After a long day of doling out Covid-19 vaccines, workers in Utah County toil late into the night entering data on every single dose. What they don’t finish, they come in early the next morning to file before the state’s daily 7 a.m. reporting deadline.
Even though the county’s appointment system is electronic, each vaccination generates a paper record which must be entered, one at a time, into an electronic system so that they can be transmitted to the state’s immunization registry. If there’s a delay in reporting, a shot that’s in someone’s arm might look like it’s still sitting in a freezer, or worse, that it’s been lost.
“Our throughput and our vaccination capabilities are not the challenge, truly,” Aislynn Tolman-Hill, a spokesperson for the county’s health department, told STAT. “It’s really the documentation.”
The early challenges of Utah’s Covid-19 vaccination effort underscore the technical hurdles faced by health systems and public health officials as they try to track every shot they administer, a critical step in keeping state and nationwide distribution systems running efficiently. And just as importantly, that data will be central in ensuring that the life-or-death race to vaccinate communities across the country is equitable.
In Utah, as in many other parts of the country, the data reported so far on the vaccine rollout have already raised concerns. Public vaccination dashboards from the Centers for Disease Control and Prevention and the state, meanwhile, show slightly different numbers about how many vaccines have been administered. While some data discrepancies are to be expected, the inconsistencies only add to the appearance of disorganization at a time when people are anxious about limited vaccine supply.
As the confusion suggests, in the fast-moving world of mass vaccination, numbers get very fuzzy, very fast.
Tracking vaccination data accurately and in real time will be crucial to catching and correcting inequities in the distribution system. There’s concern that online scheduling systems favor those with better access to the internet, and already, reports from across the country suggest that racial and ethnic disparities are emerging in elements of the vaccine rollout. In a letter Thursday, Democratic lawmakers urged federal health officials “to monitor and address racial, ethnic and other demographic disparities in our national COVID-19 vaccination deployment strategy.”
“That’s one of the biggest concerns is, you know, is only our privileged rich people getting vaccine because they know how to get it and everyone else doesn’t,” said Jon Reid, informatics manager for Utah’s health department, adding “as the Department of Health, our job is to ensure equitable access to this.”
As of Jan. 28, 209 different facilities have reported nearly 270,000 Covid-19 shots into the Utah Statewide Immunization Information System, or USIIS, the state registry tasked with keeping tabs on the state’s vaccinations and reporting that data to the federal government. The technology used to ultimately send those shots into the system, however, can vary greatly depending on the county or provider that administers them.
In Davis County, north of Salt Lake City, the public health department took over the Legacy Events Center, an old rodeo arena that was recently outfitted with a concrete floor, to use as a drive-in vaccination site staffed by between 80 and 100 workers. Eligible residents — the state is currently vaccinating people over 70 as well as few other high-priority groups — make appointments through an online system which captures their information and creates a printable record with a QR code, which they present upon arrival. The county offers to print the document for people on site as well.
“We have almost a zero wait time in line,” Brian Hatch, the county director of health, told STAT. People pull into one of about 30 vaccination stations, receive their dose in less than five minutes and then proceed to an observation area for 15 minutes. “So within 20 to 25 minutes, they’re in and out of there with their shot.”
By the end of the week, the county will have administered about 30,000 doses total, and Hatch said the facility can theoretically deliver 20,000 shots a week at peak.
That efficiency is supported by a technical system that the county started developing in September. The QR code on the printed record is scanned by a worker with a tablet who verifies the information. After the shot is administered, the record is automatically sent to USIIS.
Another model process was developed by the University of Utah Health, whose health workers were among the first to be eligible for vaccination. The system received doses soon after Pfizer first started shipping and put its resources immediately to work.
“We had the tools necessary to get stuff set up,” chief medical officer Tom Miller told STAT. “Being a research institute, grabbing a whole bunch of minus 80 freezers wasn’t wasn’t too hard.”
Much of the back-end technical system was also ready to go, too. Travis Gregory, the health system’s director of clinical data, said that “because of the reporting being so important for public health,” a critical decision was made early on to document vaccinations for employees, which are ordinarily on a separate electronic record, in the Epic electronic health record used for patients, which has long been linked with USIIS.
Employees received emails offering them a vaccine. After opting in, their data was matched with an employee record, and that information automatically transferred to Epic. Those who didn’t have an electronic record had one created at this stage.
“That just made the schedule signup process really slick,” said Gregory. “We could sign up thousands of people really fast.”
Once the vaccine was administered, the information was sent to the state. “It really streamlines that reporting,” said Gregory.
Over 400 volunteers and employees have assisted in the administration of 24,000 doses so far.
In contrast to these automated systems, Utah County is stuck entering records manually one at a time, a process that involves some 30 people laboring on the data on days vaccines are administered. Members of the National Guard have started helping the county with data entry, and Tolman-Hill said that officials are working on finding ways to automate some of the grunt work, including scanning records.
“We’re certainly looking into anything and everything that could be helpful,” she said.
Whether filed manually or through EHRs, the crush of vaccination data has put a strain on the officials who run USIIS, who are now grappling with waves of errors flowing in from vaccination sites.
“The data quality is really now going to be our top priority and probably our top headache — probably for everyone in the nation,” said Reid of the Utah Department of Health. “Because the accurate, complete data takes a lot of manual work.”
Common errors include indicating that a person received the Moderna vaccine when they’d received Pfizer or entering a date of birth where the administration date should be.
“I’m sure we have a lot of misspelling is the other issue,” said Reid. “We just don’t have the resources to dive too much into it.”
All of these errors lead to incorrect entries in the statewide system. Reid has a team of four people working to identify and correct errors with providers. In January, the state averaged 43,000 administrations per week. That’s already a time-consuming amount of entries to comb through, and it will only grow larger as vaccination becomes more widespread.
“If we wanted to get the population vaccinated in the next six months, that would require over 200,000 doses a week” he said. “The number I’m shooting for is, can we handle 200,000 doses a week.”
Reid is optimistically looking ahead to that surge in doses, which will help the state reach herd immunity. And he recently received a grant from CDC to hire four more people to help ramp USIIS capacity and make sure the state’s data is accurate as possible.
Data entry errors are common in USIIS even when there’s not a pandemic. But the need for superior data quality usually isn’t such a pressing issue, let alone one that impacts dashboards used every day by the governor’s office and state executive directors to track mass vaccination during a pandemic.
Currently officials are looking at reporting on total vaccines administered by providers and local health districts, average time to report, doses shipped, doses on hand, doses due, and doses overdue, according to Reid.
The state is also recording demographic data. And as the rollout expands beyond the current priority groups it will “begin tracking at risk populations and minority groups to ensure equal distribution,” he said.
Utah Gov. Spencer Cox told STAT last week that he’s conscious of the need to reach people of color, including Latinos and Native Americans in his state, the population of which is overwhelmingly white.
When it came to testing, those communities were harder to reach, which meant mobile testing units had to be deployed. “And we’re doing the same thing with vaccines,” said Cox. “Making sure that we have mobile vaccine clinics that can go out into these communities and and to the people that are most vulnerable. And we’ll be able to ramp those up as as we get more doses of vaccine.”
“All of the same problems we saw with testing will happen with vaccination if we’re not intentional and thoughtful about it,” he added.