As 2021 dawned and vaccine distribution has picked up, many people had one overarching question on their minds: how and when will they get vaccinated.

At the same time, providers have had to grapple with another question:  how to best approach for this historic, monumental task.

For Stamford Health in Connecticut, the way forward was clear: Leverage existing partnerships with the city of Stamford, community organizations and the state to distribute the much-anticipated vaccines.

The health system has been sharing data and information with the city of Stamford throughout the pandemic, including positivity rates, hospitalizations and other key metrics, said Kathleen Silard, CEO of Stamford Health, in a phone interview. Stamford Health and the city worked collaboratively to set up testing sites, and in the last few months, they also worked together to set up vaccination sites — including one at an old hospital on Stamford Health’s campus.

“The collaboration [with the city] really is to pool our resources, because we know, together we are better,” Silard said.

The health system began vaccinating healthcare workers, first responders and other eligible essential workers on Dec. 17, when the state was in Phase 1a of its vaccine rollout. Back on Jan. 18, it began vaccinating people older than 75 and recently added those older than 65 to the list, as part of Phase 1b of the rollout.

So far, the health system has administered around 27,000 vaccines, and is averaging between 750 and 930 doses a day, Silard said. But Stamford Health has ambitious plans to increase this number three-fold.

The health system is planning to open a new, much larger, site around March 1, which will enable the provider to administer up to 3,000 doses a day, she said.

But getting shots in people’s arms is not without its challenges.

Vaccine availability has been one of the biggest hurdles the health system has faced, but working closely with Connecticut Gov. Ned Lamont and his team has helped the system get the doses and resources it needs, Silard said.

Aside from uncertainty with vaccine availability that has since receded into the background, Stamford Health is tackling a more intractable problem: vaccine hesitancy and health inequity. Both present a formidable barrier to its 3,000-a-day vaccination goal.

To help combat vaccine hesitancy, Stamford Health is conducting outreach programs, including setting up panels with people who have already received the vaccine to talk about their experience, Silard said. The system is also participating in Stamford Mayor David Martin’s weekly Zoom calls to further educate the public on the vaccine.

The Covid-19 pandemic shone a harsh light on existing health disparities in the country, with people in minority racial groups and low-income populations most likely to get the disease and die from it.

Stamford Health has put together a task force, which includes health system members, city officials and members of community health organization Vita, to ensure that vaccines are being administered in an equitable manner, said Silard.

In addition, the health system is partnering closely with the National Association for the Advancement of Colored People and Building One Community, an organization that works with the undocumented community, to focus vaccine administration efforts on underserved populations.

Building One Community has developed a great deal of trust with a population that is typically hesitant to use healthcare services, said Dr. Anka Badurina, executive director of the organization, in a phone interview.

Through the pandemic, the organization has been working to ensure immigrant and underserved communities are included in response efforts — from testing to, now, vaccination.

One of its main areas of focus has been helping the elderly in these communities get registered for vaccine appointments, Badurina said. Those currently eligible often don’t have access to the internet or an email address, which is typically required for registration. Building One Community, which has interpreters on hand, helps them with the process.

Further, the organization helps organize transport to vaccination sites.

“Stamford Health partners with organizations like Building One Community [because] you have to go to those that have a trusted voice in the community,” Badurina said. “They are the ones that know where the community is and know exactly what the community is lacking.”

With the help of its community partners Stamford Health has established a “No Barriers” day, where members from minority groups and under-resourced communities can come to a vaccination site without an appointment, get registered and get vaccinated, Silard said. No individuals are asked about their immigration status or other questions that might keep people from coming to get vaccinated.

Stamford Health wants to eliminate any traditional barriers to vaccination to ensure that the largest swath of eligible individuals can get vaccinated, Silard said.

“We see [vaccine administration] as our moral, ethical responsibility to help fight this deadly disease,” she said.

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A major concern during the Covid-19 pandemic has been that Americans, especially those with underlying conditions, will delay necessary care. New survey results show this concern is not unfounded.

As of last September, about 40% of Americans with one or more chronic health conditions reported delaying or avoiding care, according to a new report from the Urban Institute and Robert Wood Johnson Foundation.

Report authors analyzed data from the second wave of the Urban Institute’s Coronavirus Tracking Survey, a nationally representative survey conducted Sept. 11-28, 2020. The survey polled 4,007 adults, ages 18 to 64 years.

About 36% of Americans said they delayed or did not receive healthcare due to a fear of exposure to the coronavirus or because a provider limited services during the pandemic, the report states. Black adults (39.7%) were more likely than white (34.3%) or Hispanic/Latinx (35.5%) adults to report delaying or forgoing care because of concerns about virus exposure.

About four in 10 adults with one or more chronic health conditions (40.7%) said they delayed or avoided care because of the pandemic, as compared with 26.4% of adults with no chronic conditions.

In addition, more than half of adults with both a physical and mental health condition (56.3%) reported delaying or avoiding healthcare due to the pandemic. About 43% of this group also reported delayed or forgoing multiple types of care.

The impacts of delaying or avoiding care were acutely felt by those with chronic conditions, the report shows. An estimated 23.2% of these adults reported that going without or delaying care worsened a health condition, 21% said it limited their ability to perform daily activities and 15.2% said it limited their ability to work.

Further, the report shows the kinds of care that Americans were avoiding. Dental care was the most common type of care adults delayed or did not receive because of the pandemic (25.3%), followed by seeing a general doctor or specialist (20.6%) and receiving preventive health screenings or medical tests (15.5%).

“Tackling unmet healthcare needs requires effectively assuaging fears about exposure to the coronavirus,” report authors concluded. Providers need to reassure patients that they are following public health guidelines and that these precautions can effectively prevent virus transmission.

“More data showing healthcare settings are not common sources of transmission and better communication with the public to promote the importance of seeking needed and routine care are also needed,” the authors wrote.

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The Covid-19 pandemic spurred the use of technology, but with growing use comes new challenges.

Southfield, Michigan-based Beaumont Health experienced this firsthand at the end of January, when an unknown user took advantage of an Epic scheduling tool vulnerability. But the incident served as a teachable moment, with the system quickly working to safeguard its vaccine scheduling process, said Beaumont Health Chief Information Officer Hans Keil in a phone interview.

The user publicly shared a link to the scheduling module for the clinic providing Covid-19 vaccines. This allowed 2,700 people to register for an unauthorized vaccine appointment, all of which had to be canceled.

Keil believes that the high level of demand for Covid-19 vaccine is what ultimately led to this incident.

“We had challenges with demand,” he said. “We had to triple our server capacity to be able to support the public and their high interest in getting vaccinated.”

When the vaccine rollout began, Beaumont was leveraging technology already available via its Epic EHR system. It had previously used this technology to schedule influenza vaccinations and conduct serology testing last April.

But the Epic system did not have the ability to send out randomized invitations for vaccinations, Keil said. It was important for the health system to be able to randomize that process to ensure it was administering the vaccine equitably. So, Beaumont set up that capability themselves and improved its server capacity to field the high level of demand. But that still left a gap in the process within the Epic EHR.

The vaccination scheduling process was running smoothly until the unknown user found a way to exploit that gap, short-circuit the registration and go straight to the scheduling tool, Keil said.

It was a sudden spike in traffic that alerted the health system’s IT team to the breach. The health system shut down its Covid-19 vaccination registration and scheduling services, for close to 24 hours.

Now that nearly two weeks have passed since the incident was discovered and addressed, Beaumont is focused on preventing this from happening again.

In the short term, the health system is monitoring its IT traffic and making sure every pathway coming through is legitimate, said Keil.

In addition, Epic now offers the capability to randomize vaccination invitations within their EHR. Going forward, the health system will use that capability as well as other enhancements that Epic has made to make sure it is “one individual, one ticket, one opportunity to schedule,” said Keil.

Keil does not envision any further IT issues arising in scheduling upcoming Covid-19 vaccinations. But high demand remains a concern.

“We just need to make sure that we maintain the integrity of this process and we be as fair as possible,” he said. “These tools, these platforms were never meant for this kind of demand. Epic didn’t think about that way, we didn’t think about it that way. But it’s different now.”

In some ways, the pandemic has sharpened the focus of the health system’s IT team.

Beyond the rollout, Keil and his team are thinking about how to help get the system’s surgery volumes up to help with financial recovery. This will include creating end-to-end experiences around surgery services and increasing the level of digital engagement among patients.

“You can get spread thin on lots of priorities,” Keil said. “This [public health crisis] makes it a lot more crystal clear as to what’s most important…to make a difference for the experience of patients and the financial health of the system.”

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Even as the novel coronavirus was raging in the U.S. last year, providers were concurrently fighting a different scourge: hackers. 

Several major providers experienced IT incidents in 2020, including the 26-hospital Universal Health Services and University of Vermont Medical Center. Last week, Pittsburgh-based UPMC and Omaha-based Nebraska Medicine announced that they too are on the list.

It’s not just providers who are targets.

Charles J. Hilton & Associates P.C. — which provides billing-related legal services to UPMC — alerted the health system that the personal data of more than 36,000 of its patients may have been compromised due to an information security breach. The company determined that hackers had logged into several of its email accounts between April 1 and June 25. The accounts contained various types of information, including Social Security numbers, dates of birth, bank or financial account numbers, insurance information as well as information related to diagnoses, treatments and medications.

The incident did not affect UPMC’s EHR or other computer systems, and there is no evidence that the data was misused, according to a notice issued by UPMC. Charles J. Hilton & Associates is offering credit monitoring and identity protection services to all individuals whose data was impacted.

Similarly, Nebraska Medicine and the University of Nebraska Medical Center discovered that an unauthorized party gained access to its shared network between Aug. 27 and Sept. 20, 2020. The unauthorized party deployed malware and acquired copies of some patient and employee information, including names, addresses, insurance information and clinical information. The Social Security numbers of some patients were also impacted.

In all, the data breach affected approximately 219,000 individuals.

The unauthorized party did not gain access to Nebraska Medicine and University of Nebraska Medical Center’s EHR app, and there is no evidence that any of the impacted data has been used fraudulently, the organizations said. But they are providing complimentary credit monitoring and identity theft protection services to all individuals whose Social Security numbers or driver’s license numbers were accessed.

“It is an unfortunate reality of our digital age that ‘bad actors’ are a constant threat to healthcare,” said Nebraska Medicine CEO Dr. James Linder in a news release. “Every major healthcare entity faces the same challenge, and we have seen many healthcare systems, businesses, and government agencies that were impacted by a data security attack in the past six months.”

The organizations will review their networks for unauthorized activity and work to strengthen their controls, said University of Nebraska Medical Center Chancellor Dr. Jeffrey P. Gold.

As providers enter 2021, data security will remain top-of-mind as they are the most common targets for cyber criminals attacking the healthcare industry.

From January to October last year, 513 healthcare organizations reported a breach of 500-plus patient records to the Department of Health and Human Services. Of these reported breaches, 404 occurred among providers, affecting approximately 13.5 million patients.

The threat of cyber attacks targeting the healthcare industry is on the federal government’s radar as well.

Three federal agencies released a joint notice in October 2020 warning of a credible cybercrime threat to U.S. providers and asking the industry to remain vigilant.

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UPMC Enterprises, the innovation and commercialization arm of Pittsburgh-based UPMC, launched Astrata. The company has developed natural language processing technologies that aim to improve the quality of care.

Astrata’s technologies help payers and providers assess care delivery in accordance with quality measures, like the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS). These measures aim to ensure the delivery of high-quality care and mitigate gaps.

Increasingly, the government and private payers are tying provider compensation to quality measures amid the move toward value-based care.

The company’s technologies can comb through hundreds of millions of clinical notes, and by applying natural language processing, can identify whether a patient has received care that is compliant with quality measures, said Dr. Rebecca Jacobson, president of Astrata, in a phone interview.

“[The platform] is really evaluating all the text across one member or one patient and [then it] says, yes this person is in the denominator, that is, the measure applies to them,” she explained.

Once the platform has determined whether a measure applies to a patient, it then assesses whether the care they received is compliant with that measure.

For example, there is a HEDIS measure that focuses on older women with bone fractures who have not yet received appropriate imaging and treatment. Astrata’s platform is able to analyze clinical notes and pinpoint those patients.

“That’s a true gap,” said Jacobson. “That is someone that the health plan and the provider want to know about because they want to intervene quickly so that they can prevent subsequent morbidity and mortality.”

Further, the platform allows healthcare organizations to conduct year-round monitoring and quality improvement efforts as opposed to the current system, where quality rates for many HEDIS measures can only be determined once a year via a manual process.

Astrata partnered with UPMC Health Plan to develop and validate its technologies. The platform has been used by UPMC and UPMC Health plan for several years.

“Over the last two years, UPMC Health Plan abstractors found they can work up to 38 times faster with the implementation of Astrata’s NLP-assisted tools,” said Diane Holder, president and CEO of UPMC Health Plan, in a news release. “This partnership facilitates a more rapid and accurate flow of thorough, meaningful data between our quality team and our providers.”

With the launch of the spinout, Astrata’s tools are now available in the U.S. market.

The company also plans to increase its workforce by 30% in 2021.

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Care for chronic conditions has been severely disrupted amid the Covid-19 pandemic. To prevent further disruption, providers are increasingly partnering with IT companies.

Mount Sinai Health System and Current Health entered into one such partnership in December, with Mount Sinai implementing the company’s remote patient monitoring solution.

Their goal? To enhance care for cancer patients.

Current Health provides a wearable device to patients, which continuously monitors their vital signs, said Chris McCann, co-founder and CEO of Current Health, in a phone interview. The data is then transmitted back to the patient’s care facility. The solution alerts clinicians if the data indicate any abnormalities or potential care issues. At this point, the clinician decides whether the issue can be managed remotely or if the patient needs to be brought into the hospital.

Over the course of the Covid-19 pandemic, cancer screenings and treatment dropped drastically, which could lead to an increase in patient death rates, researchers warned.

A study published last year in JCO Clinical Cancer Informatics shows that at the peak of the pandemic in April 2020, screenings for breast, colon, prostate and lung cancer decreased significantly as compared to the same period the year prior. In addition, the number of mastectomies performed reduced consistently from April through July of last year, and colectomies similarly reduced between April and May.

“These problems, if unmitigated, will increase cancer morbidity and mortality for years to come,” the researchers wrote.

For Mount Sinai Health System, the drops in patient volume were striking. In April of last year, New York City was the global epicenter of the pandemic, and Mount Sinai, like other hospitals in the region, had to suspend elective procedures. The health system experienced a 25% decrease in volume in its ambulatory as well as inpatient settings in April, said Dr. Cardinale Smith, chief quality officer for cancer services at Mount Sinai, in a phone interview.

Even now, patient volume is 10% lower than what it was during the same time period last year, “which indicates to us that there are people who are likely staying closer to home to receive treatment,” she said.

This reluctance on the part of patients — to either risk coming into a health facility or traveling to a facility further away from them — was one of the reasons Mount Sinai looked into remote patient monitoring solutions for oncology.

The system decided to deploy Current Health’s solution, funding the implementation through a Federal Communications Commission grant. The rollout is currently in the pilot phase.

“What I’m hoping that we will see is that this gives us another way to monitor our patients and be able…to get them into a higher level of care when needed, and otherwise be able to really treat them in place so that they feel both safe and comfortable,” Smith said. “And also, so that we don’t overwhelm a healthcare system that is already being overwhelmed.”

Another reason for implementing the remote monitoring system was the growing digital divide among patients.

Mount Sinai clinicians saw that some of their patients, including people of color and the elderly, were less likely to use telehealth services, said Smith.

Smith hopes that the solution will help them care for those patients since Current Health provides the wearable devices and tablets that the patients need. The patients are trained on the devices, which are easy to use — even for the less-than-savvy tech user, Smith said.

Similarly, the health system educated and trained their clinicians on the new solution. As it is a novel mode of cancer care delivery, they needed to make sure they answered all their clinicians’ questions and concerns, she said.

The demand for remote monitoring solutions has exploded during the pandemic. Current Health, which received Food and Drug Administration clearance for its solution at the end of 2019, soon saw an explosion in demand, McCann said. The company experienced a 400% expansion of its customer base. This includes the addition of hospital customers like Mount Sinai Health System and Boston-based Massachusetts General Hospital.

“What [remote patient monitoring] does is it expands the criteria of patients who can actually be managed at home versus within a hospital and that has been a huge asset to us as a company — particularly in the [current] moment,” McCann said.

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In America’s health care system, dominated by hospital chain leviathans, New Hanover Regional Medical Center in Wilmington, North Carolina, is an anomaly. It is a publicly owned hospital that boasts good care at lower prices than most and still flourishes financially.

Nonetheless, New Hanover County is selling the hospital to one of the state’s biggest health care systems. The sale has stoked concerns locally that the change in ownership will raise fees, which would not only leave patients with bigger bills but also eventually filter down into higher health insurance premiums for Wilmington workers.

Hospital consolidation has been a consistent trend unabated by recessions, bountiful times or even a pandemic. The New Hanover sale, which requires only the approval of the state attorney general for completion, prompts the question: If Wilmington’s self-sufficient medical center cannot stand alone, can any public hospital avoid being subsumed into the large systems that economists say are helping propel the cost of American health care ever upward?

“We project the prices will go up, they’ll probably lay off employees after a couple of years, and the hospital will decline in terms of its quality,” said Dale Smith, a retired Wilmington businessman who opposed the sale. Applying his professional experience buying chemical companies to the hospital industry, Smith said: “A very large percentage of mergers and acquisitions, like 90%, never succeed in fulfilling their initial goals.”

The public hospital — those owned by counties, cities or other local government entities — is an increasingly endangered species, numbering 965 out of 5,198, according to the American Hospital Association. While the total number of hospitals in the nation dropped by 4% between 2008 and 2018, the number of state or local hospitals decreased by 14%.

Many have been absorbed by large systems. Over the previous 14 years, the percentage of markets where one health care system treats more than half the cases grew from 47% to 57%. In 2017, nine out of 10 hospital markets met the federal definition for being highly concentrated.

While the industry says larger systems allow hospitals to run more efficiently, numerous studies have found that charges to insurers and patients are higher from hospitals with more market power. One study calculated the premium to be 7% to 9%; another study found 12%.

“There is a growing consensus that hospital mergers do lead to higher prices,” said Christopher Whaley, a policy researcher at the Rand Corp., a research organization.

Novant and backers of the sale disagree that prices will increase more than they would have otherwise. “We looked into the future and we felt we needed more resources,” said Spence Broadhurst, who was the co-chair of the committee the county created to evaluate the medical center’s future. “We were pretty convinced that the risk of doing nothing was significant.”

While the coronavirus inflicted serious financial damage on many hospitals by forcing them to postpone elective surgeries and improve infection control, the outbreak has not stymied mergers and acquisitions. In the third quarter of 2020, Kaufman Hall, a Chicago firm that advises companies on such deals, identified four substantial health care transactions, tying the highest number the firm has seen in a single quarter.

“In 2021 and beyond, even more activity in M&A is expected,” said Anu Singh, a managing director at Kaufman Hall.

Consolidation has been marching rigorously through North Carolina. Seventy-four percent of North Carolina general hospitals belong to systems, more than any other state except Hawaii, Maine and Rhode Island, according to a KHN analysis of 2018 data from the federal Agency for Healthcare Research and Quality. Since then, in the western part of the state, the investor-owned chain HCA purchased the nonprofit Mission Hospital in Asheville; in the middle, Greensboro-based Cone Health merged with Sentara Healthcare into a 17-hospital system; and on the coast, Novant Health is buying New Hanover.

Both the Mission and New Hanover sales provoked substantial community blowback. New Hanover opened its doors in 1967, in the midst of the civil rights movement, as Wilmington’s first integrated hospital. It grew to become the nation’s third-largest county-owned hospital, serving seven counties in southeastern North Carolina.

But unlike many public hospitals, the medical center makes money: $110 million in the fiscal year ending in September 2019, which translated to an enviable 10% surplus. It is the largest county-owned system that does not require taxpayer subsidies.

Despite its market leverage as the only general hospital in Wilmington, New Hanover charged private insurers less than did the 24 other North Carolina hospitals for which Whaley and his Rand colleagues could assess inpatient and outpatient prices from 2016 through 2018. New Hanover’s prices were 13% lower than UNC Health’s, 15% lower than Novant Health’s and 32% lower than Atrium Health’s, according to the Rand data.

New Hanover has also demonstrated its ability to provide care to Medicare beneficiaries thriftily without sacrificing quality: In the first six months of 2019, its accountable care organization, or ACO, earned a $3 million bonus from Medicare for saving more money than the government expected, according to federal data. Novant’s ACO did not reduce costs enough to earn a bonus.

“This is not your typical county hospital. This is a fairly high-functioning hospital with high-quality care and reasonable prices,” said Barak Richman, a professor of business administration at Duke Law School.

But leaders in New Hanover County and the medical center announced in 2019 they were exploring either selling the hospital or joining a larger health care system. They said they feared the hospital needed more capital and help to keep up with the surging population growth in the region and medical advances, including costly technologies.

The county’s request for proposals drew many suitors, including Novant and Atrium, which had been battling for dominance throughout North Carolina’s regional health care markets. Novant’s winning bid, which the county accepted last October, will pay the county $1.5 billion. The county will use most of the money to fund a new nonprofit endowment to bolster community health but will keep $350 million. Novant pledged to invest an additional $3.1 billion to build and upgrade medical facilities and equipment in the region, and it said it would create a branch of the University of North Carolina School of Medicine at New Hanover.

“We knew we wanted more,” said John Gizdic, president and CEO of New Hanover. “We wanted to do more; we wanted to be more.”

Along with the hospital, the sale includes other medical facilities the county owns under the medical center’s umbrella: smaller hospitals for children, rehabilitation and mental health on the medical center’s campus; a nearby orthopedic hospital, a physicians’ group and outpatient centers; and its contract to manage Pender Memorial Hospital, owned by an adjacent county.

Carl Armato, Novant’s president and chief executive, noted in an interview that Novant already owns the nearby Brunswick Medical Center, which refers some patients to New Hanover and, he said, provides affordable health care. “The two organizations have a unique cultural alignment,” he said.

Even some opponents of the deal acknowledged that New Hanover was not guaranteed to remain financially strong. “Owning and running a hospital has got some serious wind in its face,” said Bertram Williams III, an investment adviser whose father was a surgeon who helped found New Hanover. “There’s a lot of things coming down the pike making it more and more complicated to manage a hospital and keep it above water.”

Williams said he expected Novant would need to recoup the money it is spending on the deal. “That money’s got to be repaid,” he said. “It’s going to come from local payers. We know it’s going to be higher costs, there’s no question about that. Might there be higher costs anyway? Probably.”

The sale of the medical center removes the direct leverage local consumers had in influencing the hospitals’ prices. Novant agreed to create a local hospital board, with a majority of members living in the service areas, but the board’s role will not extend to setting prices.

“Novant Health, what they’re proposing to do sounds just too good to be true,” said Howard Loving, a retired naval officer who questioned the sale. “To my mind, the first thing that’s going to unravel is there’s two years with the doctors who are there now, [and then] Novant will have the ability to decide who gets to stay and who gets to go.”

State Treasurer Dale Folwell said he expects that, as part of Novant, New Hanover will press for higher rates from the health care fund that covers state employees and teachers, which Folwell’s office oversees. “I’m their largest customer,” he said. “I know we should expect quality to go down, access to go down, prices to go up. And when that happens, public service workers get hit the worst.”

Novant disputed that its takeover would lead to higher costs. “Novant Health has a track record of lowering the cost of care to patients compared to other healthcare systems in North Carolina,” the organization said in a statement. Novant also noted that more low-income people will qualify for free or lower-cost care under Novant’s charity care rules than under New Hanover’s.

Unpersuaded, opponents of the sale said the county did not take a serious enough look at finding other ways to raise capital without losing control of the hospital.

“They said the future is scary and unknown,” Smith, the retired businessman, said. “The counterargument is, Why don’t we wait and see what the future holds?”

“Once this is done,” he added, “you can never go back.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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A coalition, comprising of health technology companies, providers and nonprofits, announced Thursday that they will establish an initiative to provide people with digital access to their Covid-19 vaccination records.

Two vaccines have so far been approved for administration in the U.S. — one developed by Pfizer and BioNTech, and the other by Moderna. The collaborative effort comes as doses of the vaccines are slowly making their way across the country, and people are figuring out what the next phase of the pandemic will look like.

That new phase will likely present unique challenges, including tracking who gets which vaccine, whether they get a one-or two-dose vaccine, where they receive their vaccine and so on, said Dr. John Halamka, president of Mayo Clinic Platform, in a phone interview. Currently, both Modera and Pfizer/BioNTech’s vaccine require two doses three to four weeks apart.

As the country thinks about opening back up and resuming to pre-pandemic levels of activity, “we [will] need a vaccine credential we can trust,” he said.

Mayo Clinic is just one of the high-profile organizations that have joined the coalition to create the Vaccination Credential Initiative. Others include Microsoft, Mitre, The Commons Project Foundation as well as EHR giants Epic and Cerner.

“We saw this as a critical opportunity to help our healthcare organizations and the world start the recovery process,” said David Bradshaw, senior vice president, consumer and employer solutions at Cerner, in an email. “We know vaccines will play a critical role in that and we wanted to be able to proactively inform and design to the specifications.”

The Vaccination Credential Initiative is developing a QR code that will enable individuals to easily provide their vaccination credentials when needed, Halamka explained.

The coalition has agreed on the standard for how the vaccine credential gets displayed in the QR code, he said. The standard was created by Josh Mandel, chief architect at Microsoft Healthcare, and is called the SMART Health Cards specification. It was developed with a short-term goal of allowing an individual to receive the Covid-19 vaccine or lab results and present these results to another party in a verifiable manner. The specification is based on the W3C Verifiable Credential — a credential that has authorship that can be cryptographically verified — and HL7 Fast Healthcare Interoperability Resources standards.

Now, the coalition needs to work on the “underlying plumbing behind it,” Halamka said. This includes figuring out how the patient gets access to the code after receiving the vaccine from whichever site they select — their doctor’s office, a Walgreens, a CVS, or any other vaccination site. Patients will have full control over their QR code and will be able to access it through any smartphone. They will have also the option of printing it out and keeping a physical copy. 

The coalition’s efforts come on the heels of a much-maligned vaccine rollout. More than 30 million doses of the Covid-19 vaccines have been distributed, but only a little over 11 million have been administered, according to data from the Centers for Disease Prevention and Control.

In an effort to speed up the process, the Trump administration announced Tuesday that it plans to release all reserves of vaccine doses that were initially held back to administer second doses, The New York Times reported. The administration also told states to begin vaccinating every individual 65 and older and people with underlying medical conditions.

Looking ahead, the incoming administration has made it clear that vaccine distribution will be an early priority, with President-elect Joe Biden saying in a speech Thursday that his relief plan will include “hundreds of billions” of dollars for a national vaccination program and public health initiatives like testing and contact tracing, NPR reported. Biden has also committed to having 100 million people vaccinated in his first 100 days.

While that goal seems ambitious, were it to be achieved, getting back to normal will require a verifiable record of people being vaccinated.

Halamka believes that coalitions like this one can have a huge impact on easing that transition.

“When I see nontraditional coalitions coming together — and that means government, academia, industry — all work[ing] together for the benefit of society, we can achieve great change,” he said.

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For months, states warned that additional funding would be needed to distribute a coronavirus vaccine. Last week, they finally got their wish.

The Department of Health and Human Services said it would push out $3 billion to states for vaccine distribution, and another $19 billion for testing before January 19. Both were sorely needed.

While the current administration has kept half of all vaccine doses in reserve to be used for people’s second doses, President-elect Joe Biden said he plans to send most of them out to be used immediately. The bet is that pharmaceutical companies will be able to manufacture enough doses in time for people to receive their booster shot.

So far, the vaccine rollout has been a bumpy one. As of Friday, 22 million doses had been distributed, but only 6.7 million had been administered, according to data from the Centers for Disease Control and Prevention (CDC). This falls far short of Operation Warp Speed’s goal of vaccinating 20 million people by the end of the year.

On top of that, state health departments have largely been left to draft up plans, despite facing slashed budgets and limited staff — who are also trying to manage other facets of the pandemic.

“It just becomes more and more complex. It’s falling to an agency that has limited staff to execute this well,” Tamyra Porter, a partner with Guidehouse, said in an interview.

Different approaches by state

Most states have opted to vaccinate healthcare workers and nursing home residents first, which should be the easiest part of the process.

Volunteers are help step up the vaccine rollout. For instance, the state of California is calling for help from dentists and retired healthcare workers. Meanwhile, Walgreens and CVS have been staffing up to administer the vaccine in nursing homes.

The process, however, is a bit more complicated than giving people their annual flu jab.

“You can’t just go down the line like a flu shot. It’s a lot more time intensive. You need to survey people in advance of the vaccine, and monitor them for 15 minutes after administering it,” said Martha Roherty, executive director of ADvancing States, a nonprofit representing state aging and disability agencies.

And while giving several vaccines to a big system, such as Kaiser Permanente, might be relatively easy, several practitioners not affiliated with hospitals are still waiting for their first dose.

In other states, such as Florida and Texas, people ages 65 and older are being prioritized for the first doses, bucking CDC recommendations.  But this process takes much more careful planning. In Florida, people waited in long lines outside to receive their first doses of the vaccine at first-come first-serve sites.

“You don’t want a bunch of people milling around because that can be a transmission event. You need to have appointments scheduled out so you can see people every 2 or 3 minutes,” said George Rutherford, an epidemiology professor at the University of California San Francisco.

Even with the best set plans, all states need one critical component: people who are willing to take it. A Gallup poll last month found that 63% of Americans would be willing to take the vaccine, up slightly from September.

Testing still a big piece

As the vaccine rollout begins, testing will remain a big part of the Covid-19 response for several months ahead, as indicated by the $19 billion HHS said it plans to allocate for this purpose.

After seeing a surge in cases in advance of the holidays, many states — including California — are at a tipping point. They could see an additional surge after New Year’s, or cases could finally start to decrease again.

The detection of a new, more transmissible strain of the virus in several cities makes testing and preventive measures all the more important. Called B.1.1.7, the variant was first detected in the U.K., but multiple cases were recently found in California, Colorado, New York and Florida.

“Vaccines still work, the drugs still work, monoclonal antibodies still work, masks still work, the tests still work. Everything still works, it’s just a little bit more transmissible,” Rutherford said.

Photo credit: Geber86, Getty Images

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Though doses of the long-awaited Covid-19 vaccine are making their way around the country, the rollout is moving slowly and there have been countless reports of doses being thrown away in situations that could have been avoided, including labeling errors. Now, states such as New York, California and Florida, are threatening to penalize providers that are not efficiently and appropriately distributing vaccine doses.

More than 15 million doses of the vaccine have been distributed across the country so far, but only about 4.5 million people have received their first dose, data from the Centers for Disease Control and Prevention shows.

In New York, 274,713 people have received the first dose of the vaccine out of the 895,925 doses distributed to the state. This represents a vaccination rate of 1,412 per 100,000 people, according to the data.

On Sunday, New York State Health Commissioner Dr. Howard Zucker issued a letter to vaccine providers outlining expectations for distribution, including requiring that all vaccine doses in the providers’ inventory prior to Jan. 4 be administered to eligible recipients by Jan. 7.

“Any doses that are not administered by end of day on January 7 will be redistributed to another facility and future allocations to such facilities will be limited, and possibly eliminated,” the letter reads.

At a news conference Monday, New York Gov. Andrew Cuomo said that going forward, facilities in the state must administer their entire vaccine allotment within seven days of receiving it or risk facing a fine of up to $100,000.

In addition, providers “who do not comply or are found to be seriously deficient” may incur more serious sanctions and fines, including being disqualified from future vaccine distribution.

Florida Gov. Ron DeSantis made similar remarks at a press conference Monday, stating that “hospitals that do not do a good job of getting the vaccine out will have their allocations transferred to hospitals that are doing a good job in getting the vaccine out.”

Though he did not threaten to levy fines, DeSantis said that hospitals have been asked to submit their vaccine distribution plans to the state.

“We do not want a vaccine to just be idle at some hospital system,” he said.

Florida’s vaccination rate is similar to New York’s at 1,232 per 100,000 people. The state received 1.13 million doses of the vaccine, but only 264,512 Floridians have gotten their first dose, CDC data shows.

In California — where the current Covid-19 vaccination rate is 1,143 per 100,000 people — Gov. Gavin Newsom confirmed that healthcare providers that violate priority guidelines for vaccine distribution will have their licenses revoked.

“I just want to make this crystal clear,” he said at a news conference last week. “If you skip the line or you intend to skip the line, you will be sanctioned, you will lose your license.”

California’s vaccine distribution plan is divided into three phases, beginning with vaccinating healthcare workers and long-term care residents.

The governor’s office plans to work with the California Medical Association to create an enforcement plan “to make sure that someone’s not passing a few vials over to their cousin or aunt or uncle, or God forbid, making a buck or two on the backs of a vaccine that should be distributed to someone who is at high risk or at higher need,” Newsom said.

Photo credit: Pornpak Khunatorn, Getty Images

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