It took me some reading, but I finally found a concise explanation of why the US is unable to muster an effective coronavirus vaccine rollout. Courtesy of Slate (link: https://slate.com/news-and-politics/2021/01/concern-increases-slow-rollout-covid-vaccines.html):
“The problem right now is largely one of bureaucracy and coordination as the federal government pushes decisions to states, and some of those states then push the decisions down to local health departments and hospitals. That has produced a patchwork of systems…”
The concept of ‘it’s the responsibility of the individual States’ is a common refrain we have heard from the Trump Administration. From testing, to ventilators, to public health mitigation efforts – responsibility has been consistently pushed to the state level. The problem is, though, that public health efforts in the United States have traditionally (and quite effectively) operated in completely the opposite direction. Take a case of a food borne outbreak, for instance. In such, a local health department will perform the initial investigation and elevate their findings the state health department with the goal of containing any further spread. If needed, the state can then ask for Centers for Disease Control (CDC) assistance, which typically comes in the form of a health officer from the Epidemiologic Intelligence Service (EIS).
By turning the process of coronavirus response and now mass vaccination on its head, the Trump Administration has left the responsibility to already overburdened local health departments. Chronically underfunded and understaffed, many departments are also simultaneously managing the highest case loads they have seen since the pandemic started.
My experience in applying to be a community vaccination provider as well as my own attempts to personally receive the vaccine illustrate the massive inefficiency of the current system. Here is my story:
In mid-December, right after Pfizer had secured FDA approval for their vaccine candidate but before Moderna had been approved, I attended a virtual staff meeting at the hospital where I am on staff (Saint John’s Medical Center in Santa Monica, part of the Providence system). It was there that I learned those interested in supplying the vaccine to the community needed to seek approval from the California State Department of Health Services. There was no direct communication about this from the State or County or from the California Medical Board (who has since sent me numerous emails warning me to not give vaccine to non-priority groups – of course I don’t have vaccine so…).
The application process was (initially) swift and comprehensive – asking me questions about the size of my medical practice, how many high risk patients I had, how many vaccines we could reasonably expect to administer in one week, and also any unique characteristics of the practice (we actually have an unusually large percentage of patients >95 years of age in our practice). I also needed to provide details of my storage capabilities, temperature monitoring and handling procedures. Lastly, they requested information on our reporting capabilities which we do electronically through our Electronic Medical Record (EMR) to a state-wide database (CAIR) and to the CDC’s Immunization Information System.
It took 5 days for the State to approve our application. The CDC returned their approval in less than 24 hours. So on 12/21/2020 our application was forwarded to the Los Angeles County Health Department which is responsible for distribution. We have not heard anything since that time, in spite of repeated inquiries.
The patchwork of systems was obvious when it came to my personal effort in obtaining the vaccine from Saint John’s. The hospital had set up a very thoughtful system in which healthcare providers were asked a series of questions about their relative on the job risk. This was then compared to an institutional assessment that would prioritize those working in ICUs, ERs and laboratories handling COVID-19 samples. As my interactions are in the outpatient clinic, I was (correctly) classified into a second tier to receive the vaccine.
The assessment system then fed into an appointment generating system which was intended to email me when my vaccination group had reached the front of the queue (sort of like boarding a Southwest airplane). But the hospital abandoned that system last week and, instead, I was sent a link for to SignUpGenius. But I guess the good news is that I will be getting my first vaccination on January 4th which will be the Moderna vaccine.
I think that for a somewhat organized healthcare provider like myself, using a SignUpGenius format is a reasonable, if somewhat unsophisticated, approach. I’m sure that I will be filling out paperwork and that will get transmitted by FAX to the Health Department. I have seen social media photos of doctors and nurses with a paper WHO vaccination card as proof of vaccination.
But it makes me curious as to why in my application to the State I was asked about my electronic reporting capabilities. The massive investment that the US Government made in electronic records was precisely for these sorts of efforts – yet Providence Health and the State of Florida among others have abandoned them for SignUpGenius. How, precisely, do they intend to document allergies or adverse events to the vaccine? And, equally importantly, how do they plan for the influx of patients and to alert them when their second dose is due in 3 weeks?
In 2009, the US Government invested $27 billion dollars to promote the use of electronic medical records (link: https://www.commonwealthfund.org/publications/newsletter-article/federal-government-has-put-billions-promoting-electronic-health) and billions more in the training of consultants to help roll them out. If I’m able to use my EMR to manage a vaccination campaign among my patient population, why are much larger and better funded organizations unable to do so?
Like the coronavirus epidemic itself, the vaccination effort is now exposing the rotting core of the US healthcare system which has been referred to as “all breakthrough, no follow through.”
This quote comes from a very readable Washington Post Op-Ed from Steven H. Woolf – written in…. 2006. Fifteen years and billions upon billions later, we are sinking fast. (Link: https://www.washingtonpost.com/archive/opinions/2006/01/08/unhealthy-medicine-span-classbankheadall-breakthrough-no-follow-throughspan/d3b838a9-db0b-4b23-a410-c5de185f51d0/)