Scaling Up COVID Vaccinations: Reflections on the Science of Implementation and Spread

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Nearly every problem has been solved by someone, somewhere. The challenge is to find out what works and scale it up.”

-Bill Clinton, former U.S. President

In spite of several months of planning, the scaling up of the COVID vaccine has been challenging. Often, the scaling up of successful pilot programs and improvement projects encounter problems. Successful large scale implementation is a skill set not necessarily associated with good intentions, innovative thinking, or the size of the organization.

Stephen Dubner offers a nice introduction to this challenge in a Freakonomics Radio podcast, from early 2020.

In the last 10-15 years, a new social science concept called “Implementation Science” seeks to explain the factors leading to implementation challenges and how to overcome them. Several of these frameworks on how to increase the success of large scale implementation were combined into a Consolidated Framework for Implementation.

Here are a few major reasons that scaling up of successful pilots may fail:

  1. The pilot did not actually work (look at the actual data, not the hype).
  2. The people studied in the pilot are not representative of the general population.
  3. Efforts to scale up implementations cut corners and no longer follow key aspects of the pilot program.
  4. Scaling up does not account for limited supply of qualified staff and other inputs.
  5. Scaling up assumes the “build it and they will come” theory; that demand for the intervention will spontaneously be high. An insufficient marketing plan is included.

Over the course of our careers, as we experience or witness failed implementations, it is too easy to develop a sense of fatalism about many proposed expansions. In the case of mass COVID vaccination, our society, health care delivery system, and economy, demand that we have a different mindset. Successful implementation is hard, it is a skill-set, but it importantly reflects a “can do” mindset, not a “can’t do” mindset. It means tackling challenges head on, seeking new solutions to problems encountered, including the key challenge of vaccine hesitancy.

We at PHC thank you, and your staff, for your work on promoting COVID vaccination among your staff and in your community, in the weeks ahead.

More Infectious COVID Strain Will Require Higher Vaccination Rates

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“One of the biggest myths in medicine is the idea that all we need are more medical breakthroughs and then all our problems will be solved.”

-Dr. Quyen Nguyen, Pioneer in Fluorescence-Guided Surgery

Most recent estimates from Great Britain are that the SARS-CoV2 VOC 202012/1, also known as COVID-19 variant (B.1.1.7) is 50% more infectious than the previously dominant COVID strain. DNA sequencing of samples of SARS-CoV2 has been at very low rates in the United States, so we don’t know how quickly this strain is spreading. On Wednesday, San Diego County announced that they had detected 34 cases in the previous few days.

Fortunately, this strain is no more deadly or likely to cause serious illness than other COVID strains. It appears to be more infectious due to a higher number of particles being shed in the early pre-symptomatic or asymptomatic phase.

Unfortunately, a higher rate of infectiousness means that we will need higher rates of vaccination to achieve herd immunity and stop the spread of COVID. Some estimate that a vaccination rate of 90% will be needed to achieve herd immunity to this new strain, instead of the 70% we were counting on since March 2020. In addition, the current distance and time standards (6 feet and 15 minutes) that define high risk exposures may need to be changed as this more infectious strain spreads.

Even when we get past the current major logistical challenges involved in vaccine prioritization and distribution, given high rates of vaccine hesitancy, we have a major public health challenge ahead, which will require consistent strong communication from you, your clinicians and your staff.

By all accounts, much of 2021 is shaping up to look like 2020, from a COVID perspective.

The January 6 edition of the New England Journal of Medicine included a comprehensive overview of the many strategies that can be used to increase vaccination rates. Here is their list of recommendations for primary care clinicians:

  1. Prepare a list of common vaccine questions
  2. Investigate specific concerns of your various segments of patients
  3. Develop a list of effective responses
  4. Practice and train staff for responses
  5. Add incentives (free sports exams, prizes).
  6. Develop prompts to persuade vaccine-hesitant patients and offer compromises.
  7. Make vaccination status observable in your community

In addition, they describe how to vary the message, depending on the level of vaccine hesitancy.

The article describes the targeted strategies in more detail.

For the good of our communities, our health, and our economy, thank you for training and mobilizing your staff to rise to this public health challenge!

Our Role in Addressing Fear of COVID Vaccination

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less.”

-Marie Curie

Recent surveys have found that physicians are largely inclined to use the new COVID-19 vaccinations (80-90%), while nurses are much less inclined (30-50%), which is lower than the rate in the general public (about 60%). What is the cause of such hesitancy?

The quote above from Marie Curie, two-time Nobel Prize winner for her discovery of radioactivity and radioisotopes, is apropos to answering this question.

On the surface, the appeal to use understanding to overcome fear would seem to invoke using vaccine study data to overcome vaccine hesitancy. There is also an element of idealistic recklessness (or courage?) in this quote, since Marie Curie died of aplastic anemia, likely brought on by the radiation that she first described as a scientist. Given how little was known about radiation at the time, much less its effect on humans (DNA was identified as the basis of genetics decades later) it is perhaps not surprising that she was unafraid of radiation. In the end, her drive to generate new knowledge and understanding of the subatomic world was stronger than her fear of potential risks that would not be defined until the future.

Rosalind Franklin was another physicist to die of radiation exposure, in the pursuit of understanding. Her exquisite X-rays of crystalized DNA were the basis of determining that DNA formed a double helix, which allowed Watson and Crick to theorize on its structure. If she hadn’t died, she would have likely been a co-winner of the Nobel Prize for this work. But if she hadn’t persisted in doing radiograph after radiograph (and getting exposed), Watson and Crick would not have had the key information needed to sort it all out.

If Marie Curie had been as afraid of radioactivity as she probably (in retrospect) should have been, the nature of radiation would not have been understood for many years later. She may have lived some years longer, but her important contributions to physics would have had to wait for others to work out. I think her statement above was a reflection of courage, with some subconscious knowledge of the unknown risks, but she felt the work was so important that it outweighed these unknown risks.

The decision to use a new vaccine carries a similar balance of hopefulness and caution: vaccinate sooner to help break the cycle of infection, but potentially be exposed to a risk that is not known at this early time.

New vaccines have a long history of being treated with suspicion at first, so there is an evidence base on what helps increase vaccination rates in this setting. Interestingly, long explanations of all the ways the vaccine has been studied and found to have side effects less severe than the risk of natural infection is NOT very effective. This approach is still important, but we must realize it will not lead to mass acceptance of the vaccine.

So what does work?

Having famous, well-liked or well-respected people publicly get vaccinated and speaking up about why they are doing so is very effective. In 1956, Elvis Presley rolled up his sleeve on national television to receive the new polio vaccine. Historians say this helped increase the acceptance of this vaccine and the rate of adoption.

Making vaccination easy and matter-of-fact is another helpful tactic. Allowing social communities (like schools, churches, hospitals, and health centers) to be vaccinated as a group also increases overall vaccination rates. The combination of convenience and subtle social pressure helps overcome ambivalence.

As leaders, we can use both these strategies in our communities. Find trusted opinion-leaders (including you, the medical leaders in your community) to publicly get vaccinated and speak about it. Make it easy, make it social.

Never in human history has a vaccine been introduced so quickly nor in the face of such a raging pandemic. There may be more risk than we are aware of now, but there are compelling benefits to balance this, as a society, as healthcare leaders and as individuals.

The Origin of the N95 Mask

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“This dramatic escalation of global travel highlighted the perils of emerging infectious diseases.”

–Dr. Wu Lien-teh, talking about the role of railroads on the spread of the Manchurian pneumonic plague of 1910

Born in Malaysia and trained at Cambridge, London, and Paris, Dr. Wu Lien-teh was sent by the Chinese government to control an outbreak of almost universally-fatal pneumonic plague in Manchuria in 1910. He determined that this form of plague was transmitted from person to person by respiratory droplets and developed cloth masks to protect health care workers. European infectious disease physicians initially did not believe Dr. Lien-teh’s findings, partly due to bias against him for being ethnic Chinese. French physician Dr. Gerard Mesny and Scottish physician Arthur Jackson both refused to wear a mask in the hospital treating patients with pneumonic plague, to demonstrate their disagreement with Dr. Lien-teh’s hypotheses. Both contracted pneumonic plague and died.

Refusal to wear masks as a statement of what the person believes, with deadly consequences, is not new to COVID-19. Sadly it has a long history. Luckily, the masks initially used in Manchuria were adapted over the years into the N95 mask and associated personal protective equipment (PPE) we use today.

Dr. Wu Lien-Teh eventually traced the source of the pneumonic plague to trappers of the Mongolian Marmot, which was an endemic carrier of plague. He used a number of measures to study and control the outbreak, including mass cremation of individuals who died, which were unpopular among local officials and the local population. He had to appeal directly to the Chinese emperor for support. Like COVID-19 today, the support of the most senior leader ultimately determined if public health measures would be embraced or not, against resistance of the population.

After COVID-19 is under control, we need to think about how we train not only public health experts, but also non-scientists who may be future political leaders, about the leadership lessons and ethical tradeoffs of past epidemics to try to prevent repeating deadly mistakes of the past in the next pandemic.

Courage to Heal: A short historical novel on the life of Dr. Sidney Garfield

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Peak performers see the ability to manage change as a necessity in fulfilling their missions”

–Dr. Sidney Garfield, Founder, Permanente Medical Group

Surgeon Sidney Garfield partnered with industrialist Henry Kaiser to create what was to become the largest integrated health care delivery system in the United States, known for its high quality, its labor-management partnership, and its cost effectiveness.

In the early years, the American Medical Association and the California Medical Association sought to destroy the model and to drive Dr. Garfield out of business; Kaiser Permanente only survived due to the influence of Henry Kaiser.

Courage to Heal, written by journalist Paul Bernstein, gives a good sense of the political and personal forces that came together in the 1930s and 1940s to start the Kaiser health system, while providing a glimpse of the state of medical practice at the time.  The book highlights the skill and courage of Dr. Garfield and others who believed that everyone deserved access to preventive and curative care regardless of their ability to pay, a radical idea at the time.

This is an inspiring tribute to the ideals of medicine as a profession and a system of care.

Bringing the Patient Story Back to the Medical Record

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“A story can put your whole brain to work.”

–Leo Widrich, co-founder, Buffer

Linguists have shown that humans that do not store their thoughts or memories in written form have a remarkable ability to remember and relate long stories orally, from generation to generation.  Even with written language and now audio-visual capture of information, stories are easier to remember than a stream of facts, events or even a theoretical framework.  (The early chapters of Sapiens: A Brief History of Humankind offers a good summary.)

There is a neurologic basis for this.  Streams of facts or ideas mainly stimulate the auditory processing portion of the brain, while stories activate the deep brain structures associated with emotions and long-term memory, as well as various portions of the cortex.  A story puts our whole brain to work.

This may explain why studies of Electronic Health Records that segregate clinical tidbits into different discrete parts of the medical record decrease the ability of a subsequent reader to really understand what was going on with a patient.  The patient story is lost, making the medical record a poor communication tool.

A well written opinion article in the September 1, 2020 Annals of Internal Medicine calls on clinicians to “Restore the Story” in clinical notes.  The American College of Physicians created a “Restoring the Story Task Force” to promote this effort.  The article summarizes the attributes of an ideal clinical note:

“The ideal clinical note is more than a verbatim transcript.  It is a coherent representation of relevant data that have been sifted through and examined in the context of the patient’s life and priorities, yielding an assessment of the situation and rationale for recommended next steps.”

In the electronic health record, the two most important places for telling the story are the history of present illness and the assessment.  Utilizing the free text option in these two locations is essential to achieve this.

A Call to Action on Hypertension Control

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Join me in taking control of hypertension across our nation. Together, we’ve got this.”

–Jerome M. Adams, Surgeon General of the United States

Control of hypertension has been shown to reduce heart attacks and strokes, reducing both morbidity and mortality.

On a population basis, blood pressure control in the US has worsened from 53.8% under control in 2014, to 43.7% under control in 2018 (JAMA, September 22/29, 2020). This has led the U.S. surgeon general to declare a Call to Action on Hypertension Control. The goal of the U.S. Department of Health and Human Service’s Million Hearts campaign is to have 80% of patients with hypertension under good control, defined as a blood pressure of under 140/90.

Unfortunately, COVID-19 is likely carrying us further away from this goal. Patients with telemedicine visits only have their blood pressure assessed only 9.6% of the time, compared to 69.7% of the time during office-based visits. (October 2, 2020 edition of JAMA Network Open Access)

About 25% of adult PHC members have a diagnosis of hypertension. From pharmacy data, 17% are taking at least one blood pressure (BP) medication. Their level of blood pressure control, in 2019, averaged around 65%, much better than the 43.7% rate found nationally by JAMA, but far below the 80% goal of the Million Hearts campaign. This 80% goal is achievable, as shown by six of our larger primary care providers whose hypertension control rates were better than 80% last year:

Fairchild Medical Center (Yreka, Siskiyou county):       89%

Northbay Center for Primary Care (Solano county):      84%

Kaiser Permanente, in Marin and Sonoma counties:    82%

Shasta Community Health Centers (Shasta county):    82%

Petaluma Health Centers (Sonoma county):                  82%

Sutter Lakeside (Lake county):                                       81%

Before the 1980s, diabetes self-management (including patient monitoring of their own blood sugar), was NOT the standard of care. Patients had their blood sugar measured in the laboratory or in the doctor’s office. Since the 1980s, it has become standard of care for all persons with diabetes to monitor their own blood sugars.

Blood pressure monitoring today is where blood sugar monitoring was in the 1970s. It is time to empower patients to monitor their own blood pressure at home. One of the strategies listed by the Surgeon General is to “Empower and equip patients to use self-measured blood pressure monitoring.” The Million Hearts campaign describes the evidence base showing better blood pressure control with home monitoring, combined with a medical team that uses this data to take action.

Partnership HealthPlan of California (PHC) covers home blood pressure monitors for our members. These can be obtained from a community pharmacy with a prescription/order from the Primary Care Physician (PCP), until December 31, when the state pharmacy carve out kicks in. Medi-Cal Rx will be administered through the Fee-For-Service (FFS) delivery system. For more information and to apply for your Practice ID number, visit their website. Additionally, we have a direct distribution pilot for BP monitors on a first-come, first-served basis. Interested providers will need to complete the DME Request Form on our website. This program will be continued and expanded in the year to come.

Petaluma Health Center had a best practice with us. Instead of reminding their clinicians to remember to prescribe BP monitors, they sent a text message to all their PHC patients with hypertension and asked them to respond if they wanted a home BP monitor. This was an effort to reduce the exposure to COVID-19, by reducing the trips into the office to check their blood pressure. About 10% of those texted responded with a request for a BP monitor. Petaluma Health Center set up a streamlined system to send the orders to PHC (through our direct distribution pilot), and we delivered the devices directly to the patients’ home.

We hope you will consider an active outreach campaign like this, for your patients with hypertension. As our Surgeon General says, “Together, we’ve got this!”

Informed Consent: Alternatives to “Weighing Risk and Benefits”

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Beware of words – they are dangerous things. They change color like the chameleon, and they return like a boomerang.”

–Dr. William Osler

The words we choose to use in our interactions with patients convey underlying meaning. Sometimes this underlying meaning can affect patient decision-making in unintentional ways.

In an editorial in the September 8, 2020 edition of JAMA, entitled “Improving Physician Communication About Treatment Decisions: Reconsideration of “Risks vs Benefits,” the authors argue that the commonly-used phrase “risks vs benefits” implies that harms from a procedure are possible, but the benefits are assured. This asymmetry would be corrected by using the phrase, “weighing the chance of harm and chance of benefit” of a particular intervention.

One physician responded to the editorial, noting that additionally, the “chance of harm if nothing is done” must also be accounted for, if a complete picture of the probabilities to be weighed is to be presented.

This may be the most accurate presentation of everything a patient must consider, but humans have difficulty understanding what the probability of an outcome really means. Experts in shared decision-making recommend using visual representations of probability, or comparing the probability to something more understandable, like the probability of a car accident while driving home.

Such devices may still be too hard to grasp for patients seeking certainty when making decisions. Such a desire for certainly is a big driver of vaccine hesitancy, in which the absence of certainty of safety of an intervention is used to default to not taking action.

Logically, a decision of whether to act or not should balance the chances of harm or benefit of the intervention, accounting for the chances of harm of no action. In reality human brains are generally wired to choose to not take action if they are not certain of what they want. Psychologists call this omission bias, the tendency to favor an act of omission (inaction) over one of commission (action).

Of course, this is just one of many biases, which come into play in the clinical interaction between clinician and patient that may impact the patient’s willingness to undergo an intervention.

Nonetheless, changing our language from “weighing risks vs benefits” to “considering the chance of harm and the chance of benefit of the intervention with the chance of harm of doing nothing” may help some patients weigh their options in making therapeutic decisions.

Managing to Optimize Quality: The Case of Southcentral Foundation

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“So you may be reading this and thinking,
‘Yes I do all of those things – there’s nothing to learn here.’
My challenge back to you is, really?”

-Karen Barnett, NHS (England), reflecting on the success factors of Alaska’s Southcentral Foundation

Southcentral Foundation, a tribal health center in Anchorage, Alaska, is recognized as one of the world’s leading models of health care redesign and is a recipient of the 2011 and 2017 Malcolm Baldrige National Quality Award, the only health center in the United States with this record. Their Nuka System of Care is based on a Native Alaskan value framework. “Nuka” is an Alaska Native word that means strong, giant structures and living things. It is also the name given to Southcentral Foundation’s whole health care system, which provides medical, dental, behavioral, traditional and health care support services to more than 65,000 Alaska Native and American Indian people.

In the Nuka System, strong relationships between primary care teams and patients (known as customer-owners) have helped manage chronic diseases, control health care costs, and improve the overall wellness of the people they serve. Recognizing that individuals are ultimately in control of their own lifestyle choices and health care decisions, Nuka focuses on understanding each customer-owner’s unique story, values and influencers in an effort to engage them in their care and support long-term behavior change.

Southcentral Foundation’s management theory can be broadly defined as “tight-loose-tight.”

“Tight” management means that there is considerable structure that is set by leadership that employees must adhere to. “Loose” management means that there is no rigid structure in place and employees have more flexibility to do as they see fit. Their approach to management employs both types.

There are two major things that are “tight” under this management style.

The first is the overall philosophy and the broad picture of how they approach health care. All care teams must follow the organizational philosophy and operational principles. They must practice relationship-based care and strive to understand the story of each customer-owner they serve. They must make use of communication techniques such as advocacy and inquiry to facilitate the formation of the strong relationships, which are at the core of the Nuka System of Care.

The other element of clinical care that is “tightly” managed is outcomes. Each care team has certain health outcomes, for the panel they care for, that they are responsible for reaching. These health outcomes are tracked and are compared to national benchmarks; care teams are able to view their panel’s status on these outcomes at any time. The team is accountable for reaching these outcomes and if they fail to do so, management will step in and determine how best to support them so they can.

Management of all other aspects of clinical care at Southcentral Foundation is “loose.” This means that the specifics of how the team operates, and how they organize their work day-to-day, is mostly up to the team itself. So long as they are following the philosophy of the Nuka System of Care, and achieving the outcomes they are accountable for, teams have considerable freedom in how they operate. They are free to innovate and experiment. Their management does track what teams are doing in these areas, but only so that practices that are working well can be spread further across the organization.

This “tight-loose-tight” philosophy of management has allowed their care teams a great degree of flexibility while maintaining the values of the Nuka System of Care, and supporting good health outcomes for customer-owners.

Southcentral Foundation shares its best practices on leadership, management, quality, and COVID-19 on its website, in publications and at conferences.

Staying Connected, Virtually

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“I define connection as the energy that exists between people when they feel seen, heard, and valued; when they can give and receive without judgment; and when they derive sustenance and strength from the relationship.”
–Brene Brown

The physical separation forced on us by COVID-19 has led us to better value the connections we have with each other. Video connections can help (compared to email and phone calls) but nothing beats the in-person sighting of a friend or family member, even while wearing a mask.

Not shaking hands or hugging can take a toll, though. Human touch between friends is associated with release of oxytocin, the hormone that stirs maternal and paternal bonding to children. In a sign of the times, blankets containing weighted glass beads that mimic the effect of a hug have seen increases in sales during the pandemic.

Seeing warm friendly smiles from co-workers and strangers is also a rare event.  Seeing a smile triggers the brain’s mirror neuron system, the physiologic foundation for empathy, a key component of successful clinical and professional interactions as well as a promoter of positive feelings.

For health care professionals, the increased use of virtual patient visits, and virtual meetings with colleagues, can impact our professional satisfaction and identity. There are many ways to mitigate this:

  1. Use video instead of telephone for interactions where possible
  2. Ensure video setups allow consistently good quality video and audio
  3. Adjust content to allow more back and forth communication
  4. Use expressive eye contact when interacting while wearing a mask or on a video call