The Vaccine Challenge Podcast

Transcript of "The Vaccine Challenge Podcast" Episode 8, April 1, 2021, hosted by Priyanka Asera and featuring Cimarron Buser.

PRIYANKA ASERA, HOST: Hello and welcome to the vaccine challenge. Our mission is to speed up the distribution of the COVID-19 vaccine by bringing to light all of the supply chain and distribution challenges involved with this meta task, and by connecting the various stakeholders that can benefit from working together. I'm Priyanka and we're in conversation with Cimarron Buser. Cimarron is the CEO of the Appointment Scheduling and Booking Industry Association, or TASBIA. Now, we spent a number of weeks talking about various supply chain challenges with regards to the vaccine and the first mile, middle mile and last mile.

Cimarron, would you please take us through your journey of TASBIA, and how it's impacting the vaccination effort in the United States.

CIMARRON BUSER, TASBIA: I founded the Association to promote the idea of appointment scheduling and booking. There are so many situations where it can improve an experience between a customer or a user of a service, and the provider of that service. Many people don't really understand it, and that was the founding of the Association. Based on my experience in the industry, a lot of the companies would like to promote the idea without necessarily trying to “sell” people.

About a year ago, when the Covid-19 crisis began, I noticed that a lot of the COVID-19 testing was appointment driven. A lot of those systems were not very good, and it wasn't easy to find out whether there were actually appointments available. I began to investigate how to make this happen, which led to the government agencies, as well as working with vendors. That was really the beginning of my interest in the area.

When vaccinations started, the same problem occurs. And now you have the complexity of supply and you have two different appointments you might have to make. But the idea is the same: how do you make it easy for somebody to get this service, whether it's a COVID test or a vaccination. This is obviously a very critical type of appointment: it's different than just making an appointment at a store, or the bank, or to get a haircut! But when you look at it, it's the same problem and a lot of the same technology can be applied.

ASERA: Let's talk a little bit about what kind of efforts the is government making in order to solve scheduling crisis. Are they even effective?

BUSER: In the United States there are lots of issues around this, including the supply chain management itself, which is getting supply out to the places where it's needed. In the United States, because there was also a transition in presidential administrations in January [2021], what happened is that the ability to get the supply was really separated from the ability to deliver it to the people.

That's where a lot of the problems have occurred. With the COVID-19 pandemic there's so many people that have tried to do the right thing and they're really working hard. They want to help. They want to make sure the vaccine gets out. They want to make people better. I don't think it's for lack of trying, but I think that even with the best of intentions you have complexity in the systems, mixed messages, or different approaches.

It’s very decentralized so that at the national level they said “we're going to get this supply out to you, and you're apportioned this amount,” which is appropriate. But then it was left up to the states and to the jurisdictions--which might be counties, cities or other geographical areas--to really get that last mile problem solved.

The government tried to create an appointment scheduling system to manage the supply chain, appointments, scheduling, and data analytics. They hired a firm to do that and build it for the CDC, and then offer that for free to the states. But there was not as much “take up” on that as they wanted. It was very large, complex, and bureaucratic system. It also built very quickly.

They recognized they needed something at the federal level. They tried to come up with something they could offer, but it was just probably a bit too much to bite off in too short a time.

ASERA: Alright, so the government did come up with a scheduling system of their own. Does that mean that if it wasn't used, or deployed by different clinics or health authorities at different states, that they are then able to choose what kind of scheduling system they want to use? Do they have that kind of autonomy?

BUSER: They absolutely do have that autonomy, and it was positioned as “this is an option for you.” The system is called VAMS--the vaccine management system--and it was adopted by some states. But, even those that that did adopt it, and really tried to use it, but found it was challenging.

This gets to the heart of the matter: medical scheduling systems of any type are really for the convenience of the “system,” and not for the convenience of the user.

You are asked to put in a lot of information. Who are you? Tell me your medical situation? Do you have health insurance? There will be question after question, page after page, and all you really want as a user is to know “can I get an appointment somewhere near me?”

You also know whether you’re qualified or not because it was pretty clear what the criteria were. First it was are you a first responder? Then, are you over 65? I don't think that that was a big problem to identify.

Yes, I am qualified now! Just tell me where I can get a darned appointment!

These systems didn't make it easy, because they were built bureaucratically. You had to go through this entire form, and it might take 15-20 minutes. And then you get to the end, and it says “oh, sorry there's no appointments.”

And that was incredibly frustrating. And it was even more so because those states had not adopted a centralized system.

They were using something they may have purchased, or may have tried to modify what they had. In some cases they used “off the shelf” software like Calendly.  Literally, a local county or city would say “look, we got to solve this – go use some software.” And someone says “oh, I use Calendly, let’s use that.”

There are probably at least 20 systems being used.

ASERA: Wow.

BUSER: The vendors don't even know they're being used for that “use case” because somebody would just go and choose it. The challenge with this all was that the users of the of the systems need to research it and then look and see where the appointments offerings were.

“So, I see there are some central locations that the state has. Plus, they’re at the pharmacies. And oh, they're also at the grocery stores.” And you'd literally have to go and click on every link. Each link takes you to a different type of system.

Sometimes you went to a site where it was a grocery store or pharmacy where it said “please create your account with us”. I don't want to create an account! I don't want to get marketing e-mails, I just want to get a vaccination.

So, even though the systems themselves may have worked perfectly (that wasn't always the case – some of them crashed for various reasons) it didn't really matter because also there was a lack of supply.

Now. we hopefully will have more supply.

There's a lot of well-meaning people that have tried to make it work. There are people called the “Vaccine Appointment Angels.”  There are communities of people, in every state, every region, at town levels, that will help folks that are 75 years old, or didn't really have any computer expertise. The stuff was kind of complicated, and they go and do the work on behalf of somebody to get them an appointment. They became what would be called a “medical scheduler” in the industry. They were all volunteer networks.

Also, people were building systems to find all the places where there's appointments and show you if there are any available. This happened in Massachusetts, New York and many other places where individual programmers would get frustrated and say “I'm going to build something.”

So, there was a lot of grassroots work to fill in the gaps that the systems were not providing the answer for.

ASERA: Wow, that's obviously sad. And, amazing at the same time, right? I think it goes back to showing that what you said originally, which is that there's a lot of well-meaning work, and sometimes it really does take a village. Let's talk about some private and tech enabled initiatives then to help with scheduling.

BUSER: The most recent global offering is something called vaccinefinder.org, which was launched about three weeks ago in the US. This is an attempt to centralize. For example, if I lived in a particular location, could I see all the places near me, and could I find if there are appointments.

Unfortunately, at this point, the data there is very sparse. It only supports about 7 States, and the data is provided by the endpoint locations. Those people have to daily upload files. You and I know that if you ask people to do that, you're not going to get very good data—it’s going to be spotty. And you’re at the mercy of that data.

So even though it's a well-intentioned system, it really is not quite there yet. If the data was sent automatically by the providers then it would be a really good system. So unfortunately, it is an attractive user interface, but it's frustrating.

So that was one effort that's the CDC had helped to do. A lot of states have their own systems which initially were showing a map of all the locations, and then again the users would have to click and then know that a particular site might be available, or that vaccines were being released.

On the technology side, most of the companies that were providing the software were scrambling to try to fix some of the issues. There's one company called Prepmod which is used by a lot of the states and jurisdictions. They were already in the business of building these systems for clinics.

But if you back up for a moment, a lot of these systems were designed for a different use case, for example, to set up a clinic and do flu shots. And the scale was relatively constrained.

If you think about the scale of the Covid epidemic it's orders of magnitude bigger: ten to hundred thousand times the number of people. And that was one of the issues: the technology solutions, even though they worked from a functional standpoint, were not intended to be the system where if the governor of the state says “tomorrow morning, everybody that's 65 and older go to this website address at 9:00 o'clock in the morning.”

You and I know that isn't going to work when you have a million people hitting the website and 5,000 doses.

So, whether or not the website crashes, or whether or not the website works perfectly but simply says “There are no appointments”, it's still the same result.

ASERA: Right.

BUSER: And that's an issue with policy and the way things are rolled out, not an issue with technology.

Any appointment scheduling system has very common features.

You want to be able to see availability.

You want to be able to make sure that you know that appointment is going to be confirmed with an email or an SMS text message.

You want to be able to let people reschedule or cancel. That gets a little tricky, as in this case you have the complication of a second appointment requirement with the Moderna and the Pfizer vaccine.

What's interesting is that companies realized they better offer a second appointment as part of the process, or make it easy for people to do that. Some did not, and in when the person showed up to get their vaccine, they would take them aside and say “OK, now let's schedule your second vaccine.”

They would say “go use the mobile app” -- and some people said I don't know how to use a mobile app.

We’re techies and we think, oh, just tell somebody to go use a mobile app--and that does not always work! You know you have to sometimes get people on the phone, or sit down with them to do that.

The technology was rapidly trying to catch up with those kinds of requirements that were very specific to the vaccination program, which were different than other kinds of appointments.

ASERA: That makes a whole bunch of sense. Is there a way of cross-system training? And also, is there some way of aggregating the lessons or the data or the analytics that you have from what these systems tell you? For example, if there is a way to know all the number of that you expect in a specific location. Do you know the number of people that actually successfully show up to a second appointment? How long it takes someone to book an appointment? Is there any learning to come from it?

BUSER: A lot of these systems have analytics. And, when you think about it, many of them were designed to be either general purpose, so they're not necessarily specific for the medical or healthcare use case.

Some people were using generic systems like a Calendly.  Eventbrite was being used in Florida, which was meant for things like going to dance parties. Because somebody just said “I'm going to pick this,” they were constrained by whatever that system had and whatever analytics built in.

But when you get into the more advanced capabilities, during this period there was not enough time to even figure out what was going on. They were so overwhelmed with the volume of people coming in and there really wasn't enough supply. That mismatch blew up a lot of the analytics.

With things like cancellations, it gets even trickier. Because of the way that those clinics or “point of dispensing’ (PODs) work, they typically know in a certain day they're going to dispense a certain number of vaccination shots, and they're going to match the staffing a certain way.

When you have cancellations, it could be very disruptive, however, if you get them, and you know a couple of days in advance, you could then reopen those slots. Typically, software will automatically do that.

So, if somebody refreshed, they could see that slot availability, but again, because you had so many people coming in, it almost is overwhelming.

I was watching the news wire and it would pop up almost every day or so in some location in the US where people had made appointments, and then they had to cancel because they didn't have the supply.

ASERA: Oh, no.

BUSER: They were told they were going to receive X number of vials and they didn't. And now they're like, “Oh my God, we've got to reschedule all these people.”

Some of the software automates that, so that it will send out an automated email or text message saying “I'm sorry—click here to reschedule.”

And some of them didn't. Which meant they had to manually do that. That's an example where you want to make sure the software has that capability—and not every system does that.

It's tricky because there's a lot of unanticipated things that occur when you have such a complex system. That's one example where some of the features will make a difference.

ASERA: Yeah, that's just so interesting. The flip side off this specific incident is where there have been so many articles about how there has been too much supply in a specific clinic, because of either no shows, or because they weren't expecting it.

In that kind of scenario, do these scheduling systems have the capability of having some kind of wait list where they can notify people on the wait list saying, “hey, you didn't have an appointment, but it turns out that we actually do have additional supplies.”

BUSER: Some of the systems already have that. But then, as a user, I literally have to go to each of those places and figure out how to register.

A lot of what was happening was in “the grey area”—where people knew someone at the fire station and said “when you get to the end of the day, call me.” In the early days some of the hospital chains were quote “testing the system” and they invited some of the hospital trustees to come in. That didn't go over too well, right?

That brings up all sorts of equity issues. It's not a fair system.

ASERA: Yeah.

BUSER: There's a guy that built a system exactly like this called “Dr. B”, built by the founder of Zocdoc.

The site is called hidrp.com. You put in where you're located and register for when there's an appointment available. It would text you and you get 24 hours to respond. If you don't, you go to the back of the line. Now I know very little about that system because it's not incredibly transparent. It says “your’re number 2,400,000 in line.” But obviously that's not accurate because it’s done by state.

They're reaching out to clinics and saying “If you register with us you can publish at the end of the day, or when you have extra supply, to our platform, and we will broadcast it out so you don't have to do it.”

I think it's a really admirable thing, it’s purely volunteer.

I'm not sure how high the take-up rate is, but the idea is exactly what you're talking about, they did it as an aggregated site rather than everybody having to individually do it.

ASERA: That's amazing, let's move a second from talking about grassroots initiatives to big tech, because how can we not? Now, there's obviously talks about Facebook and Google recently kind of getting into vaccine scheduling. Can you walk me through how that effort is panning out, what is their role and how effective is it?

BUSER: Facebook, Google, Microsoft, Apple (Maps). These companies have an audience, and they have mapping capability, and very scalable platforms. They have a responsibility to try to help. The challenge is how to do it in an organized way. Because the last thing you want to do is ask every clinic: “Hey, can you log into Microsoft, Apple, Facebook, and Google and tell us what's going on.” They’re never going to do this.

One of the things that vaccinefinder.org did is to work with Castlight and Boston's Children Hospital to centralized the approach, so that clinics send data to them. They then aggregate the data, and syndicate it out. This is what Facebook announced. Google may be announcing something similar because they don't want to reinvent the wheel either.

The idea is if you can get everybody to cooperate, and they can use the data in other systems.

Now, those systems could display the data differently. The Google map might look different than the Microsoft map or the Facebook interface. The idea would be that no matter where you are and whatever platform you like to use, you would have access to that data in a way which would be equivalent.

My only concern is that if the data itself that is being fed in is not complete, or, in some cases is incorrect that just multiplies the errors.

That brings us back to how do we solve that problem?

That's a separate issue, but they are all trying to I think help in whatever way they can. Google had put an announcement—the CEO had blogged—about how they were, donating money to the effort, and that they were trying to help by using their physical facilities for offering vaccination appointments.

CDC has blessed the Boston Children’s Hospital and the vaccinefinder.org team to do this.

ASERA: This right that makes sense. Yeah, that's very interesting. One of the problems that the US has is that it's you know, a lot of the effort has been down to the states. It's not like the UK or Canada where it's a centralized system. Which states have used the scheduling infrastructure in the most effective manner?

BUSER: If you go up to 40,000 fee, one of the differences between the US—which is very decentralized with the states, the counties and the different jurisdiction—and the UK, which has the National Health Service, is they know who all the people are, and their demographic information and health information.

You can come up with a centralized registration system because you already have everybody and then you can decide what your strategy is. For example, we're going to start with the 75 year-olds, then 70 year-olds and so on.

You can come up with something that's transparently communicated and then start executing on it.

In the US there have been a couple of states that have done that, but they tended to be the smaller states. One of them was West Virginia.

Tinglong Dai [Johns Hopkins] has looked at this, and one of the things that they were able to do is leverage a close-knit community model.  They could use the local pharmacies, because in that particular part of the country the local pharmacy was a hub and people knew everybody personally. It worked very effectively based on the specific demographics.

That same model doesn't necessarily work in California, New York or Massachusetts or other bigger states. I think they're using the method called “pre-registration”, where we know who everybody is and we're going to reach out. Everybody could trust that we're going to reach out in a way which makes sense and is orderly.

Now that doesn't work so well as the state population gets bigger. What's happened to the states in the middle is you've got two efforts going on. One is the state led effort, which might be mass vaccination sites or centralized models of registration.

The second one is the federal government, who said they’re going to distribute out through 20 or more pharmacies and grocery stores for distribution. But, that was not done in conjunction with the states.

It was done as a parallel effort. So now you have the situation where I personally could go register with the state to get in line, but on the side I could try to get an appointment at the at the pharmacy. They said that's OK, go do that, but that's awkward. We have a two track system going on.

ASERA: Right.

BUSER: The challenge is that he bigger the states, the more complicated. When you get into jurisdictions like New York City, City of Los Angeles, or the City of Chicago they've got a huge population base, and they have lots of challenges.

In Chicago, they have six different systems running in parallel, some from off the shelf vendors, some from the state, some that are pharmacy systems that happen to be in use.

It's great, but they said “Let's flip all the switches on and see what happens.”  There's a little bit of panic: we have do something! Unfortunately, in that rush to do things it created a lot of different parallel systems.

ASERA: Yeah.

BUSER: The smaller population, with known distribution channels made it a lot easier, but that's just hard to replicate.

ASERA: Right, that makes sense, and I guess because the effort is so crucial, and this has never happened before, we are also hedging. You know things that could potentially go wrong. Because if you're just trusting one scheduling system and if it goes down, you have nothing more to work with.

So, that’s the “pro” that if you’re using multiple systems there is at least something to go off of if something doesn't work.

BUSER:  If you back up to the very early days—going back at the end of last year—there was a known set of people that everybody wanted to vaccinate. The first two groups were the health care workers and front-line workers.

The second group were people in the nursing homes. As you remember there was a terrible situation where there were huge mortality rates amongst people in the congregate settings. They did a very good job because they could identify them! We know where all the nursing homes are, we got a lot of lists We're just going to go out there and we're going to do it - so that worked well.

It was a well-defined population.

But as soon as you got beyond those very defined then it got a lot more complicated because we don't really have that central database like you do in the UK where you know everybody and where they are located.

ASERA: Right.

BUSER: Here, it was up to individuals. Or, if you have insurance, they will reach out to you. But not everybody is the same insurance company and they're all different systems. And, it very quickly became a highly decentralized spaghetti once you got beyond those highly defined groups.

ASERA: Yeah, absolutely. Well, we've been talking about vaccine scheduling this whole time. What about Covid testing? In the early days people were getting tested only when they had like a symptom or something like that. I can imagine now it's a lot more commonplace that people have to get tested regularly if they have to go into work. What is happening in the testing space for Covid tests?

BUSER: Testing is still going to be required. For example, if I leave the state of Massachusetts right now, even if I go next door to a state and I come back in as a resident, I have to register get a negative Covid test or be quarantined for two weeks. It's a similar situation in many other places.

To your point, I think one of the biggest issues in the United States is who's paying for it.

ASERA: Oh no.

BUSER: Unfortunately, that's a reality, as sad as it is. With the Covid vaccinations it was very clear that the government was going to pay for it. They were going to reimburse. You were asked to give your insurance information, but it wasn't really necessary.

However, Covid testing still is one of those things that it is a “chargeable item,” unless you happen to find a place that will do it for free.

Google’s Project Baseline provides free Covid testing, which is an excellent system. They have great registration and appointment scheduling, but it's only in certain places.

ASERA: Yes.

BUSER: So I think the same challenge is that we need to have a centralized system. We need to make it easier. I think it should be free because you want to remove as many of the barriers as possible.

The last thing you want to do is if somebody should be tested--but doesn't get tested because they're worried about having to pay for it. I think that unfortunately still a barrier, in addition to the technology and other issues.

That that is something that we have an opportunity to fix.

And by the way, this whole situation we find ourselves in with the pandemic – we may be doing something like this again in two years. In five years.

It would be nice to learn from the mistakes and to build something out now. Public health professionals have been talking about the fact that the whole area has been underfunded.

They need to step up at the federal level and say “we're going to create systems so that this should this happen again we're not scrambling and trying to fix the problems on the fly.”

ASERA: Speaking of learning better, are there lessons being learned from the scheduling industry or in other countries?

BUSER: The idea of scheduling—other than for Covid vaccinations--has become in some industries a “must have,” where before it was not.

Examples are true both in the US and the rest of the world. For example, things as simple as going to get a hair appointment. Before, you could just walk in and say “I'm here.” Well, we’re not doing that anymore. You walk by those stores and it says you “must make an appointment.”

ASERA: Yeah.

BUSER: It could be for going to the bank to do a banking transaction, get access to your safety deposit box, open an account, or do some kind of transaction. It could be for going to a fitness center.

This has also led to other innovations, for example, telehealth has just exploded. People with “schedulable visits “to the doctor couldn't go to the doctor [in person].  So, telehealth took off because they could do video.d

That is also happened with yoga and exercise. It’s opened up an interesting opportunity for the appointment scheduling companies, and for the businesses to offer this.

It's changing the dynamic of how people work with different retailers and businesses, as well as healthcare.

So that is one of the questions that I'm really curious about: Is that going to survive? In other words, when we're past this crisis, are people just going to go back to their old ways? Or will we have people saying “that was really convenient to be able to make an appointment, come in, and not wait in line.”

Or, “You know that video thing that I did, that was pretty good. I think I'll do that again.” (I mean, people may be burned out on zoom calls by then.)

This has been a big discussion in the retail industry as to whether or not appointment scheduling will survive. Will this kind of interaction be something that the consumer will want later? My feeling is yes, I think they will, because they have learned that it's in some ways it’s a better experience for working with people.

ASERA: What are some of the things that you would personally like to see within the industry, once we get past the pandemic.

BUSER: The companies that are offering this technology have learned a number of things from the vaccination use case.

First, Ease of use—which we talk about a lot in software—but it really makes sense to simplify things as much as possible.  How do you make it easy for the user to schedule whether they have a computer or phone?

On the phone there's been a lot of work being done on voice interfaces using AI. Up to this point, nobody really likes talking to the computer or the “automated voice.”

But, what if you call and it says “would you like to schedule an appointment? I can help you do it”. Perhaps people say: I'll give this a shot, and if it works well, people are willing to do that.

I think some of the AI on natural language may get a boost. I've been talking to companies doing that and they've said there is definitely an increase in interest because if your whole point in calling is just to make an appointment, do you really need to have a person doing that?

If you can automate it in a in a friendly way, so that's one very specific thing, but it's actually fairly important because that industry has looked for something that they can leverage and take advantage of. Technology could really play a big role and people will become much more comfortable with it.

ASERA: Ending on a hopeful note then, but when do you think will be done with the vaccine distribution and the vaccination effort?

BUSER: Oh boy, I already predicted this once, and I was completely wrong! I think part of the challenge is that this is a worldwide problem. Every region of the globe is going to be different on how they bounce back from these situations.

The travel industry is a great example. International travel has been heavily affected: hotel rooms, tours or whatever. But they found is that a lot of people are traveling locally. What's happened is that both consumers and businesses have tried to adapt to what's going on.

You know the dire consequences that were predicted a year ago. For example, that there would be a worldwide depression. it doesn't mean that we won't have some kind of reaction later on, but my feeling is that there is a desire to get back to normal.

There's a phrase that's used in the industry which is “business as usual.” We're not quite there yet.

Everybody wants business as usual, and I think that’s probable the latter part of this year. We're going to see it happening in certain regions. It may start in the US, Canada or Europe in certain pockets. It may start in certain industries. It's not going to be universal, but as it starts, it will start to spread to other verticals and other parts of the world.

Consumers want to engage in certain things that they would never thought of doing before, like going out to dinner or going to a movie or going for a trip. These are all the things that will drive the economy, but I think that's likely to be the Fall.

So that will be my prediction. We'll have to come back and see!

ASERA: Right, OK, well I'm going to hold you to it but we'll see what happens. This was fantastic. Thank you so much for taking the time to chat with me. That’s if for today from us at the vaccine challenge.

We continue to work towards our mission, bringing to light all of the supply chain and distribution challenges that can help speed up the distribution of the COVID-19 vaccines flowed over.

If you're doing anything worthwhile in this space, have any suggestions of who to talk to or any other ways that we can improve the podcast please write to us at contactus@thevaccinechallenge.com

At until then, stay safe, stay responsible.

NOTE: Transcript Edited for Brevity and Clarity. Listen to the original podcast "The Vaccine Challenge Podcast" Episode 8.