- 1 Full Title or Meme
- 2 Context
- 3 Problems
- 4 Current Use Cases
- 5 Sources of Vaccination Data
- 6 References
Full Title or Meme
This is an examination of the actual experience of COVID Vaccination and how well-meaning effort collide to create mass confusion.
The COVID Vaccination experience as the US comes out of the first phase of the pandemic and begins to deal with vaccination.
- IIS = Immunization Information Systems (run by states or other jurisdictions)
- PCP = Primary Card Physician, often called a family physician.
- EHR = Electronic Health Records (typically run by the PCP)
- COVID testing or prophylaxis is required by many countries today.
- Employers do have some rights and liabilities associated with exposure.
- COVID-19: US State Policy Report – February 24, 2021
- There are at least two views of the Vaccination problem posed by COVID and other diseases. The distinction is made clear by the view of whether a vaccination certificate can expire. From a patient healthcare perspective, it should never expire as it is a health event that a physician would want to know.
- The healthcare problem as seen by the patient. (The patient care plan.)
- The security threat as seen by the state. (Public health or epidemiology.)
Current Use Cases
Pre-scheduled at a Pharmacy in Florida
States have found different solutions to the same problems which means that data flows might be different from state to state. If Florida pharmacists have only recently started to give vaccinations. Some times, like in the case of nursing homes, the pharmacist may give shots but the data is entered into the EHR of the nursing home. When shots are given in the pharmacy, the data entry process includes getting the payor (insurance) card at registration. The payors all have a record of the PCP and so they are responsible for sending the shot records to the PCP which then enters them into the PCP EHR. It is unclear if the pharmacy or the payor is responsible for sending the data to the IIS.
Pediatricians have been the normal source of vaccinations as these are primarily targeted to children at specific ages of development. Here the physician handles all of the shot scheduling, typically based on annual check ups. The shot records are sent to the state IIS at the same time that they are entered into the EHR maintained by the practice. Note that by 2021-02-28 that no COVID vaccine was approved for use in children.
Pre-scheduled at a Pharmacy in WA
I got a shot 2021-02-11. Here is the way I see it today. At the end I will explain why this is broken. I called (more that once) to sked a shot. I finally got on the calendar. At that point a record was made of my name and birth date. I went it to get the shot, my data was validated, the pharmacy checked my insurance card to ensure they would be paid and i was given a shot. My record was updated at that time and a label was printed out that was (in effect) a shot cred. They peeled off the print out on sticky tag an applied that to a CDC Covid-19 Card form MLS 319813_r This is the credential I could put in my wallet, but it is not the medical record. The medical record should be in the lab, the paper card is the credential. I went home i tried to avail myself of the 21st Century Cures act to download my health data. It turns out that since it was a pharmacy administering my shot, the standard pharmacy proof-of-presence was a prescription number. Since i had never been to that particular pharmacy before, i could not authenticate myself and so could not get a digital record of my shot.
So what is the problem? The medical record existed, but no method to authenticate me to the record was available. The paper form will (with any luck) be sent to the CDC which might, at some future date, actually record the event but under some privacy-enforcing de-identification code. One needs to wonder if privacy and public health will ever be able to talk to each other.
Local Public Health District Lottery
A local district receives COVID doses on a schedule that is beyond their control. It has more eligible candidates than doses and so has every one eligible sign up for a lottery. (Unlike the above case where the lottery is created by constantly scanning web sites and registering when the web site become open.) Now the health district can send out notices on vaccination as doses become available. All of the CDC cards are pre-created with the date and batch. As each person gets a shot they are given a card and told to fill in their own name and birth date. No one checks that this information is correct. At the end of the line the filled cards are entered into a local laptop and then sent to the state IIS in a batch, sometimes that day, or whenever an employee finds the time to complete the process. Whenever the state IIS has resource, they processes the received batches and send the results to the CDC. The timing of this process is evident if the vax data is reviewed and shows consistent variability by day of the week.
Virginia No Data in Advance
I got my first shot ind week ending 2021-02-12 in VA. The scheduling process uses my name and birthday as identification. When the shot was given, I was expecting something like that describe above, meaning, there should be a record of me (name and birthday) being given the shot. Instead, the nurse hand wrote the card and collected my consent form. I asked her how would the health department know that I (name and birthday) had the shot, she said someone will enter the info according to the consent form. In my case, my card (hand written, no digital record) is the cred. The information on the consent form will become the medical record. These 2 items are disconnected. With some luck, someone can read my handwriting on the consent form and enter into the system my name and birthday correctly.
Net, net, the current system totally depends on the white card as the source of truth. I am not confident that we can find a reliable downstream data source. Nor is it clear when it will become available.
Stuck in a Snowstorm in Oregon
CNN reported that Josephine County Public Health workers were returning from a mass vaccination clinic at Illinois Valley High School in Cave Junction when about 20 members of the group got stranded in a snowstorm at Hayes Hill. They had with them six leftover doses of the vaccine. To keep those doses from going unused before expiring, the workers went from car to car to offer people the chance to get a shot. An ambulance was waiting nearby in case any recipients had an adverse reaction. All six doses were administered to the waylaid motorists, including a sheriff's office employee who had intended to be at the earlier mass vaccination event but got stuck in the snow.
COVID 19 processing experience at the VA
- Received an announcement that govern shots were available at the local Veterans Administration hospital.
- Called to make an appointment, provided my name and last 4 of social # Verifying I was a veteran and had a record. (My identity was validated last October via my PII, SS#, DL and DD214)
- Arrived at designated time with 40+ in line ahead of me but having an appointment, the nurse had a master appointment schedule, I was taken to the head of the line which was a covered area outdoors.
- Was escorted into a registration station, provided my name, last 4 of social and driver’s license; I was being activated in the VA COVID registry system as receiving my first shot.
- Was then escorted to a prep area where I was informed about the shot, adverse effects and asked me questions about allergic reactions, med and foods. I was given a blank CDC COVID shot record card/credential and told to fill in the top line with my demographic info, PII; the roaming nurse verified such. At that time I was told my follow-up shot date and told to write it on the card and to write it on the information sheet they gave each person.
- After about 10 minutes was escorted into a screened in nurse injection station with CDC card in hand which was reviewed and updated by nurse with manufacture, med, lot number and his initials, all of which was entered into the computer at that time before being given a green light to go to a 15 minute rest area before being released.
- The vaccination data referencing each of my COVID-19 shots was documented, real time while I was present, by the nurse giving me my shot, to My Healthy-Vet record in the Vaccination Profile section
- Viewed vaccination profile dates and clinical data for accuracy in the Electronic Health Record sometime l later. I did not get an HL7 FHIR download of my vaccine record.
n.b. The VA has a new EHR system, but it is (in 2021-01-01) only deployed to Spokane WA hospital.
Sources of Vaccination Data
States and territories
- States, cities and territories = There are currently 63 immunization information systems across the United States, one in each state, eight in territories, and in five cities. They are funded in part by through the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases (NCIRD).
- HHS Awards Funds to Expand Immunization Information Sharing Collaboration This award is interesting in that it includes HIEs (health information exchanges) and IIS's (immunization information systems). It's unclear if this simplifies things or complexifies them. While HIE's reach 93% of the US population, they might be incentivized in some way to issue creds in a way that could be more difficult in states, which have off-loaded their reporting in some cases to sites like https://wa.myir.net/login/ which are not very good at matching users to medical records.
These are not part of the data collected by the CDC for their database. It is unclear what channel they use for reporting.
- Tribes and Indian Organizations
- Overview of Tribal Epidemiology Centers The IHCIA’s 2010 reauthorization included a provision designating TECs as public health authorities and authorizing TEC access to data held by the US Department of Health and Human Services.
- The Indian Health Service (IHS) COVID-19 Vaccine Distribution List includes the 341 IHS direct, Tribal health programs, and urban Indian organizations that choose to receive COVID-19 vaccine from IHS.
These are not part of the data collected by the CDC for their database. It is unclear if they use any channel for reporting.
- The federal government itself, primarily Defense and State, does vaccinations abroad.
- At least military health records are likely to wind up in the VA hospital system.
Clinical Health Data
- Generally user health data is collected by the Primary Care Physician (PCP) which SHOULD contain all vaccination data.
- Patients may need to take the initiative to report vaccination data to their PCP. This is a most haphazard process.
- It is only the PCP that is likely to be able to combine all the test and vaccination data for a complete COVID health statement.
- Using the 18913-5 standard for vaccination data.
- HL7 Version 2.5.1 Implementation Guide for Immunization Messaging, Release 1.5 2018 Update
- International monitor: vaccine passports and COVID status apps Ada Lovelace Institute. A tracker collating developments in policy and practices around vaccine certification and COVID status apps as they emerge around the world
- why existing HL& IPS doc is not useful for Public Health
- The international standard for identifying health measurements, observations, and documents. like COVID-19 and SARC-CoV2 data fields.