prepmod vaccine :: Article CreatorWhat Went Wrong With The 'Tiny Nonprofit' Behind The State's Beleaguered Vaccine Site
When Gov. Charlie Baker released vaccine eligibility to a million more Massachusetts residents last week, state websites crumpled under a virtual stampede of people rushing to secure appointments. Users were left in online limbo for hours, and many gaped at how something so critical could be entrusted to, in their eyes, flimsy web services and fragile program designs.
"Foolish system. Ill-Designed. Who are the people that designed it?" seethed Steve Rosenfeld, 70, from Worcester in a written comment to WBUR after he failed to get an appointment.
The nonprofit Maryland Partnership for Prevention runs one of the crucial websites that crashed last week, a service it provides in more than two dozen states across the country. The company's software allows people to register their COVID-19 vaccines and make appointments. In Massachusetts it is used, among other things, to manage signups at state-sponsored mass vaccination sites.
By its own account, the company is a "tiny little nonprofit." For two decades, it built and managed simple software programs designed to streamline flu vaccine consent forms and registrations in Maryland school districts.
Then, in just the last year, this "tiny" nonprofit transformed its software into a massive program to manage COVID vaccinations. It's called PrepMod. It powers the appointment systems of vaccination sites and health clinics in 27 states including Massachusetts.
Although local health clinics say, by and large, the software helped their sites run smoothly, the failure last week exposed glaring flaws in PrepMod's design and management choices.
These flaws and the problems they caused were preventable, according to Jay Jamison, an executive at Boston-based web technology company Quickbase. Developers have long had solutions to what he calls the "news day problem" - typically when media reporting causes a surge in traffic to a normally sleepy website.
"These are known problems that you can design around," Jamison says. "These are problems that many firms face, and many others have solved the problem of how do you stand up applications that get a ton of traffic quickly, and how do you do it reliably."
Companies just have to plan for it, Jamison explains, and those with a deep pool of experience in web application development wouldn't make what he sees as, essentially, rookie mistakes.
I knew what the system needed to do. I designed the screen and the functionality because it's the work that I do.
Tiffany Tate, executive director at the Maryland Partnership for Prevention
When Tiffany Tate, the executive director of the Maryland Partnership for Prevention, began working for the nonprofit, she was fresh out of graduate school. She saw the position as a stepping stone to bigger, more lucrative corporate opportunities.
"I thought, I'll work this job for a couple of years, and then I'll go on and make the big bucks and run a company," she says.
The nonprofit had a single purpose: boost flu vaccination in Maryland school districts. At the time of its founding, two decades ago, Tate says she and her co-workers were floundering under piles of paper consent and registration forms. The information on those hard copies had to be manually transcribed into electronic school and state systems, and it took forever.
"We said, 'there's got to be a better way.' So, we got this idea to create software to collect consent electronically and manage that information by school," Tate says.
This concept led to ReadiConsent, the precursor to PrepMod. Tate says it worked fantastically, saving her organization time and increasing the flu vaccine coverage rate in Maryland schools. Districts in other states also began using the software.
Tate is proud of the impact her work has had, and her passion for vaccines bloomed. Instead of gunning for a cushy corporate management job, Tate dedicated herself to immunizing students, particularly in those in underserved schools.
"I love immunizations. Vaccines save lives," she says. "For 24 years, I've been working in public health. It's all community-based work where my beginnings are in Baltimore City, trying to reduce the disparities between African-Americans and whites for flu vaccinations. Making sure people who need vaccines have access to them."
Tate believes her experience managing ReadiConsent and other vaccine programs for the flu prepared her — and the nonprofit she now runs — for the massive undertaking of rolling out critical software during the pandemic. She'd been thinking about just such a possibility since the H1N1 scare of 2009, she says, and knew that many of the features she'd implemented in ReadiConsent would come in handy for clinics rolling out COVID vaccines. And so, in late 2020, PrepMod was born.
"I knew what the system needed to do. I designed the screen and the functionality because it's the work that I do," she says. "When the pandemic came along, we said, 'well let's evolve [our software] and add a few more features and make it available to everyone."
If you're going to pay a lot of money, no matter what that number is, you want it to perform.
Jay Jamison, executive at Quickbase
According to documents provided by the state, the Maryland Partnership for Prevention, under a subsidiary called the Multi-State Partnership for Prevention, invoiced Massachusetts $318,000 for a lifetime license to PrepMod and other programs, including the flu vaccine software ReadiConsent. The nonprofit invoiced another $120,531 for personnel costs over three months, starting in January 2021. It appears to be a better deal than what some other states got – Pennsylvania paid over $850,000 for its contract.
The new income must been a welcome sight for the Maryland Partnership for Prevention. Financial filings from the last decade show the nonprofit has been operating in the red since 2014. Its most recent public tax form, from 2017, lists Tate as the only "key employee." The nonprofit lost almost $150,000 that year.
Tate says even with all the PrepMod licenses sold during the pandemic, Maryland Partnership for Prevention will likely not make it into the black. The price charged to states for its licenses was only designed to cover the cost of developing the software, Tate says, not to stuff her pockets with public health dollars.
"We're here to serve, and we have not positioned ourselves to make, you know, millions and billions of dollars," Tate says. "We have a lot of expenses that are probably going to cause this to break even or go in the red."
But Maryland Partnership for Prevention's lack of stable revenue is a concerning sign to Quickbase's Jamison. From running a tech company of his own, Jamison knows how costly developing web products can be – particularly when those products handle health information. That also means a tech firm needs to have good cash flow to develop and deliver a good service, he says.
"A vendor having financial stability is a really important signal of being able to maintain and continue to deliver a repeatably above expectations experience for their users," Jamison says. "I think that's a really important frame to think about."
The money the state spent on PrepMod seems not quite worth it to Jamison. It's not just that nearly half a million dollars is a lot — although, "that's a lot of money for software, there's no doubt about it," Jamison says. It's that Maryland Partnership for Prevention failed to deliver a reliable and robust product. The website the nonprofit set up to handle Massachusetts vaccinations ended up being an obstacle to residents.
"If you're going to pay a lot of money, no matter what that number is, you want it to perform. For me, it seems like a lot, mainly because it didn't meet expectations," Jamison says.
[PrepMod]'s really been helpful. It's taken the burden off a local board of health... It's been a great tool.
Kristin Black, Health Agent at Northborough
Local health clinics that have used PrepMod for weeks disagree with Jamison on some points. Kristin Black, a health official for Northborough, says PrepMod was one of the reasons why the vaccine clinic at the Northborough Senior Center was able to run smoothly.
"It's really been helpful. It's taken the burden off a local board of health," she says. "There's currently a 24-hour requirement for reporting vaccines administered, and so I think it was only because of that tool we were able to really meet that requirement of 24-hour reporting. So, it was a great tool."
For Black, PrepMod streamlined the registration process. It made it easy for her to send the vaccination data to the state's immunization information system and helped manage appointments. For day-to-day clinic operators, Black says PrepMod wasn't hard to use – although it required some training and had "a big learning curve."
Tate's background in influenza immunization also meshed well with the operations of local clinics. Black says PrepMod was good fit for small administrative jobs like those at local boards of health.
Black does have some criticisms, however. Mainly, she says a couple of design flaws created inefficiencies. For one, she and her staff had to start a completely new registration for every patient's second vaccine dose. She wished the system would remember patients, so they didn't have to walk people, particularly seniors, through the electronic process twice. She also knows the sign-up process hasn't been easy for a lot of her residents.
Worse, Black says some boards of health experienced crashes with PrepMod. In Hopkinton, the software went down during a vaccine clinic. The staff had to revert to paper records until the system came back online.
"It was a mess," says Hopkinton's health director, Shaun McAuliffe. Luckily, he had printed all of the registrations at home the evening before the clinic.
"Had I not, I [would] have had to run the clinic blind, unable to confirm which resident of the Commonwealth had registered," he tells WBUR. "Since the system was down, I had to enter and close out every registrant by hand and then enter everything digitally."
I would get a message that sorry, there were no slots available at that time. So, I'd go back … and do it all again… I was able, at the end of 5 hours, to see how many times I'd tried: 57
Sarah Metcalf, 67, from Northampton
On the morning of Thursday, Feb. 18, an estimated million Massachusetts residents suddenly became eligible for COVID vaccines, and the appointment system's flaws became catastrophic. Millions of clicks flooded the PrepMod website each hour. It sputtered in the sea of traffic.
"Typically, we're dealing with about 60,000 queries an hour," Maryland Partnership for Prevention's Tate says. "It went up to 70,000 hits per minute… about 4 million an hour. Our system just didn't catch up with the demand. The sites were impacted – they weren't prepared."
Tate describes the problem as a lack of "web provisioning." This includes server capacity and personnel tasked with maintaining the site. If traffic exceeds a website's resources, it will slow down or fail, as many users experienced that day. Despite the problems, 60,000 people managed to secure appointments on Thursday, Tate points out.
But Tate agrees mistakes were made.
"I think there should have been things in place that would have made for a better, smoother experience for the people of Massachusetts (…) We're accepting responsibility for the challenges people experienced with our site," she says. "This is an opportunity to apologize and do better. We just know that as we move froward, we are now ready for whatever comes our way because we've had this happen, and we won't have it happen again."
An error message from MAImmunizations.Org, the site that runs the PrepMod software and manages COVID-19 vaccinations at state-sponsored sites.
As for the design flaws with PrepMod, Tate says that's less about the program and more about how Massachusetts customized it. Each state that uses PrepMod can tailor the interface to its needs.
"The system is highly configurable. The system does what the state asks it to do, so we have versions that handle appointments differently than your state does," Tate says.
California also uses PrepMod, and the interface in the Golden State is far different from Massachusetts. It also allows residents to select an appointment time before filling in pages of personal information rather than the other way around, one criticism that Massachusetts residents had, especially as the website failed, and they found themselves entering that information over and over and over again.
But California has also encountered some problems with the service. Health officials there griped that the program slowed down appointment scheduling. In Pennsylvania, some health bureaus stopped using PrepMod after finding software glitches like duplicated entries for people who had only been vaccinated once.
And customization shouldn't come at the expense of robustness, says Quickbase's Jay Jamison. Designing software that is easy to use and able to handle failures– like saving work when something goes down – are things that tech companies can do.
"It has to do with people who are experts on the processes talking through how they want [the software] to flow," he says.
It was a bad user experience, which we own. We need to do better.
Governor Charlie Baker
After the PrepMod website and, independently, the state's vaccine finder website went down, Gov. Baker was livid. He vowed to improve the system and make sure that such crashes and slowdowns didn't happen again.
"It was a bad user experience, which we own," he said this week. "We need to do better and people have been working to improve both the user experience, but also the capacity of the system to manage millions of people at one time."
Baker has announced 11 regional vaccine sites that will have improved server capacity and a digital waiting room to allow users to queue up for appointments during times of high traffic. Maryland Partnership for Prevention's Tate says she's also taken steps to improve the robustness of PrepMod and the state's vaccine signup website.
As the rollout continues, increasingly younger and computer-savvy populations will begin jostling for appointment slots. They will test whether the improvements were sufficient, or whether the problems that plagued the state's websites last week will only return with greater intensity.
How To Get A Covid Vaccine: Everything We Know, From Cost To Effectiveness
How much will it cost?
Zilch, according to the federal government.
Whether or not they have health insurance, everyone in America will get the Covid-19 vaccine for free, according to the Centers for Medicare and Medicaid Services and the CDC.
Vaccine providers can charge a fee for giving the shots, but insurance companies are expected to cover it.
"It will be covered like other vaccines," said David Allen, spokesperson for America's Health Insurance Plans, an industry trade association.
The government has set aside a separate pot of money to cover the uninsured.
How effective are the vaccines?
Both the Pfizer and the Moderna vaccines have been found to be about 95 percent effective. That means a small slice of the population that receives them wouldn't be protected against the disease.
But Moss, the Johns Hopkins vaccine expert, said he suspects the vast majority of those would probably have "mild illness" if infected.
"I think we could live with that," he said.
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As a point of comparison, the flu vaccine is typically about 40 percent effective.
Both the Pfizer and Moderna vaccines require two doses, which should be taken at least 21 days apart in the case of Pfizer and at least 28 days for Moderna. People who get the shots will not be fully protected from illness until after they receive the second dose.
Will I be able to choose which vaccine I want?
By the time most people in America are able to receive the vaccine, there could be as many as four or five available.
Some experts think the vaccine manufactured by Johnson & Johnson, which expects to have the results of its Phase 3 clinical trials by January, could become the most widely available. It requires only one dose and, like Moderna's, can be stored under normal conditions.
"I think we'll get to a point where a person can choose which vaccine they want, but it won't be in the early months," Moss said.
Can children be vaccinated?
Currently, you must be 18 or older to take a coronavirus vaccine.
Pfizer has launched trials involving children as young as 12. But it's unlikely a vaccine would be available to kids until at least next fall, experts say.
Dr. Sara "Sally" Goza, president of the American Academy of Pediatrics, said the organization hopes a vaccine will be approved before the beginning of the next school year.
"We know that once we have a vaccine for children, that will make it safer for children and for the adults in the school system," she said.
Should pregnant women get the vaccine?
It's a difficult question.
Pregnant women have been excluded from the clinical trials thus far, but a CDC study found that pregnant women are at increased risk for serious complications.
So, what to do?
"There isn't a simple answer to questions about whether pregnant people, or those considering pregnancy, should take the Covid-19 vaccine, especially since no vaccine is currently approved," Dr. Christopher Zahn, the vice president of practice activities of the American College of Obstetricians and Gynecologists, said in a statement.
"When the vaccines do become widely available, unfortunately, we have no data on the safety of the vaccine in pregnant and lactating individuals because they were excluded" from the clinical trials, he added.
Zahn added that women who are pregnant or considering pregnancy should consult their doctors and base decisions on the available data and their "individual risk factors and the potential benefits."
Could I be allergic to the vaccine?
Each vaccine has gone through large-scale trials with thousands of people to make sure they are safe. Still, there is some concern that people who have allergic reactions to other vaccines could also be allergic to the coronavirus vaccines.
The U.K. Is currently looking into reports that two health care workers suffered serious allergic reactions after receiving the Pfizer-BioNTech vaccine, though investigators are still trying to determine if they were caused by the shots.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said the situation was "of some concern" for people with tendencies to have allergic reactions.
Could there be setbacks that delay the availability of the vaccine?
Yes. Rolling out the coronavirus vaccine to every American is among the most complex logistical challenges the country has ever faced. Several things could hamper the effort.
Doses could become scarce. Crucial supplies, such as syringes and gloves, could see shortages.
The virus has already put an unprecedented strain on hospitals and pharmacies. Staffing issues could hamper their ability to administer the vaccine.
"It was hard enough for us to just make masks and distribute them, which is a much easier thing to do than what we're about to do with vaccines," said Dr. Paul Offit, an infectious disease specialist and director of the Vaccine Education Center at the Children's Hospital of Philadelphia.
"I think it's going to be a real learning curve here over the next few months."
Are there crucial things we still don't know about the vaccines?
Yes. It remains unclear how long a person who receives a vaccine will be protected from the illness. Will it be a year? A few years? A decade? As more data becomes available, there will be further guidance on whether people will need to receive booster shots.
"I don't think there's any reason to suspect that this is going to be a vaccine that only offers several months or a year of protection," Moss said. "I think it's going to be at least several years, if not longer, but we don't know."
Another unknown: Could there be rare side effects that emerge several months after a person receives the vaccine?
The available safety data, which shows minor symptoms not unlike those caused by a flu shot, is short term. That's usually good enough. The vast majority of adverse events that stem from vaccinations occur within 30 to 40 days, and the data covers that period.
But experts say it's possible that some rarer, long-term side effects could emerge, though the risk of this does not outweigh the benefits of receiving the vaccine.
Finally, it's still unclear if the vaccine prevents transmission of the virus. Both the Pfizer and the Moderna trials focused on disease as the primary outcome. They didn't look at whether an individual can get infected without symptoms and transmit the virus.
If it turns out the vaccines are only, say, 50 percent effective at preventing asymptomatic transmission, people who receive them could still spread the virus.
"I think what's going to happen when people get vaccines is they're going to think, 'I'm good. I can throw away my mask. I can engage in high risk activity,' when in fact, they may still be at risk of shedding the virus and therefore being contagious to others," Offit said.
How soon after the vaccines reach most Americans will life return to normal?
This is one of the most complicated questions.
Nine months after the pandemic began, Covid-19 is raging across the U.S. It will take more than a vaccine alone to bring a sense of normalcy to our everyday lives, experts say.
"Right now, the U.S. Is on fire with this virus," Offit said. "You're not going to be able to put out the fire with just a vaccine."
But it will certainly help. Experts said the introduction of the vaccines will likely lead to a gradual reopening of society.
Public health officials will no longer advise against small family gatherings. Indoor dining at restaurants will no longer be prohibited. Then, we could see the opening up of places such as movie theaters and concert halls as more people become vaccinated.
Assuming most of the population is vaccinated by early fall, the Thanksgiving, Christmas and holiday season could resemble what they did before the virus broke out, with large family gatherings and outdoor festivities taking place without fear of falling ill.
But calls to mask up are likely to remain deep into the new year, especially if it turns out the vaccines don't fully prevent asymptomatic transmission.
Experts say the outlook will also depend on whether most Americans agree to get vaccinated.
The anti-vaxx movement in the U.S. Is strong and multiple studies have shown large swaths of the population are reluctant to get vaccinated.
"The biggest disaster is if we have all these vaccine doses and people don't want it," Moss said.
"I do think that this virus is not going to just disappear," Offit said. "I think what's going to happen is that you'll see cases decrease. You'll see hospitalizations decrease. You'll see deaths decrease. And then the question will become, when are we comfortable enough to say that that level of infection, that level of death, is something we can live with?"
Which, he said, is "pretty much what happens every year with influenza."
CEO Of Company Behind Some Mass Vaccination Site Bookings Speaks Out
The CEO of the company that manages booking for some of the mass vaccination sites is pledging to work closer with the state after a massive failure Thursday.Maryland-based online appointment vendor PrepMod said it took "full responsibility" for the vaccine site's Thursday morning crash that frustrated newly eligible vaccine seekers.PrepMod says it didn't know the state was expanding eligibility to more than 1 million people.When asked about what appeared to be significant communication breakdowns between the company and officials with the state, CEO Tiffany Tate responded. "I wouldn't say that because we meet with them regularly," Tate said. "I think responding to a pandemic is something none of us has done before."The cause of the problem, the company said, was "a sudden and unprecedented surge in traffic to the site.""Unfortunately, the system did not scale fast enough to accommodate the increased volume," the company said.PrepMod vowed that there would be excellent communication moving forward, and the issues that users faced on Thursday would not happen again. The Baker administration said PropMod addressed the issues and the state was pressure testing it to check the vendor's work."I'm not blaming anyone. We should have been ready," Tate said.
BOSTON —
The CEO of the company that manages booking for some of the mass vaccination sites is pledging to work closer with the state after a massive failure Thursday.
Maryland-based online appointment vendor PrepMod said it took "full responsibility" for the vaccine site's Thursday morning crash that frustrated newly eligible vaccine seekers.
PrepMod says it didn't know the state was expanding eligibility to more than 1 million people.
When asked about what appeared to be significant communication breakdowns between the company and officials with the state, CEO Tiffany Tate responded.
"I wouldn't say that because we meet with them regularly," Tate said. "I think responding to a pandemic is something none of us has done before."
The cause of the problem, the company said, was "a sudden and unprecedented surge in traffic to the site."
"Unfortunately, the system did not scale fast enough to accommodate the increased volume," the company said.
PrepMod vowed that there would be excellent communication moving forward, and the issues that users faced on Thursday would not happen again.
The Baker administration said PropMod addressed the issues and the state was pressure testing it to check the vendor's work.
"I'm not blaming anyone. We should have been ready," Tate said.
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