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By Elizabeth S. Goar for For the Record
As vaccination efforts roll ahead, larger questions about the country’s public health infrastructure have emerged.
As of the beginning of May, about 31% of the US population had received two COVID-19 vaccine doses since the first pair of vaccines received FDA approval in late December. That figure, when viewed through the lens of Dr. Anthony Fauci’s statements that an 80% vaccination rate was required to reach “herd immunity,” demonstrates that the nation’s approach to getting shots in arms is moving full steam ahead.
Nevertheless, it has also laid bare the disjointed state of the nation’s health care system—HIT systems and patient data in particular.
“The pandemic has exposed the cracks in our health care and public health systems,” says Shaun Grannis, MD, MS, vice president of data and analytics at the Regenstrief Institute. “We have known—and now know with greater clarity—that public health and health care systems need to be better integrated. That requires not only an investment in technology but also an investment in workforce development, particularly in the public health space.
“IT systems between public health and health care must be more seamlessly integrated and must quickly scale the demands posed by pandemics,” Grannis continues. “For example, vaccine registry infrastructure must be capable of meeting the data exchange and data analytics demands related to COVID vaccinations.”
HIT Falls Short
Theresa Cullen, MD, MS, public health director of the Pima County (Arizona) Health Department, notes that the COVID-19 vaccination effort underscores several significant HIT shortfalls—most notably, the lack of a shared registration platform and health information that would enable the efficient management of individual eligibility based on prioritization phase, available vaccination options, scheduling, and an individual’s access to his or her vaccination data.
“HIT has, in different venues, been able to provide solutions to each of these areas,” Cullen says. “However, the lack of a coordinated platform for public health departments, organizations providing vaccines, and individuals has contributed to increased frustration as well as disparities due to the time and skills required for an individual to navigate the multitude of steps as well as options.”
For example, Cullen points out that many counties and organizations are leveraging their HIT solutions to schedule appointments and provide documentation of the vaccinations. In these cases, most HIT solutions are automatically sharing data with both the state immunization (IMM) tracking solutions and the patient via patient portals.
“However, in cases where there are other points of distribution, other vaccine management software has been developed. In most cases, there is not sharing of information between the different HIT solutions—the sharing occurs once data are uploaded to the state IMM registries,” she says.
Cherie Holmes-Henry, vice president of government and industry affairs for NextGen Healthcare, also points to scheduling and reporting as particularly problematic areas—both of which can be addressed by taking time to understand the various settings in which the vaccine is being administered and the types of HIT being used in those places. Armed with that information, currently available scheduling and messaging tools could have been identified and more accurately evaluated for their ability to boost the role of existing platforms in an efficient and effective vaccine roll-out.
To maximize impact, HIT and EHR vendors could have been brought to the table early in the planning process to help evaluate options and ensure a smooth, efficient integration, Holmes-Henry says.
“For ambulatory providers, we are seeing contracts being made with third-party companies for either newly built applications or the implementation of applications that were developed for high-volume vaccination situations such as county hubs or FEMA-run hub sites,” says Holmes-Henry, adding that vaccines administered at these hubs are not typically documented in an individual’s EMR.
Further exacerbating the situation are the disparate systems being used to track who has been vaccinated and when and where the vaccination took place. Holmes-Henry notes, “Pharmacies are using their own information systems to schedule, document, and report to the registry, [while] hospitals and practices are typically using their existing EHRs with updated code sets from the now three approved vaccines for scheduling, ordering, documenting, and reporting.”
She adds, “Utilizing an integrated software platform actually simplifies the COVID-19 vaccine workflow, and the more [vendors] work closely with clients, regulatory bodies, and public health organizations, the better [they] can serve the health care community.”
What of Informatics?
When it comes to technology and the nation’s inefficient approach to vaccination administration, blame does not rest solely on HIT systems. Holmes-Henry notes that other factors come into play. For example, the role of informatics in organizing efforts, “from eligibility confirmation for various priority groups set by the CDC and their respective states to scheduling—which is one of the biggest challenges,” she says.
Informatics also aids with workflow documentation (eg, ordering administration of the COVID-19 vaccine, required codes, and data elements) and reporting to state immunization registries and the Centers for Disease Control and Prevention, Holmes-Henry says, adding that it also “supports vaccine inventory management and the demographic detail of the patient, including capturing of race and ethnicity in support of the goal to remove health-equity challenges.”
Cullen, who is secretary of the AMIA board of directors, notes that while informatics has a significant role to play in organizing and recording vaccination efforts, “the response has been fragmented at best. The lack of historical public health informatics infrastructure as well as the lack of coordination between clinical and public health solutions has contributed to this fragmentation.”
She adds, “Patient identity and reconciliation remains a potential area where informatics has developed many solutions that can be utilized; state IMM registries, using standard terminology and messaging, are critical components of improved tracking. Facilitation of the effort also depends on transparent supply chain tracking.”
According to Grannis, success also requires close collaboration between clinical and public health informatics stakeholders to identify and deploy the appropriate people, processes, and technology requirements—and to build stakeholder consensus.
“Informaticians provide not only a technical perspective but also expertise in coordinating complex architectures and developing governance processes among stakeholders [and] developing processes that align with not only the technical requirements but also business process requirements—for example, including assurances regarding privacy and confidentiality,” Grannis says. “I believe that many in the field of public health informatics and clinical informatics, particularly at the regional level, have stepped into leadership roles to guide these processes forward.”
Enhancing the Approach
One way to improve wide-scale vaccination strategies is to make better use of the tools already available. For example, Grannis points to the health information exchanges (HIEs) that are active in many parts of the country. These organizations can typically aggregate, standardize, and exchange information with large numbers of individuals.
“Given that these organizations exist today and can play a more prominent role in partnering with public health stakeholders to support large-scale management of vaccine data, we should be contemplating closer collaboration between public health and HIEs,” Grannis says.
Holmes-Henry notes that integrated platforms allow providers to execute functions such as informing patients in need of follow-up doses and reporting to federal and state vaccine registries. They also can help providers identify high-risk patients through population health tools.
Also needed are more sophisticated scheduling tools intended for high volume, as are “better coordination and plans for integration with the respective EHRs used by the administering organization for the vaccine,” Holmes-Henry says.
In terms of specific HIT-related areas for improvement when it comes to streamlining the nation’s approach to getting shots in the arms of all who need and want them, Grannis would like to ensure regional and state immunization registries are both scalable and responsive. He notes that demand for vaccine data is high at the institution level for Health and Human Services reporting and at the regional and national levels for population-level reporting—as well as at the patient level. As the source of record, immunization registries must be able to respond to information requests that come in from a variety of channels and in various formats.
Advancement of data standardization should also continue, as “syntactical and semantic standardization of data exchange across clinical systems will mitigate inefficiencies by reducing the data wrangling,” Grannis says. “While many—most—EHR systems use HL7 [Health Level Seven] version 2 as an exchange standard, there is significant interest in leveraging the HL7 FHIR [Fast Healthcare Interoperability Resources] standard for vaccines.
“[Furthermore], public health agencies must receive, aggregate, standardize, and exchange data for a variety of purposes, including vaccine data exchange. To date, public health information infrastructure has been underfunded, and a significant investment must be made to modernize and improve capability and capacity,” Grannis adds.
Marc Whinnem, vice president of operations with Hospitality Business Network Solutions (HBNS), notes that today’s HIT and EHR systems can optimize workflows for enhanced vaccine distribution management, but they are just one-half of the equation. Equally crucial, he says, is a support team experienced with those systems.
“One without the other can lead you down a path to disaster,” Whinnem says. “Utilizing these people, processes, and tools at the service delivery level keeps the end users safe and, when used correctly, keeps the service providers ahead of the state and national level distribution groups.”
Whinnem points to the success of Santa Rosa Community Health, a Sonoma County (California) nonprofit providing primary health care and health education to the area’s underserved population, which has leveraged HIT systems to communicate directly with patients via text and phone to ensure they receive proper vaccine doses. The health center’s EHR team works with HBNS to maintain its technology.
“Without this technology and partnership, the 40,000 lives that depend on them daily would not be as well served,” Whinnem says.
From a public health perspective, Cullen would like to see patient portals developed that include standard terminology and messaging capabilities as well as the ability to share immunization information with registries. She would also like to see inclusion of test data for those who have previously tested positive for COVID-19, a factor that could impact vaccination schedules.
Also needed are rapid registration mechanisms that can be used at mobile/pop-up clinics—which typically revert to paper documentation when volume is high—the ability to scan paper-based registration, and options for non–computer-based registration. Furthermore, standard metrics with clearly defined and field-tested denominators and numerators, which are relevant for improving outcomes, must be implemented.
Finally, Cullen’s wish list includes attention to equity throughout the process—not just as an afterthought—and ways to reconcile race and ethnic data through interfaces with other data sets, such as those in HIEs.
“Reliance upon computer-based registration has contributed to inequity in vaccine distribution, exacerbating the impact of the pandemic in socially vulnerable communities,” she says, adding that the digital divide “has not been successfully ameliorated, especially for seniors and vulnerable populations. Computer literacy is a critical issue in older populations. Mass vaccination requires multiple ‘open doors’ for vaccine registration to be successful.
“Longer term, individuals will require access to their vaccination records,” Cullen says. “The lack of state-based IMM systems to be used historically to record adult immunizations contributed to many of the problems that exist concerning identity, since the adults are not in the systems. Integration of HIEs with public health data is critical and should be foundational to HIE expansion in the near future.”
— Elizabeth S. Goar is a freelance writer based in Wisconsin.
BEST PRACTICES AND LESSONS LEARNED
When it comes to improving the nation’s approach to the COVID-19 pandemic, there are a number of best practices that could help streamline processes and improve vaccine distribution and administration. For starters, Marc Whinnem, vice president of operations at Hospitality Business Network Solutions, recommends using built-in lot management workflows and automated certified state forms, as well as integrating vaccination data with IT systems.
Utilization of the built-in lot management workflows would help organizations be better organized in terms of vaccine expiration dates, inventory management, and billing. The obstacle, however, is the significant amount of work and internal resources doing so requires, Whinnem says.
Furthermore, EHR systems have the capability to build out each states’ certified forms directly into the system so they can be updated and printed at any time. “This would allow for information to be entered directly into the system, and the need to hand-write these forms would be eliminated,” Whinnem says. “This would be a massive [time-saver] but does initially require a significant time and resource commitment for health care providers in a time where their resources are already stretched.”
Despite the capability to input state vaccination data into EHR systems, the process remains largely manual. And much like the situation regarding state forms, the automation process “would need to be built and implemented, but in the long run would save the organization time and money,” Whinnem says.
Shaun Grannis, MD, MS, vice president for data and analytics at the Regenstrief Institute, adds three more best practices to the mix. First, think strategically. “HIT systems are more likely to be sustainable if they leverage existing infrastructure where possible, and any new infrastructure created is ideally highly leveraged for other use cases. Managing vaccine data requires patient matching, data exchange, and data standardization,” he says, adding that these functions can be supported by a master patient index and vocabulary management tools—all of which have applications in public health beyond vaccinations.
Next, invest in population health. “Clinical systems are increasingly called upon to support value-based care by understanding the health of their patients at the population level,” Grannis says. “Population-level analytical tools can support use cases such as vaccine data management.”
Third, establish consensus. Clinical systems and public health stakeholders must work together to capture, analyze, and respond to information, making collaboration critical when battling a public health crisis such as COVID-19.
As for lessons learned, Grannis cites the need for more—and more targeted—investments.
“While significant progress in vaccine data exchange has been made over the last several years, the COVID-19 pandemic highlights the need for continued improvement,” he says. “EHR systems must be able to share vaccine information in a consistent, standardized format with necessary stakeholders, including public health. To do this, investment in vaccination workflows within EHRs is necessary.”
Also required is significant investment in public health infrastructure to augment existing capabilities, as well as to establish a consistent patient identification strategy—the lack of which hinders the nation’s ability to provide the best possible vaccination data, Grannis says.
“Unlike most other countries in the world, the United States treats health care separately from public health,” he says. “This separation leads to some of the challenges that we see today: The health care system receives significantly more funding for its IT infrastructure, while the public health system much less so. This dichotomy leads to a mismatch of capabilities that, until addressed, will sustain these issues.
“Consequently, the US needs a more strategic approach to the relationship between public health and clinical health care, not only at the technical level but also at the policy level.”