This is an excerpt from Medically Necessary, a health care supply chain newsletter. Subscribe here.
The shock: In the early days of the COVID-19 pandemic, it was so difficult to find personal protective equipment that Susan Patrick Harris, director of procurement for the corrections health care provider Wellpath, called concessionaires at baseball stadiums in search of safety gear.
She called Disney World, hoping to buy ponchos to use as gowns. Tattoo parlors and shuttered dental offices provided some PPE.
“We hit 15 tattoo parlors in North Carolina and half of them came through,” she told FreightWaves earlier this year. “We found a guy in Atlanta who had 15 pediatric dentists’ offices that closed. We rented a U-Haul and I sent one of our operators to … pick up gloves, face masks, gowns, thermometers.”
Victor Mitry, assistant director of logistics and materials management for the UCLA health system, recalled a similar feeling of panic when he couldn’t find PPE for his providers.
“Our supply chain dropped right beneath our feet,” he said at a September conference hosted by the Association for Health Care Resource & Materials Management.
Blair Childs, who serves as a liaison to federal policymakers for the group purchasing organization Premier, said the problem was that government agencies, medical distributors and health care providers couldn’t easily see where supplies were needed most.
“There was a desperate need for PPE and other equipment. … They couldn’t get it to the right place at the right time,” he told FreightWaves. “Supplies were going all around the country and weren’t going to the places of greatest need.”
The response: Those groups quickly realized they needed more visibility into their supply chains and a better understanding of the demand for medical products.
In the spring of 2020, the Assistant Secretary for Preparedness and Response (ASPR), part of the Department of Health and Human Services (HHS), started a project called the supply chain control tower. The system was supposed to provide health agencies with a clear picture of the state of medical supplies across the country, from manufacturer to end user.
“The supply chain control tower is part of a broader supply chain situational awareness capability we’re trying to build, in partnership with [the Strategic National Stockpile] and others,” control tower program director Mary Beth Hill said during an HHS webinar in February. “This team is really cross-functional and includes representation from across ASPR.”
Around the same time, the National Institute for Occupational Safety and Health (NIOSH) launched its own program to monitor supplies of PPE. Nonprofits like Get Us PPE started monitoring demand for protective gear as well.
That spring, Childs said a group of distributors, group purchasing organizations and manufacturers started meeting daily to share information with each other and public health officials.
“We were on daily calls literally seven days a week with the government,” he said.
These programs were far from perfect, but leaders in the health care industry and government agencies say this type of detailed visibility will be critical for the response to the next pandemic. They’re hoping to expand those capabilities going forward.
“If done correctly it will highlight to us where we have some unique, potential risks in the supply chain,” Premier CEO Mike Alkire told FreightWaves. “If you don’t have capabilities like that, everybody’s in the market at the same time. … All it does is exacerbate the situation. It’s a lot better to have the technology upfront.”
The data: During the control tower webinar in February, Hill said HHS first focused on gathering information from medical distributors.
There are only a handful of major medical distributors and they already had detailed data on their own supplies. The control tower consolidated all of that information into one place. Eight distributors send the control tower reports nearly every day about supplies of five PPE products and 38 drugs, Hill said. Those files are then “cleaned, processed and merged.”
Hill said control tower staff also meet regularly with distributors to ask whether they anticipate any bottlenecks. In return for their efforts, distributors receive lists of states and health care facilities that are having supply chain issues.
However, Childs, who worked closely with Hill during the development of the control tower, said distributors were initially hesitant to share that data with the government.
“That is competitively valuable information. The distributors know what they have. They could probably infer the market size of others,” he said.
Distributors AmerisourceBergen and Cardinal Health declined to answer questions about their participation in the control tower project. McKesson did not respond to requests for an interview.
In an email, Jessica Falcon, director of security, intelligence and information management with ASPR, argued that distributors benefit from participating in the project.
“Strengthening the domestic supply chain is mutually beneficial,” she wrote. “We provide share-back and analytical insights from their data, which gives us all insights into gaps in the marketplace.”
HHS was able to work with distributors to share data by mid-April, according to Childs. But the control tower still needed information about inventory at hospitals.
In March, HHS awarded a $20.4 million contract to the health data company TeleTracking to collect information from hospitals about COVID-19 cases, hospital capacity and supplies of PPE. By February, Hill said 5,000 hospitals were reporting data to the control tower.
The TeleTracking program generated controversy because it asked hospitals to report data directly to HHS rather than the Centers for Disease Control and Prevention as they had previously. In April, HHS extended the TeleTracking contract.
The final piece of the puzzle was data about production of medical supplies from manufacturers. The manufacturing industry is much more fragmented than medical distribution and the majority of production happens overseas, Hill said.
That makes gathering manufacturing data a much more difficult task. However, Falcon said manufacturers are now providing information about typical production capacity and the ability to surge in response to a pandemic.
The problems: The process of collecting detailed data from manufacturers and hospitals has proven difficult.
Childs said the TeleTracking system involves mostly manual data entry and compared it to SurveyMonkey. Health care providers told NPR that the system nearly doubled the number of elements they had to report while data scientists claimed the information wasn’t always reliable.
Despite the burden associated with gathering all this data, Childs said it still didn’t provide enough detail to be useful, such as information about the sizes of available PPE.
“It was very chaotic, very ineffective in many ways,” he said. “It was directionally helpful. It allowed them to do some forecasting … but it was not ideal.”
Robert Handfield, a supply chain researcher at North Carolina State University who has reviewed documentation about the control tower, said the system needed more automation to be truly effective.
“It sounds very sexy. … But from what I’ve seen, they don’t even have the basics required to support it,” he told FreightWaves. “It’s a great concept, but it’s going to be kind of a dataless control tower. … It would take a lot of work for them to be able to put in tracking systems.”
Falcon acknowledged that reporting hospital data is labor intensive. She said the control tower can pull data from other sources if reporting from hospitals is inadequate.
Lessons learned: A decade before the launch of the supply chain control tower, NIOSH worked with Vanderbilt University to launch a pilot program designed to monitor PPE supplies in hospitals.
The pilot, along with follow-up research, revealed that hospitals saw value in monitoring PPE and were even interested in sharing that data with other entities. But they worried that manual reporting would be a large burden and they were uncomfortable uploading data to a government-owned database. Those concerns turned out to be some of the main issues with the HHS control tower.
“This system was not ideal during public health emergencies,” Emily Haas, a research scientist for NIOSH, wrote in an email, referring to the NIOSH pilot. “We realized that the information we were seeking was spread across multiple systems within the hospitals. Essentially, representatives had to coordinate across units and systems to compile the data and then enter it manually.”
In 2019, NIOSH, working with the Center for Medical Interoperability, decided to try again. They launched a new pilot in the spring of 2020 that attempted to reduce the reporting burden by automating some data collection.
However, Haas said the project encountered a new problem. The details, such as model numbers of the name of a product’s manufacturer, were often wrong. More than a quarter of the PPE model numbers reported could not be verified by NIOSH. About 65% of the manufacturer names reported were inaccurate.
Haas argued that future PPE monitoring systems need to have a standardized reporting nomenclature to avoid those issues.
“Accurate representation of PPE availability can detect early warnings of supply chain disruption,” she said during a recent presentation at an AHRMM conference. “Inaccurate model reporting makes it difficult to understand true supply and demand.”
In an email, Haas wrote that NIOSH leaders have been working with local, state and federal agencies since the beginning of the pandemic on PPE monitoring projects, including the supply chain control tower.
She expects the results from the pilot conducted in 2020 to inform the control tower’s future efforts on PPE monitoring.
“The success of this effort provides confidence that automated PPE inventory data may be obtained from hospitals across the nation,” she wrote.
NIOSH is continuing to work with stakeholders to create a standardized PPE nomenclature to make it easier to capture data, Hass wrote. The goal is to create standards that can be used by any system, including the control tower.
What’s next? As the U.S. continues to battle the COVID-19 pandemic — and prepares for the next plague — the federal government wants to expand programs that increase visibility into the health care supply chain.
A White House report released in June suggested giving the Food and Drug Administration authority to collect information about the volume of drugs and active ingredients produced at specific facilities. A September report from the Department of Defense Office of Inspector General recommended gathering more information about a drug’s country of origin to reduce reliance on foreign suppliers. USAID is getting in on the action too. The agency wants to build a supply chain control tower for its global health program to “increase visibility down to the point of service.”
Childs described the control tower as a system that was “cobbled together” during an emergency, but said it’s clear that the U.S. needs the kind of visibility it aims to provide. He believes there’s momentum in Congress to formalize and strengthen the control tower.
“There’s a lot of interest in this on Capitol Hill. They’re working on legislation to create a system to do this,” he said. “You can see how much is being manufactured, see how much is in the pipe. … That’s the vision.”
The White House’s June report strikes a slightly less optimistic tone, questioning whether “voluntary sharing of data will be available beyond the public health emergency.”
However, the control tower is already providing support for emergencies beyond the COVID-19 pandemic, Falcon said. During hurricane season, the federal government is using the control tower to anticipate how major storms could disrupt manufacturing, storage or transportation of medical supplies.
The Strategic National Stockpile has requested a 28% increase to its budget for the upcoming year, and Falcon indicated that the agency wants to keep expanding the control tower project.
“The [supply chain control tower] is really in its infancy; we expect it to keep growing and to be more inclusive and comprehensive for all hazards,” she wrote. “We aren’t starting cold the next time this level of information is needed.”
She stressed that the control tower isn’t just for emergencies. In a steady state environment, the control tower will continue to help health agencies get a complete picture of the supply chain so that they’re ready to respond quickly the next time a mysterious virus emerges.