HR staff as they hire staff and coordinate with contract agencies.

The great endeavor to update the e213 application was completed at the end of September 2020. This collaborative effort among HCPH personnel dedicated to the response has helped in guaranteeing that all divisional needs are met, and the COVID-19 response operates as smoothly and efficiently as possible. Because the application was created in-house, it can be maintained and operated with ease by HCPH staff post-response and in future responses. Without this application, COVID-19 and future disaster responses would have continued to be negatively impacted by arduous and outdated processes. Swift delivery of resources and services to the community is no longer hindered by slow communication and the inability to efficiently fulfill requests, which frees activated staff to focus their attention on response activities and serving the community.

Evaluation of the e213 application was ongoing throughout the development process. The e213 group met with Section Chiefs multiple times each week to capture any issues noted by response personnel in their respective sections. After hearing feedback from all the sections, the e213 group would prioritize the updates and changes that needed to be addressed amongst the greater issues facing each response section. The goals and objectives of the application updates were to:

·         Streamline the 213 approval and communication processes;

·         Capture and document all necessary and required information;

·         Reduce risk for errors and ensure quality control of data; and

·         Increase compliance and reporting for financial reimbursement.

Throughout the evaluation and development process, the e213 group worked alongside a developer and PBT staff to identify solutions and make needed changes to the application. As updates were made, they were published into a staging environment where the e213 group could evaluate their functionality and identify any bugs or errors prior to official release. The testing process was extensive. Not only did the e213 group have to test the changes, but the entire application had to be re-tested to ensure that all previous processes were functioning properly. Once changes were completed and tested, they would be published into the live application. The e213 group would demonstrate and preview all modifications with each of the Section Chiefs during weekly calls. This process allowed the response sections to give attention to the updated areas in the application while evaluating the modifications in real-time throughout the response. As an additional quality assurance measure throughout the development timeline, the e213 group walked through each section's business processes to confirm that all aspects were accounted for.

Standard examples of this process played out many times during the review of each section's business processes. It was once brought to the attention of the e213 group that the Administration/Finance Section's staff were unable to reconcile POs to specific requests. The e213 group discussed an appropriate solution with the developers which allowed the ability to upload documents associated with the request, such as POs, invoices, and contracts. Throughout the response, the Logistics Section received requests for supplies and equipment that did not contain the needed quantities or units of measure which presented an obstacle for prompt ordering and fulfillment. As a result, the application was updated to require line item entry of supplies and equipment requests to ensure that the Logistics Section had adequate information for fulfillment. The process of refining personnel requests required the creation of sub-type requests (Request Personnel, Reassign Staff, or Demobilize) so that the application could require different information based on what was needed. If a request was submitted to activate or reassign a staff member, then a desired start date and time, reporting address, supervisor name and qualifications became required fields. To demobilize a staff member, the staff name and demobilization date would be required. Overall, the iterative process of updating the e213 application added functionality to improve efficiencies within the response.

Toward the middle of the response, after several major updates had been made and a number of new users were given access to the system, the e213 group led virtual trainings on the application. The group offered three trainings at various times and days to increase the opportunities for all activated personnel to participate. The trainings reviewed the basics of creating a request and provided a live demonstration of the different request types. All trainings were recorded, and the presentations were then made available to staff so users could review as needed.

As part of a mid-response In-Action Review (IAR), OPHPR offered an opportunity for any activated staff or formerly activated staff to provide feedback. During the review, staff indicated they were pleased with the functionality of the application and how it had improved since the beginning of the response.

The e213 application took the antiquated paper-based 213 form and transformed it into an application that allows users to submit, track, and fulfill requests for a variety of resources in a more efficient manner. The program also houses purchase order details and generates completed 213 forms for FEMA reimbursements. Receiving reimbursements from FEMA is essential for sustaining HCPH operations for emergency responses.

The lessons learned from Hurricane Harvey, and from the continual feedback during the early phases of the COVID-19 response, helped to strengthen the application and make it versatile and scalable depending upon the unique needs of each response or disaster. The program is not only equipped for future responses, but also preserves historical information from past responses. Elimination of the paper-based system has made the process more efficient and feasible during a socially distanced and decentralized response. The centralized system is ideal for any type of response as it can be accessed from a computer, tablet, or mobile device with an HCPH staff log in. The application itself is scalable in allowing as many or few staff as necessary to use the application while having various ICS roles assigned. It also provides an environment where staff may change roles in the application as they move roles or positions in the response.   

Throughout the development process the e213 group documented SOPs, workflow approval and matrices, code changes, and created a user help guide as resources for future disaster responses. The team created SOPs to standardize user roles and permissions, workflow matrix and visualization to help diagram the chain of approvals along with technical documents containing the code implemented by the developer. If e213 requires future modifications, the code manual explains how the back end of the application operates in detail. Additionally, the request approval chain is run via workflow matrices and the associated technical document explains how the matrices work and how they can be modified. Super users can be given administrator access to the application, which allows special access for making changes to the workflow matrix, adding incidents, and updating permissions. This feature allows future e213 administrators to make changes without the help of a developer. The e213 help guide also provides users general directions for the program. If staff are new to the response, or have forgotten procedures, they are able to reference these documents located within the application for assistance. Lastly, staff may learn how to use the e213 application by watching recorded e213 trainings which demonstrate proper use.

HCPH PBT staff were included throughout the development of the e213 including implementing updates and code changes. In the future, they will be able to assist with maintaining the application internally as they have been provided all documentation and are proficient in working with the program as a whole.