Never in the history of electronic health records has there been a more important public health recordkeeping task than the one that is at hand at this very moment in the nation’s history: tracking COVID-19 vaccinations.

As a result of this all-important development, EHR vendors from across the industry have been preparing their products and their healthcare provider organization users to make sure that when a patient receives this critical vaccination, it is recorded correctly, pushed to the necessary parties, and is accessible now and in the future by all the appropriate caregivers.

Healthcare IT News discussed this huge issue with top executives at Allscripts, athenahealth, Cerner, DrChrono, Epic, Greenway Health, Meditech and NextGen Healthcare.

They offered insights into preparations that began earlier this year, described the changes they’ve made to their EHR systems and discussed how they’ve been rolling out – and helping train for – these new design and workflow changes.

Preparations and initial thoughts on the vaccines and EHRs

Meditech has had its Coronavirus Task Force up and running this year, assisting clients through all stages of their pandemic response.

“As word of a vaccine started to circulate, we were already working with customer advisory boards to determine what steps would be needed for preparation, looking to our Immunization Registry and patient registries as solutions for tracking and reporting on vaccine administration,” said Helen Waters, executive vice president at Meditech. “We are fully vested in ensuring our customers are well-positioned to hit the ground running.”

The EHR maker said of course its work required guidance from the CDC, HHS, public health officials and industry organizations. These efforts ramped up on Oct. 29, when the company attended the CDC Operation Warp Speed Town Hall.

"The CDC informed us of the vaccine codes that would be available and urged vendors to build these codes into their system ASAP."

Helen Waters, Meditech

“Here, the CDC informed us of the vaccine codes that would be available and urged vendors to build these codes into their system ASAP,” Waters explained. “Since the codes were released on Nov. 12, we have updated our customers by sharing these codes along with vaccine guidance. Also, we immediately began working with our interoperability team to review the CDC’s HL7 draft specifications.”

Meditech continues to attend weekly EHRA/CDC breakout meetings to monitor evolving updates provided by the CDC. In addition, it is collaborating with its Meditech User Group, MUSE, and soliciting feedback from its customer base through email surveys.

“Providing the solutions and guidance to support our customers through this critical venture and bring an end to this pandemic remains Meditech’s top priority, with all divisions fully invested in these efforts,” Waters said.

Getting provider clients up to speed

Cerner began preparing for potential COVID-19 vaccines back in April as cases were rising in the U.S. It then ramped up efforts by mid-summer to make sure its solutions and clients were ready.

At that time, Cerner recognized that some of its clients would play a community-wide vaccination role and would need a patient-first strategy that included tools outside of the company’s core EHR workflow.

“When it became clearer in October that an approved vaccine was likely in early 2021, we engaged with the CDC and some of its information technology suppliers in order to successfully interoperate with federal and state registries,” said Dr. David Nill, vice president and chief medical officer at Cerner. “We needed to make sure that our clients were ready on the IT front to handle such a monumental and important task.”

Cerner was able to put in place many of its model recommendations for the fall flu campaign, gaining insights to modify the workflow based on recommendations for COVID-19 vaccine administration, he added.

At NextGen Healthcare, preparations for vaccine administration and reporting began several months ago. Dr. Robert Murry, chief medical information officer, said the EHR vendor initially focused on the four areas most important to its ambulatory clients:

• How to equip the EHR to be able to document vaccine administration (with new CPT/CVX codes, inventory control, VIS sheet, etc.) for large numbers of people, both in the context where the patients are current patients and where they may not be.
• How to equip the EHR to be able to report to appropriate agencies the vaccines that the practice administers, for example, a state immunization registry.
• How to equip the EHR to be able to do electronic case reporting of COVID-19 (and eventually immunizations, a kind of alternate reporting mechanism).
• How to equip the EHR, if needed, to be able to report any adverse outcomes from vaccine administration.

From Jan. 29 to today

EHR company athenahealth has been focused on rapidly responding to the COVID-19 pandemic and supporting its customers all year.

“We made the first COVID-driven changes available to all our practices back on Jan. 29 when there were only a handful of confirmed cases in the U.S.,” said Paul Brient, chief product officer at athenahealth. “We deployed COVID screening questions, diagnostic test orders and direct links to the latest CDC recommendations to all our providers overnight.”

"We engaged with the CDC and some of its information technology suppliers in order to successfully interoperate with federal and state registries."

Dr. David Nill, Cerner

The vendor is fortunate to have a cloud-based, single-instance EHR that enables changes to be made quickly and immediately available to all provider clients, he added.

“Since then, we have pushed out approximately 150 updates ranging from updated assessment content to align to initial CDC travel and exposure guidance, to updated code sets for COVID-19, to patient testing and risk dashboards for our practices to monitor their panels, to workflow enhancements for remote and in-car check in – all delivered immediately in the cloud to the entire athenahealth network,” he explained.

The company’s preparedness for a COVID-19 vaccine began in spring 2020. It kicked off a research effort to understand how its practices were managing their patient populations with risk stratification, patient outreach and testing protocols. It also spent time learning what it could from experience with past flu vaccination efforts. All these learnings are foundational to identifying and engaging patients as COVID-19 vaccines become available, Brient said.

“As more details of vaccines emerge, we have a team of subject matter experts working to understand the requirements and distribution guidelines defined by the federal government and states in order to provide best practice workflow recommendations and support to our practices,” he said.

“This includes staying abreast of registry updates, partnering with clients that are participating in early vaccination efforts, and making updates to our global compendiums and code libraries as soon as they are available.”

Talking with HHS, the CDC and Warp Speed

Allscripts has been participating in conversations with HHS, the CDC and Operation Warp Speed through the course of the pandemic, most recently meeting weekly to address the need to track and report vaccine administration.

“The good news is that there are no changes yet from a federal perspective that require EHR development because we have met the existing ONC certification requirements associated with connectivity to immunization registries,” said Leigh Burchell, vice president of government affairs at Allscripts.

“The only area in which we are finding ourselves having to do new development specific to tracking the COVID-19 vaccines is where some states are requesting the transmission of unique data elements. We certainly favor a more consistent approach rather than the state-by-state adjustments to what is necessary to be reported.”

"All of the workflows, safeguards, handoffs, inventory controls, billing mechanisms, automated reporting, etc., that are currently well-known will be utilized for COVID-19 vaccines as well."

Dr. Robert Murry, NextGen Healthcare

At Greenway Health, the primary concern is ensuring its healthcare organization clients have what they need to properly document immunizations and communicate with patients and government bodies seamlessly without any workflow disruptions.

“As pharmaceutical companies began their efforts to develop COVID-19 vaccines in earnest with Operation Warp Speed, Greenway Health simultaneously initiated a cross-company initiative to ensure our two EHR solutions were enhanced to support our ambulatory care providers as they began to administer the vaccines,” said Dr. Michael Blackman, chief medical officer.

In parallel, Greenway Health participated alongside other EHR vendors in Electronic Health Records Association-led discussions with the CDC, HHS and the state immunization registries to stay abreast of the fast-moving events related to the rollout of the vaccine. As an industry, it’s vital that EHR vendors all fully understand and meet the government’s data requirements that are required by providers to fulfill, Blackman said.

Creating custom fields

Daniel Kivatinos, COO and co-founder of DrChrono, said his company’s product is a flexible software platform.

“The platform has an electronic medical records app with powerful technology that enables a medical practice to build a practice in a bespoke way,” he said. “With different options for tracking fields, a practice for example can select a ‘custom field’ creating a field tied to the medical record for ‘COVID-19 vaccines’ allowing data points and record keeping.”

DrChrono also offers other fields that can be created in the custom note, along with tailored tagging. Depending on the practice, a care team can configure the EHR to best suit their needs, he added.

How current efforts are coming along

At EHR giant Epic, the company recently released software updates specific to the COVID-19 vaccine. Dr. Nichole Quick, who works on the clinical informatics team at Epic, explained that these updates include:

• Automatic scheduling of follow-up appointments. Patients are reminded through MyChart to come back for their second dose at the right time based on which manufacturer’s vaccine they received. For example, Pfizer’s vaccine requires a second dose 21 days after the first, while Moderna’s vaccine requires a second dose 28 days after the first.
• Decision support tools. New reminders ensure that patients receive the correct vaccine when they return for a second dose.
• Additional support for mobile workflows in mass vaccination settings. Updates to Epic’s mobile app, Rover, are designed to make it simple to track vaccine administrations in mass vaccination and drive-through sites.
• COVID-19 vaccine analytics. Epic created specific metrics to help healthcare organizations keep track of things like how many people have been vaccinated and who still needs to come in.
• Vaccination status in MyChart. Patients can complete pre- and post-vaccination questionnaires and share their immunization status with their healthcare providers, employers, schools and others.

The vendor is adding these updates to an array of tools, Quick said, that customers already use to facilitate and track tens of millions of annual vaccine administrations:

• Vaccine prioritization. Health systems can identify priority patient populations for vaccination based on criteria such as age, risk factors and occupation.
• Patient outreach. Healthcare organizations can use MyChart to send targeted notifications and communications to patients. Patients can use MyChart to schedule their immunizations and receive reminders to come in for both their first and second doses.
• Coordination of immunization across healthcare organizations. Using standards-based interoperability, Epic can share vaccine administration data with other healthcare organizations. For example, patients may receive their first and second vaccine doses in different locations – getting their first dose in a pharmacy and their second dose in a clinic.
• Efficient mass vaccination. The software is designed to support mass immunization efforts, such as flu shots and pediatric immunizations, in traditional and non-traditional care settings.
• Post-vaccination surveillance. Providers can use Epic to communicate with patients and track potential side effects and safety indicators. The software can collect adverse event data for submission to the CDC’s Vaccine Adverse Event Reporting System, or VAERS. It can also identify affected patients if a vaccine is later recalled.
• Public health reporting. Epic helps healthcare organizations share vaccine administration data electronically, in near real time, with state and local Immunization Information Systems, public health agencies and tribal health departments.

A holistic approach to vaccines and EHRs

Meditech said it views vaccine distribution holistically, taking into account the importance of patient safety, the speed with which this has to happen, the volume of individuals who are going to need to be vaccinated, and the timeframe and sequence of the vaccine requirements.

“Our approach is to remain agile, as there are a number of factors to consider, including the different vaccine manufacturers, eligibility phases by state, whether the patient is known or unknown to a facility, whether the patient has comorbidities and risk factors, and where the vaccine will be administered,” said Waters of Meditech. “Vaccine distribution requires careful collaboration across all venues of care, as well as across all distribution sites across the community.”

"We have a team of subject matter experts working to understand the requirements and distribution guidelines defined by the federal government and states in order to provide best practice workflow recommendations and support to our practices."

Paul Brient, athenahealth

To guide its clients, Meditech is providing best practice guidance and scenarios for vaccine administration across each of its integrated care areas (for example, practice, acute, ED, LTC and clinics) to ensure the best possible outcome, Waters added.

“We understand that vaccine administration is not a one-size-fits-all approach, so we’re preparing our customers for a variety of scenarios,” she said. “As frontline workers will be among the first vaccinated, we’re tracking them in our EHR. Registries will be available to identify other eligible patients for vaccine distribution according to phase-based guidelines and FDA and CDC recommendations.”

For those patients known to an organization, clinicians benefit from embedded clinical decision support, which helps identify patients who are high-risk or immunocompromised, including those with severe allergies or pre-existing conditions and women who are pregnant, she said. Clinicians can view comprehensive EHR data, including allergies and medications, to identify potential risks or conflicts based on FDA guidelines, she added.

A mobile system to gather vaccine info from anywhere

“In addition, they can see if a patient is under treatment for other conditions,” Waters explained. “We are also providing a short form, web-based mobile solution that supports the capture of the COVID-19 immunization quickly from any venue – such as a drive-up site – without an appointment and medical record on file. This is particularly important for high-volume vaccination sites, where the patient is not always known to the health system.”

Since the vaccine will be distributed in two doses, it is equally important to accurately track and share which dose was given and when. Meditech is enabling its clients to track vaccine distribution across its EHR and communicate important distribution details with state, federal and third-party sources, including distribution date, dose and manufacturer, Waters said.

“Per CDC guidelines, our system will produce a certificate as proof of the individual’s vaccination to present as required,” she said. “We also offer a bidirectional immunization registry to report vaccine administrations to the state, and to verify whether a patient has received a first dose elsewhere and which pharmaceutical company manufactured that dose.”

"We certainly favor a more consistent approach rather than the state-by-state adjustments to what is necessary to be reported."

Leigh Burchell, Allscripts

But the safest way to ensure a patient receives the correct second dose is by having that patient return to the same location, Waters contended. To encourage this, Meditech’s scheduling solution includes inherent decision support to drive the vaccine appointment sequence, with proactive confirmation and reminders shared with the patient, she explained.

“Finally, we are making it easy for our customers to seek appropriate reimbursement from a program or plan that covers related COVID-19 vaccine fees by patient, without charging the patient,” she said. “Our emphasis is on achieving these goals as efficiently as possible. This will be a large-scale endeavor, and creating solutions that work for a variety of scenarios is imperative. We are approaching this challenge as an opportunity to support our customer needs in an agile manner.”

Model workflow recommendations

Cerner is preparing end-to-end model workflow recommendations for U.S. and non-U.S. healthcare organization clients that incorporate patient outreach, scheduling opportunities, clinician administration best practices, billing, and reporting and analytics tracking after administration.

Reminder outreach is essential because some COVID-19 vaccines require two doses for full efficacy, said Nill of Cerner.

“The recommendations also can include an optional mass vaccination solution at no cost to our clients, helping to supplement rapid vaccination without sacrificing safety checks or administration documentation,” he explained. “Mass vaccination procedures help make it quick to register patients, identify vaccines needed and document administration of vaccines at a large scale.

“For example, Boston Children’s Hospital has successfully used Mass Vaccination this fall to expand its flu vaccination efforts to its parking garage and additional non-office based clinics.”

The EHR maker has reached out to clients big and small, urban and rural, to understand their plans and best support and prepare their EHR domains appropriately ahead of receiving the vaccine, Nill added.

“In addition, we have offered several webinars, office hours and client workflow discussions to prepare the ideal socially distanced workflow, including drive-through vaccination,” he said.

Working on some of the very first vaccinations

Athenahealth has healthcare organization clients participating in some of the first vaccinations. Even before the emergency use authorizations were approved, and as NDC, CVX and MVX assignments were being finalized, the EHR maker updated its drug compendium to include available COVID-19 vaccine orderables. Brient said the company has been working to understand how best to support these early sites and respond in near-real time to make sure they are successful.

“We will continue to stay very close to the evolving guidance and protocols from CMS,” he said. “In addition, we are examining our entire vaccine and patient management workflow so that we can best support our clients in this very important and unique effort. Both the transition to high numbers of telehealth visits and the high volume of COVID testing have necessitated important changes to our software.”

"As pharmaceutical companies began their efforts to develop COVID-19 vaccines in earnest with Operation Warp Speed, Greenway Health simultaneously initiated a cross-company initiative to ensure our two EHR solutions were enhanced to support our ambulatory care providers as they began to administer the vaccines."

Dr. Michael Blackman, Greenway Health

The high volumes of vaccines (and unique requirements such as two-dose vaccines) similarly require changes to the core athenaOne workflows to allow practices to operate optimally, Brient added.

“We have a cross-divisional working group that is considering all our clients’ diverse needs and is spearheading enhancements and workflow guidance across a myriad of use cases,” he noted. “This includes identifying patients, or healthcare workers, who are high priority for a vaccine; engaging patients around COVID vaccination; managing the coordination and scheduling of patients across the two vaccine doses; properly documenting vaccinations according to guidelines; and reporting across clinical measure, registry and billing needs.”

All enhancements will be deployed immediately to all clients as soon as they are available, he added.

Following what works

At NextGen Healthcare, the vaccine administration workflow will be identical in the NextGen Enterprise EHR to other vaccines.

“As an ambulatory EHR vendor, we have thousands of practices administering a variety of vaccines currently, with some practices administering hundreds of vaccines a day now – for example, large pediatric practices,” said Murry of NextGen Healthcare. “So all of the workflows, safeguards, handoffs, inventory controls, billing mechanisms, automated reporting, etc., that are currently well-known will be utilized for COVID-19 vaccines as well.”

The EHR and population health tools enable providers to document the particular vaccine provided to each patient. Once the reporting requirements at the state and federal level become available, the mode of transfer of this data and the specific data elements can be determined, he said.

The most important thing is that – at least at this point – there should not be major changes to EHR workflow, said Blackman of Greenway Health.

“Clinicians should be able to administer vaccines the way they always do, and our products can transmit this information to state immunization registries,” he said. “There are certain new optional data elements the CDC is requiring from registries, such as identifying demographic priority groups. The registries may, in turn, require these additional elements from providers.”

"Most of the changes we’ve made to the software that are specific to the COVID-19 vaccine are turned on automatically, so there’s very little manual setup involved – allowing our customers to focus on adjustments that are specific to their organization."

Dr. Nichole Quick, Epic

The vendor said it continues to monitor the situation closely as this aspect is still in flux.

“From a product development standpoint, we are making sure that the clinical terminology sets our products rely on include the necessary drug and procedure codes to support the COVID-19 vaccines, and that our interoperability connections with state registries continue to facilitate immunization reporting,” he noted.

Rolling out changes, training, looking ahead

Over the past several weeks, Epic healthcare provider organization clients have joined webinars led by Epic experts who have walked through system setup and recommended operational workflows.

“Most of the changes we’ve made to the software that are specific to the COVID-19 vaccine are turned on automatically, so there’s very little manual setup involved – allowing our customers to focus on adjustments that are specific to their organization,” Quick explained. “We’ve also published written guidance that ranges from high-level, executive-facing recommendations to detailed technical instructions.”

Most of the development for the COVID-19 vaccine already is complete, and the final updates will be finished and available to clients worldwide by the end of December, she added.

Training is the key to success

Meditech’s most important concern has been determining how to record the vaccine data and leverage the depth of an integrated EHR as efficiently as possible.

“We’ve supplied customers with build guidelines for new vaccine codes and easy access to frequently asked questions to make them aware of preparations they can make today to be ready to administer these vaccines as they become available,” said Waters of Meditech. “Training is the key to success. Our customer service team works with customers daily on training and preparedness to ensure content has been updated and modified to reflect this guidance.”

Key guidance includes how to enter data quickly into the system and how to create appointment reminders to assist with COVID-19 vaccination preparation. Meditech also is training clients on its new mobile offering for high-volume vaccine administration locations for individuals who are not patients of a health system.

“One of the benefits of our EHR is its flexibility,” Waters contended. “As updated guidelines become available, we will continue to proactively communicate with our customers through a variety of channels.”

Training and coaching

Right now, athenahealth is working jointly with its clients that are participating in early vaccine distribution to understand their needs and support them as those needs evolve, Brient said.

“A key element of this work is to formally document our learnings so we can provide training and coaching for clients as we roll out enhancements and workflow recommendations,” he said. “This training is provided in informative best practices guides within our software. As we did in the early days of the COVID-19 pandemic, we will make these enhancements immediately available to all our clients across our cloud-based EHR as soon as they are ready.”

The goal is that most users will be able to adopt these changes without training, but for users who need training or have unique workflows, the company has named customer success managers who can provide any additional support clients need to begin successfully administering, managing and recording vaccines, he added.

Since DrChrono has a cloud-based EHR, it is able to roll out new features and enhancements every week; it trains users on new features weekly via ongoing webinars, posting information to its YouTube channel and putting updated content in its knowledge base.

“We have a dedicated account management team that works to keep our user base informed,” Kivatinos said. “We are accustomed to making changes fast; for example, when COVID-19 hit the United States, the DrChrono team created a large effort quickly to roll out a telehealth solution, creating a telehealth offering within a short window and training our user base on the telehealth offering.”

Coding, tracking, transmitting

Murry of NextGen Healthcare said most users do not need additional training since the workflow is similar to what they already use for vaccination management and reporting.

“The key difference will be new specific COVID-19 coding,” he explained. “Tracking would need to be improved to strip out, document and record only COVID-19 vaccination information for transmission to the CDC. We are working toward making the first system changes that allow documentation of vaccine administration with the new CPT/CVX codes available to our clients as soon as possible.”

Communication with clients will be more critical than the training aspect because each state’s circumstances are different, he said.

“We are meeting with all constituents by specialty and market to help them prioritize a plan for their specific situation.”

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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