Imagine if we could track, for every patient seen in a healthcare facility, which Covid-19 vaccine they had received, when, and what their clinical evaluation revealed. We could then have near real-time information about how well vaccines work, how that works over time, how new viral strains alter it, and what viral and host characteristics (including underlying medical conditions) lead to advanced infections in people. immunized. Such monitoring would require a strong link between clinical outcomes (including details of clinical interventions and laboratory studies), data on the specific vaccine administered and the date of administration, and information on the status of the pandemic in the relevant geographic area. .
This effort is not an act of futuristic vision. Tightly integrated population-based health care organizations in countries like Israel have directly informed public health policies, such as recommendations for one-third pushing vaccination, at the scale of several million people.1 Unfortunately, these successes accentuate the relative failures in linking public health and health care elsewhere. In most high-income countries, vaccines are recorded in electronic databases (registries) for public health purposes. However, even when patients’ clinical courses are documented in electronic health records (EHRs), information about the relationship between a particular immunization history and an associated clinical course is not readily available from the health care system.
We are particularly aware of this challenge in our own work in a growing international voluntary consortium (now including nine countries and 335 hospitals) that has been constantly analyzing Covid clinical trajectories since March 2020 (www.covidclinical.net). We have used a variety of analytical data validation and verification techniques and “boots on the ground” to obtain insights into the clinical course of Covid in hospitals during the various waves of the pandemic.two However, we are all well aware of the information gaps between public health and clinical care. Even in countries with universal health identifiers (which the United States lacks) such as France, Singapore, Italy, and Germany, the process of integrating immunization data with the health record is complicated and often delayed despite the many national e-health initiatives and the European Union. 2018 Commission Strategy for the Digital Transformation of Healthcare.
At the same time, several hospital systems, including some in the United States (eg, Keck Medicine in California3), have closed this gap by implementing proprietary systems (or systems designed by EHR providers) to match individual clinical records with state or national immunization registries. The UK and the Netherlands have been successful at the national level.4 Although these systems are the exceptions, they demonstrate the feasibility of bridging this crucial gap between public health and clinical care. They also illustrate challenges specific to the United States, where, unless patients revisit a hospital for care, data about their vaccinations since the last visit, which is stored in a state registry, is not automatically updated in the EHR.
What can we learn from hospital systems that have bridged the gap between immunization registries and their patients’ EHRs? As summarized in table, several factors would allow more health systems and governments to close this gap between public health and clinical care in the short term. None of these desires require innovation in technologies or governance, but they do require the involvement of local clinical leadership in a dialogue with local public health authorities and a commitment to implement much simpler software processes than have been required of vendors. or EHR buyers in the recent past.
Specifically, hospital systems could contact their existing patients to ask them to submit new immunization data (either images from their immunization record or encoded immunization data from increasingly standardized smartphone apps, such as in Massachusetts and California). That way, each hospital would have a complete, licensed immunization record, including vaccine mixes, matched to patients’ medical records, independent of, but complementary to, the patient’s most recent visit. To the extent that patients do not participate, adjustments to the data will have to be made.
This proposal is far from being a panacea. The bridgeable gap we describe here is of interest only to countries and healthcare systems where comprehensive EHR systems have been implemented at scale. Additionally, we have not addressed additional steps that could be taken to further advance public health, such as exporting EHR clinical data to state or national registries. Nor have we addressed aggregation of data on patients’ clinical courses linked to vaccination history in real time across multiple borders that viruses do not recognize but regulations must recognize. Even more significant are the basic logistical challenges of “last mile” vaccine delivery.5 And we know that some experts would argue that systematic nationwide updates to the health information infrastructure are preferable to an incremental mosaic approach focused on specific diseases.
Despite these limitations, we have focused on this small registry-EHR gap because it can be easily filled in the short term, has immediate clinical and public health utility, including detection of the potential second wave of omicron infections now emerging in Europe, and can serve as a bridgehead for broader and more ambitious efforts to link clinical medicine and public health in the future.