The Unique Use of An Application to Monitor Health Care Providers Of The Special Pathogen Patient

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The Unique Use of An Application to Monitor Health Care Providers Of The Special Pathogen Patient

Karen Emery and Karin Montgomery - St. Joseph Mercy Health System


As a result of the 2014 West Africa Ebola Virus Disease (EVD) outbreak, the Michigan Department of Health and Human Services (MDHHS) formed the Special Pathogen Response Network (SPRN) with the goal of strengthening Michigan's response to new or emerging public health threats.  Six (6) hospitals in Michigan were identified as Ebola treatment centers (ETC) including, Saint Joseph Mercy Ann Arbor (SJMAA).

Prior to receiving designation as an EVD/special pathogen treatment center in July of 2015, SJMAA received its site visit from the Centers for Disease Control and Prevention (CDC).    One of the opportunities/gaps identified during this visit was the need for effective twice daily monitoring of care providers.  Several solutions were suggested, including a survey monkey tool, an Excel spreadsheet maintained by a member of Employee Health Services that would track telephone calls, a simple paper form, and a monitored voicemail system for employees to call in and self-report.  Database options were also surveyed and included PeopleSoft and Redcap.  SJMAA was transitioning away from PeopleSoft at the time and Redcap was determined to be too complicated for SJMAA purposes. 

It quickly became apparent that a new system was required to effectively monitor healthcare workers.  Fortunately, SJMAA had successfully used a tool called TwistleTM during a previous pilot for colorectal patients.  The question was, could this application be used successfully to monitor care providers during response to a special pathogen outbreak?

What is Twistle™?

Twistle™ is a care automation and communication platform that SJMAA uses to help patients navigate their care journeys through a sequence of personalized messages that are automatically sent based on pathways.  Although Twistle™ had been used by SJMAA solely for surgical populations, the platform appeared to be versatile enough such that it could facilitate the monitoring desired for EVD/ special pathogen care providers. Appropriate personnel were contacted to join the group with the intent of exploring the Twistle™ application utilization.  After the subsequent group meeting, the results were outstanding:  It was determined that Twistle™ would work well for the special pathogen caregivers to monitor for symptoms and psychosocial impact throughout the actual caregiving phase and the three-week post-exposure phase. 

How to Use Twistle

Twistle™ is a telephone, computer, or tablet-based communication platform that uses ­­­­­­­­­­­­­­­push notifications in standardized, automated forms and provides data exchange to the patient/caregiver that can be individualized for specific populations and service lines through secure channels.   This includes a free-texting, bi-directional format which enables the personnel monitoring for special pathogen concerns to securely text the care providers to seek additional information when the application’s automated pathway raises alerts. The unique capability of  Twistle™ is the real-time, quick and easy modification for any pathogen or education.

After the initial approval of utilizing Twistle™ for the special pathogen care providers monitoring, workflows were then developed to include the required specified questions regarding temperature, headaches, bleeding, and weakness as defined by the CDC.  In addition, algorithmic directions, education, resources, and queries were included to better triage and further inform the caregivers on options or the necessity for further follow-up.  Free-text response options were included for any pertinent information exchange between the care providers and a member of the monitoring administrators.  A validated tool for monitoring of psychosocial impact of ongoing care of the  special pathogen patients will be sent via the Twistle™ application bi-weekly.  This will enable monitoring administrators to identify those care providers who require additional support or even a temporary hiatus from the special pathogen population.  

Application and Demonstration

A live simulation was conducted on February 22, 2018 to test all points of the special pathogen use of Twistle™ with a post-simulation debrief.  This revealed a 15-minute lapse between when the invitation was sent to the user to download Twistle™ and when the initial invitation was received.  In an event of a special pathogen outbreak, this would represent the elapsed time from when an initial notification of the outbreak would be sent to Twistle™ and when the care providers would be entered into the Twistle™ database initiating prompts to download the application to care providers' phones.   This process was completed 45 minutes faster than initially anticipated.   The simulation provided participants at all levels the opportunity to experience the activation, implementation, and response to the application following a simulated special pathogen exposure.  In addition, all components of the developed monitoring process were simulated and tested for no less than a 30-day exposure process.

Twistle™ is an application which utilizes an encrypted platform and all communication including messaging capability and photos are managed/completed within the application. This preserves health information privacy and meets Health Insurance Portability and Accountability Act (HIPPA) requirements.

In addition, a live, full-scale special pathogen exercise was conducted on June 20, 2019 with full activation of the Twistle™ application mobilization for the care providers of the patient.  Twistle™ was notified of the activation on June 19, 2019 with final personnel contact information provided immediately prior to the activation. All participants were sent instructions on how to download the application, and soon thereafter, the welcome message followed by the Special Pathogen Symptom Survey. To showcase the entire process in a short length of time, a depression screening tool and Twistle™ product survey was sent after the initial form.  As the exercise progressed, real-time modifications were made to the forms and timeline to meet ongoing needs. All respondents to the post-use survey stated the application was easy to use/download and helped them feel supported by the medical team. 


It is our expectation that Twistle™ will allow the monitoring administrators to obtain feedback from care providers in a timely and meaningful manner. Care providers of the special pathogen patient felt supported through the use of this real-time monitoring platform.  The inclusion of the depression screening and on-going monitoring will assist in meeting the significant complex psychosocial needs of the care providers. In the fluid environment of a special pathogen exposure, a highlight of the platform is the ability to adjust in real-time to the ever-changing information and needs of the care providers for this challenging patient population.

The authors would like to give special recognition to Kenneth Onye and Denise Bechard for their ongoing support and expert advice throughout the development process.