COVID-19 vaccine generic

Fort Belvoir Community Hospital sets up a COVID-19 vaccination clinic at the Community Center, Tuesday. The Hospital continues phase 1B, vaccinating the garrison first-line workers and medical staff.

From local health departments to the coordinator of Virginia’s vaccine campaign, there was no debate that VAMS wasn’t working.

The software system, provided to states by the U.S. Centers for Disease Control and Prevention, was meant to offer a coordinated platform for scheduling, tracking and reporting thousands of immunizations. But within weeks, it was clear the system had major problems.

One of the biggest was its inability to create closed vaccine clinics for Virginians who registered for the shots — events that were only visible in the system to targeted groups (teachers or seniors, for example). In practice, this meant that anyone who logged into VAMS to book an appointment could view and register for clinics anywhere in the state, and sometimes even farther.

Breanne Forbes-Hubbard, population health manager for the Mount Rogers Health District, said some residents living near the border of West Virginia called last month to complain after they were able to book appointments at hospitals across the state line — and then received a notice that those appointments had been canceled.

“We’d have to explain, ‘You can’t go to a West Virginia hospital — it’s just for their employees,’” Forbes-Hubbard said. But health departments across the state still found themselves fielding angry calls or being forced to turn away residents when they showed up at the wrong clinic. On top of that, many health officials complained the system was hard on users, with frequent error messages or emails that went straight to spam folders. Registering on VAMS required a user profile and two-step authentication, and it couldn’t distinguish between first- and second-dose appointments.

“We just didn’t use it,” said Dr. Colin Greene, director of the Lord Fairfax Health District. “We got a look at it and decided it really wasn’t practical.”

When Virginia decided to phase out the software in late January, it wasn’t alone. The MIT Technology Review reported that many states were either abandoning the program or had never used it to begin with, instead opting to build their own registration systems.

Virginia turned to PrepMod, software developed by a Maryland-based company that advertises an “end-to-end electronic system” for pandemic management. Virginia Department of Health spokesman Logan Anderson said Wednesday that the state paid $746,195.65 for the program, which “went live” on Jan. 21 “with a handful of pilot sites.”

But as local health departments transition to the software, it’s become clear that PrepMod is presenting just as many challenges as VAMS — forcing many districts to abandon the platform or develop their own workaround solutions.

The most visible problem is the system’s inability to create one-time registration links for its users. PrepMod was seen as an improvement over VAMS in part because it does allows health officials to create closed clinics that — in theory — are only viewable for targeted groups.

In reality, though, links sent through PrepMod are completely shareable and can be used over and over again. Multiple health officials told the Mercury that it can cause a domino effect, with links circulated across text messages or community Facebook groups.

To make things even more complicated, appointments made through a shared link are still confirmed by the system. It often ends in disappointment — including at a clinic last week in Norfolk where some older residents waited more than an hour in line for a shot they never received.

“We saw the writing on the wall about this for several weeks before we were asked to transition from VAMS to PrepMod,” said Ruth Morrison, the policy director and Phase 1b vaccine lead for the Richmond-Henrico Health District. Before it fully launched the program, the department decided to test PrepMod exactly as it was intended to be used for a single vaccination event — anticipating that links would be shared widely throughout the community.

“Essentially, our forecast came true,” Morrison said. Only 57 percent of the appointments booked for the clinic were residents who originally received the link, even with the department monitoring the system and reaching out to eligible recipients to make sure they could schedule a slot. The department had organized the event for people 65 and older, and it didn’t cancel appointments for anyone who fell into that category — regardless of how they had gotten the link.

But Morrison said it took up additional staff time and dissuaded the district from using PrepMod on its own. Because of the link-sharing problem, Richmond-Henrico has cobbled together a workaround solution using RedCap, another software program offered through VDH. With RedCap, users get an initial registration link and enter their basic information into the system, which then sends them another — nonshareable — link to finish the process in PrepMod.

Morrison said the process has been most successful with tech-savvy residents who booked their first-dose appointment through VAMS before the district transitioned away from the software. Officials also used the workaround to help register thousands of seniors for two vaccination events at the Richmond Raceway on Jan. 30 and Feb. 2.

Around 75 percent of the appointments were booked online, but the system isn’t totally seamless. Morrison said the department had to assign an employee to manually track the number of appointments booked for different times and remove those slots online once they were filled. At the same time, the department was calling to register seniors on its vaccine waitlist who weren’t able to navigate the online system.

“We’re both really proud that we’re continuing to facilitate these fixes, but we also know it’s falling far short of our own goals for doing that at scale,” Morrison said. Anderson, the VDH spokesman, said the agency is working with PrepMod on “enhancements” to the system, including individual registration links. But the timeline for those improvements is still unclear.

“This enhancement is in our testing environment right now and we hope to deploy it to production in the next couple weeks,” he wrote in an email on Wednesday.

Local health officials are worried that the urgency they feel on the ground isn’t matched at the state level. Multiple health departments pointed out that their employees are on the frontlines when the state’s registration system forces them to cancel appointments for seniors and other vulnerable residents. But Morrison said it’s also an issue of equity and scale.

For Richmond-Henrico, setting up thousands of vaccine appointments through a system that requires extensive manual oversight takes hours of staff time that would otherwise be dedicated to other responsibilities (which, for local health departments, still include testing, contact tracing and enforcing the governor’s executive orders, along with running vaccination clinics on the ground and educating the public about the vaccine).

For other districts, Morrison said that might not be feasible. Local health departments are already using a slew of different systems to register their residents for the state’s limited supply of vaccine. Some, like Prince William, only recently began the process of transitioning away from VAMS. Right now, the district is using its own locally developed registration form along with a call center to bridge the gap as they prepare to transition to PrepMod.

But the federal system is still sending out automated emails that are confusing to some residents. Tom Menzies, a Nokesville resident, sent the Mercury a message intended for his 80-year-old mother-in-law that listed two separate sets of instructions depending on whether the reader was booking their first- or second-dose appointment.

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An email from the Prince William Health District lists a complicated set of instructions for booking a vaccine appointment. (Courtesy of Tom Menzies)

Menzies said the email didn’t even apply to the family because his mother-in-law isn’t eligible for her second dose until later in February. But without careful reading, it still prompts readers to register for a vaccine through VAMS — even though Menzies said there are no more available appointments listed in the system.

“I just worry that we’re trying to get these elderly people vaccinated and we’re sending out things that are totally inappropriate for them,” he said. “That email may be understandable to a 40-year-old, but not for an 80-year-old.”

The inconsistency between health districts, combined with varying levels of local resources, make the vaccination process even more complicated for many Virginians. As the Richmond Times-Dispatch reported, the state still doesn’t have a centralized website or call center to connect residents with vaccine.

Morrison pointed out that not all districts have the time or staff to develop workaround solutions to PrepMod, which leaves them reliant on the system — and vulnerable to its challenges — or inhibits their ability to organize wider-scale clinics. Some districts have turned to paper registration, limiting the number of people they can vaccinate at an event (and forcing employees to manually enter vaccinations into the state’s database once a clinic is over).

“It’s been a Herculean effort, but Herculean is not scalable,” she said. “There’s only so many paper registrations we can do. There’s only so many poor humans I can ask to manually monitor RedCap. I think that we have done double, if not more, of what we would have otherwise even weeks ago told ourselves was possible given the limitations of our tools. But it’s not going to enable us to pick up the pace.”

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