The COVID-19 pandemic illuminated inequities in access to care, socioeconomic disadvantages, and the fragmentation of the public health system. The public health system has been struggling for years due to lack of funding and investment. As new and emerging public health threats loom over the world, it’s important to evaluate if our public health system is prepared for the next global pandemic. While the COVID-19 pandemic proved to be a challenge to the current public health system, the pandemic also provided an opportunity for reassessment and growth. Many innovations were developed and successfully stood up during the COVID-19 pandemic that have the potential to support day-to-day and emergency public health functions.
The role of the individual
At the beginning of the COVID-19 pandemic, diagnostic testing was accessible solely through a medical provider or testing site. Typically, testing was only offered to individuals who met certain criteria, including those based on symptoms and recent travel. After a COVID-19 test was performed by a trained provider, these tests were commonly sent to laboratories for results. This process of provider-based testing and laboratory-based results functions well for non-emergent communicable diseases. However, with the rapid increase in national COVID-19 infections, demand for testing and results far outweighed the provider testing capacity. This unfortunately resulted in delays in testing and results, with some waiting for test results for over 10 days, limiting the ability for public health to react in a timely manner.
The introduction of at-home COVID-19 tests, however, provided an opportunity to break open the diagnostics bottleneck. With at-home testing, community members are able to have immediate access to their test results. Furthermore, the provider burden is alleviated as providers are no longer the sole responsible party for diagnostics. This allows individuals to know their infection status and make behavioral decisions based on their test results. With this at-home testing innovation, community members have the ability to actively participate in the public health process. Initiatives like Make My Test Count support the role of the individual in the public health process, by providing a way for individuals to anonymously report their at-home test results. Increasing transparency in the public health system, by including the individual, may have the potential to increase trust in the system and limit opportunities for misinformation.
This innovation developed during the COVID-19 pandemic not only released the bottleneck in provider-based testing, but additionally included the individual in public health. This model can be used for future communicable disease pandemics to reduce delays in public health action and mobilization.
Public-private partnerships (P3s), or a collaborative effort between a government agency and a private enterprise, create a system to better address the health needs of the public while working to reduce inequities and relieve burden on the public partner. P3s offer an opportunity to better address the needs of the community, as the public partner does not need to build and scale a new program. Without P3s, the public partner must develop, build, and deploy, as well as support the ongoing maintenance of the new program, usually with little resources. Additionally, the ability to scale may be reduced, as it hinges on available resources and workforce capacity, which may not be easily accessed or available. This may lead to delays in public health mobilization and action, resulting in a diminished impact in the community. Employing products developed through P3s not only allows for a more successful program, but has the potential to increase adoption and engagement in the program through increased access and ease of participation.
A successful example of a P3 established during the COVID-19 pandemic is the Say Yes! COVID Test (SYCT) program, which provides free at-home COVID-19 antigen testing to residents in participating states. Through this program, state health departments are able to leverage the distribution and public health reporting capacities of a private company to supply residents with at-home test kits. Using their procurement channels, state health departments were able to obtain test kits and house them in Amazon distribution centers. Through the SYCT website, residents place an order that triggers a shipment process leveraging the fulfillment and distribution capabilities of Amazon. Amazon has the ability to quickly ship large order quantities, allowing for the scale of this program. Residents receive their test kits in standard Amazon packaging, allowing for discrete procurement of test kits and supporting the privacy of the individual. After testing using their at-home rapid antigen tests, residents are able to report their test results to the Association Public Health Laboratories (APHL) using the Digital Assistant developed by CareEvolution. Individuals are able to choose to share PHI/PII when reporting their test results. Test results are transmitted to state health departments via the APHL, allowing states to assess and analyze their outreach.
The SYCT program has demonstrated a P3’s ability to scale, increase access to healthcare, and support the needs of local and state health departments to support their communities. Through the SYCT program, over 25 million test kits were successfully delivered across the nation with support for 38 languages. P3s are especially important during public health emergencies, as they allow for immediate ability to scale to address the needs of the community. Additionally, innovations in one community are more likely to be shared through the private partner bringing the innovation to new communities as was the case with the SYCT program.
Vulnerable populations, or those at highest risk of developing COVID-19 due to socioeconomic (SES) or geographical disadvantages, were left behind during the COVID-19 pandemic. These populations were less likely to be able to access valuable resources, such as testing and masks, as well as medical care. Vulnerable individuals may have difficulties with accessing transportation to receive medical care, may not have resources to purchase over-the-counter at-home tests, or may not have the ability to leave work to access care. These situations, among many others that result in inequities in access to care, place individuals at a higher risk of severe outcomes associated with COVID-19. This led to great disparities in COVID-19 outcomes.
A local initiative, developed by the Washtenaw County Health Department (WCHD) in Michigan, sought to reduce the disparities in COVID-19 outcomes in vulnerable populations, by providing free access to at-home tests and COVID-19 treatment. This digital initiative, called COVID Plan4Health, allowed for any community member in Washtenaw County to access free at-home tests, before an exposure or development of symptoms. This program specifically prioritized those without access to consistent medical care and those who are under- or uninsured. These populations are typically overlooked by traditional medical centers who are unable to provide care to those who have not previously established care or those who do not have insurance.
Through Plan4Health, at-home tests are shipped directly to the resident’s self-attested place of residence, including apartments, shelters, and temporary residences, reducing barriers in access to transportation and funds or insurance to pay for testing. Community members were educated about how and when to test for COVID-19, as well as how to get evaluated for COVID-19 treatment upon positive test result. In the event that a community member enrolled in COVID Plan4Health tests positive, they are connected with a knowledgeable healthcare provider at WCHD, and evaluated for treatment of COVID-19 with Paxlovid. Through COVID Plan4Health, barriers to treatment were removed with access to treatment delivery services, such as the health department’s Nurse On The Run program, where a qualified Nurse drops off the prescription to the individual’s place of residence. While the individual is taking Paxlovid, they are followed-up with and provided support, as well as educated on what to do if they have questions or need assistance.
Prioritizing vulnerable populations and reducing barriers to care using a digital model should be employed in future populations to limit disparities in health outcomes. Digital initiatives, such as COVID Plan4Health, are especially important to increase access to care.
During the initial phases of the pandemic not only were there challenges providing testing and care but access to basic data about the prevalence, at-home course, and impacts on other conditions such as cancer and heart disease were lacking. Rapid access to rich and high quality data not only enables faster informed decision making but also becomes a framework for building trust through more population-specific and data-supported recommendations. Initiated with the Cures Act of 2016, and further supported by the Promoting Interoperability and Patient Access API initiatives, there has been significant adoption of FHIR and SMART on FHIR standards to enable individual patient-level access to provider (EHR) and payer (claims) data. This access not only benefits patients, but also, through patient-mediated exchange, provides consumer-controlled sharing of significant new sources of healthcare data, enhancing clinical and public health use cases.
Similar to how at-home testing was important to augment the COVID screening response, patient-mediated data exchange provides access to a rich set of data that can easily be incorporated into public health analysis and strategy. Using these standards, an individual can share any data element from the United States Core Data for Interoperability (USCDI) from most institutions they visit with other providers, research trials, or public health organizations. Particularly impactful for public health is the ability to provide demographics, diagnosis, lab results, and medications in a consistent interoperable format, regardless of source.
Although relying on individuals to share data will present its own challenges, this approach will likely expand with the Trusted Exchange Framework and Common Agreement (TEFCA) and the emergence of Qualified Health Information Networks (QHINs). Using the same standards and approach supporting patient-mediated exchange, the QHINs will create an infrastructure to access data from anywhere an individual has received care with provisions being evaluated to support public health use cases. As a result, today public health organizations can augment their access to key population data through patient-mediated exchange and use the same tools and infrastructure to take advantage of the expanding interoperability networks and broader access to data.
The public health system is facing a period of growth that will allow it to become more effective and efficient to better meet the needs of the community. Through the use of digital interventions, interoperability, and public-private partnerships, the public health system has the potential to not only be prepared for, but successfully manage, future health threats.
Want to learn more about the current and future needs of the public health system? Check out these resources: