Rethinking Vaccination Scheduling

Thinking about getting shots into arms, scheduling and planning and logistics for this.  There are a lot of resources that you need to keep track of.  Any one of these could be a rate limiting factor. 

1. Vaccination supplies (Not just doses, but also needles, cleaning and preparation materials, band-aids and alcohol wipes)
   I'm simply not going to address this issue here.  This is logistics and situational awareness, and this post is thinking a lot more about managing and scheduling vaccination appointments.
2. Space to handle people waiting to check-in
   If you use cars and parking lots and telephone / text messages for check-in, you can probably handle most of the space needs for check-in, but will not be able to support populations that do not have access to text messaging.  You might be able address that issue with a backup solution for that population depending on size.
3. People to handle check-in
   The tricky bit here is that the people who handle check-in need to be able to see or at least communicate with the people administering vaccinations so that the queues can continue to move ahead, and see or communicate with people who have checked in and are ready to get their vaccination.  There are a lot of ways this can work, and much of it depends on the facility's layout.  A football stadium provides much more space and opportunity for handing this problem than the typical ambulatory physician office.  With a small enough volume, checkin can be handle by the administering provider, with larger volumes but the right technology, it could still be pretty easy.  
4. Handling Insurance Paperwork
   The biggest challenge with check-in will be the whole insurance paperwork bundle.  Ideally, this could all be addressed before making the appointment.  Because while patients will pay nothing for COVID-19, Medicaid, Medicare and private insurers may still need to shell out to providers who do it.  A smart intermediary could address this by supporting some sort of mass vaccination protocol for logging patients to payers, and vaccinations back to "appointments" (see more on scheduling below).
5. People to administer vaccinations
   Right now, the two vaccinations use intra-muscular injection and multi-dose vials for administration.  Anyone who's had a family member taking insulin, or having been through fertility drug treatment understands that for the most part, the injection part isn't brain surgery, and also doesn't take that long (I've dealt with both in my family).  This is probably the least rate limiting factor after vaccination supplies.
6. Space to handle people who've had a vaccine administered, but still need to be monitored for an adverse reaction.  The two to three minutes it takes to administer a shot requires 10+ minutes thereafter and a minimum of 20 square feet of space for each person to whom it is administered to address potential adverse reactions (with 6' social distancing measures).  
7. People to monitor adverse reactions
   I don't know what the right ratios are here, but one person could monitor multiple patients at a time.
8. People to treat adverse reactions
   This is a different ratio and skill set than for #6 above.  The skillset to treat a problem is likely more advanced than to detect it, but you can probably only treat one adverse reaction at a time, and might need to plan for two or more just in case.

And then there's scheduling.

Scheduling for this within a single facility with existing systems in ambulatory or other practice environments would be rather difficult.  Most ambulatory appointment scheduling systems are broadly designed to handle a wide variety of cases, not designed for highly repetitive case loads like a mass vaccination campaign.  The closest thing in the ambulatory space for this is laboratory testing, where specimen collection is more "assembly line" oriented.

For tracking laboratory testing, it's less about the appointment, and more about the order in the ambulatory setting. The order is placed, and when the patient shows up, the specimen collection is done.  If we work on mass vaccination more like that, then scheduling could be a bit easier. The order basically grants you a place in line, but you still have wait in line until your turn. If you've ever tried to get a blood draw done during lunch hour, you may have been in this situation.  This seems like a better way to go for a mass vaccination campaign.

You no longer get an appointment for a 10-25 minute slot, but instead maybe get a day and possibly a 2-3 hour time period assignment that you are asked to show up within, but can use that slot any time after that point in time. The time period assignment is used to maintain the flow throughout the day, but it's more advisory than a typical ambulatory appointment slot is.

Regional Scheduling

The value of this in scheduling is that each facility can estimate a volume of patients to handle on any given day (or broad time period within a day) based on staffing and other resources.  These volumes can be fed into a system to support scheduling on a daily basis, which can then be used to broadly manage scheduling, not just within a facility, but perhaps even across a state.  If the scheduling system is also capturing insurance information, that could get more complex, but I think more realistically, the scheduling system can be used to feed data to vaccination sites, and the vaccination sites can follow-up with the patient out-of-band regarding insurance stuff using whatever system they have to handle that.  That's a more flexible approach.  This would mean maybe a 24-48 hour delay between scheduling and first appointment slot availability, but perhaps not, because it could be possible that some providers would also be able to set up web sites for patients to register their insurance details, and others might already have the necessary details.  I could use the state system to schedule appointments, and still go to my regular provider for the vaccination.  Providers participating in this might reserve some capacity for their regular patients.

If other service industries can handle scheduling in a 2-3 hour block range to manage their workloads, maybe we can apply this technique to scheduling for a mass vaccination program.  We don't need a precise schedule, we need a sustained rate and flow.  In any case, it's worth thinking about.

This is all just a thought experiment, I'm not going to say it will work, or even that I've convinced myself that it has some value.  It just seems to address one of the key problems in getting shots into arms, which is getting the arms to where the shots can be placed.

   Keith