Mass Vaccines, Epic, Apple, 5G, UCHealth. Sometimes it all comes together.
This data dilettante (see previous posts: dilettante #1, dilettante #2) has enjoyed armchair theorizing with all of you, my best (online) friends. Today we explore how our super-smart team scrambled our way to improving sepsis care with a predictive algorithm we built.
The old saying goes: the success of any major project in a large organization follows the 80:20 rule. 20% of the work is getting the technology right, and 80% is the socio-political skill of the people doing the work.
We all underappreciate this fact.
It turns out that we spent months building a sepsis alert predictive tool, based on various deterioration metrics, and a deep analysis of years of our EHR data across multiple hospitals. We designed it to alert providers and nurses up to 12 hours BEFORE clinicians would spot deterioration.
We patted ourselves on the back, deployed the predictive score in a flowsheet row, and in the patient lists and monitoring boards, with color coding and filters, and stepped back to revel in our glory.
Turns out that our doctors and nurses were ALREADY FULLY BUSY (even before the pandemic) taking are of critically ill patients. Adding YET ANOTHER alert, even with fancy colors, did NOT result in a major behavior shift to ordering IV fluids, blood cultures, or life-saving antibiotics any quicker.
See the fancy patient-wearable tech on the left (Visi from Sotera, in this case), and one of our hardworking nurses, with ALL of our current technology hanging off her jacket and stethoscope. She should be the visual encyclopedia entry for “alert fatigue.” 😦
Back to the drawing board
As result of our failure, we huddled to think about transforming the way we provided care. It was time to disrupt ourselves. We decided to implement a Virtual Health Center, mimicking what we had seen in a couple places around the country: we deployed 2 critical care physicians and about a half-dozen critical care nurses on rotation, off-site at an innovative, award-winning Virtual Health Center.
This second time around, we created a cockpit of EHR data and predictive alerts to the VHC clinicians, who were dedicated to watching for deterioration across ALL our hospitals, and responding quickly. This does several things:
- Takes the load off busy front line clinicians
- Creates a calm environment for focused, rapid response
- Dramatically improves the signal-to-noise ratio coming from predictive alerts
This way, the VHC nurses view all the alerts, investigate the chart, and contact the bedside nurse when the suspicion is high for sepsis, and start the sepsis bundle immediately.
Soon, by tweaking the ways our teams worked together, we were able to reduce the burden on bedside nurses and physicians and simplify handoffs.
See chart above: Before the VHC, bedside nurses were responsible for detecting sepsis (infrequent, subtle signals during a busy shift with lots of loud alarms for other things), with many ‘grey box’ tasks, as well as ‘magenta box’ delays.
After implementing the VHC, the VHC nurses took over the majority of ‘green box’ tasks, reducing the bedside ‘grey box’ work and completely eliminating ‘magenta box’ delays.
As a result, we have dropped our “time to fluids” by over an hour, and “time to antibiotics” by 20 minutes, which we estimate has saved 77 more lives from sepsis each year.
CMIO’s take? Predictive analytics, data science, machine learning, call it what you like. This is a paradigm shift in thinking that requires disrupting “business as usual” and is hard, but rewarding work. I can’t wait to see what we all can achieve with these new tools.
A new study finds that small groups of laypeople can match or surpass the work of professional fact checkers—and they can do it at scale.
— Read on www.wired.com/story/could-wisdom-of-crowds-help-fix-social-media-trust-problem/
Those of us stuck in the “last century” take heed: TikTok and 15 to 60 second videos are IN.
My Tiktok channel: https://www.tiktok.com/@ctlin99
The TL;DR? 15 seconds should be the length of your educational videos. Wanna know why? and how? read on.
I was a Late adopter of Facebook
I’ve been thinking about the evolution of social media. In early days, I was a late adopter of Facebook, not getting why it was any better than email. Now, I get it: saying something once allows your network to see it, from close friends, to casual acquaintances. Medical residents explained to me that photos and memories were easier to share more broadly. AND, an existing large network made participation more valuable (hey! look at all the people I already know on here!).
Just like in the old days, getting a telephone was INCREASINGLY useful if there were MORE people and stores you could call. The network effect.
That led me over the years to LinkedIn (mostly for work contacts and posting my CV and work products publicly) and Twitter (still figuring it out, but a good way to keep up with news if you curate your network carefully, and also a way to post blog content). Also, Twitter allows you to curate for yourself an international community with similar interests, like #medtwitter.
And, my brilliant younger sister taught me that Twitter could also be good for lecture commentary and discussion (she will give a talk on 2 screens: one with her slides and another with a live pre-filtered Twitter feed: how brave! and give out a custom hashtag, like #postitpearls_lecture, and ask the audience to submit questions this way: wow).
And, some of you know that I’ve dabbled in amateur song-parodies with EHR songs on my youtube channel.
Finally, I’ve figured out how to blog regularly and then use IFTTT to cross-post my content auto-magically to my other platforms (Facebook page, Twitter, LinkedIn) so that I can seem more connected and omni-present than I really am (Thanks for another great tip, Sis).
BUT! TikTok is another thing altogether. My colleague and her daughter suggested that I take my latest Hamilton parody song (that I had gamely posted to YouTube and here I am shamelessly showing it to you again)
#notthrowinawaymyshot and now post it on TikTok, a post-millenial social media platform restricted to 60 second videos. Leaving aside the recent kerfuffle about Chinese ownership and control, this is qualitatively a different animal: getting your thoughts across in 15 seconds (preferred duration, and the time restriction being a result of the music industry’s maximum replay length of a copyrighted song). It has since been extended to 60 second maximum if you have an original soundtrack on your video.
So, I dove in. Unlike my “dozens” of views on my YouTube channel (with which I was satisfied; my broadcast domain is, admittedly to a relatively small physician informatics audience), my TikToks quickly blossomed to nearly 1000 views in 2 days.
Wow! I thought. I am AMAZING on TikTok.
What I did not appreciate is the 15 to 60 second format is much more attuned to the rapid “swipe” of post-millenials, and EVERYONE racks up lots of views. And, ultra-short videos are so easy to consume one after the other. AND, TikTok doesn’t need you to establish your network before your video gets out there; it shows your video to a random selection of viewers, and then those who LIKE it or SUBSCRIBE to you trigger the algorithm to show it to more viewers. So, an easy way to game the system is to use trending (but highly inaccurate) hashtags, like #superbowl, etc. Sadly, this user does not seem to have understood, or be willing to follow, some of these informal rules.
Furthermore, if you read online chatter about TikTok views “500 views total, is pretty sad; what you want is 500 views per hour.” For example, Nathan Evans, of Sea Shanty fame? He went viral at about 250,000 views, and now he’s at 12.9 million. Oh, well. Here’s my paltry Covid Sea Shanty, currently at 62 views (not 62,000) and SIX LIKES.
In contrast, our Informatics team at UCHealth just retired/deleted a 17-minute video I made a 10 years ago for a full “walkthrough” of how to use the Electronic Health Record for our ambulatory clinic physicians. Whew, how out of touch was THIS guy? Here’s a one minute snippet of the kind of video I posted back then, when we were on Allscripts Touchworks. So young, so naive.
Our more recent training videos are more like 1-2 minutes and focused on ONE technique or tool. Now, I’m thinking, maybe we need to shoot for 15-30 seconds. The cool thing about TikToks is that you can trim seconds, speed things up, because those viewers who “get it” can be done watching in 15 seconds, but the video can be paused and also it automatically replays so the viewer can catch subtle details. Hmm, is this a paradigm shift? Should we embed TikTok length education videos into our EHR?
Put Road Signs On the Roadway
As we say internally, shouldn’t we put the Road Signs and Driving Directions (our tips and tricks) on the Roadway (where our users are actually using the EHR) and not in the Garage (our online reference library and training webinars)? Aren’t our users more likely to click on tips WHEN they’re doing work, rather than when “oh, I have some time, let me see what I can go learn.” (which is never)
Austin Chang is my hero
There clearly is an entire evolution of thinking needed to succeed in this TikTok medium. And I don’t have the savvy (yet), the luck, or the persistence to grind out the many tries needed to break through. However, there are medical professionals who have. For example, Austin Chang.
Austin is … well, just go watch him. In 15 seconds, with hilarious music over-dubs, he uses captions and terrible dancing while in scrubs (ok not so terrible), to get his medical facts out there.
I both bemoan the general public’s deterioration of attention span (15 seconds now? Really?) and his ability to fit his tiny education bites (bytes?) into this format. It works. Some of his TikToks are over 2 million views. On MEDICAL TOPICS. Nice. Here’s the NYTimes writing about him.
This reminds me of reading The Shallows, a book about what the Internet is doing to our brains. Are we losing the ability to read a book? I don’t know. I, for one, did not finish reading the book. Ironic.
CMIO’s take: Beat ’em or Join ’em? What are YOU doing about TikTok in your field?
The better angels of our nature also exist on social media.
I love stories like this. Jimmy Choi has a TikTok page where he documents his athleticism. He also has Parkinson’s Disease, with an uncontrollable shaking in his arms. At one point, he complained about how difficult it is for people with Parkinsons to take their medications; the shaking often completely spills the pills from the bottle.
As a result, a community of TikTokkers began brainstorming and then modeling and then 3-D printing an innovative pill bottle design that ensures only ONE pill is dispensed at a time.
CMIO’s take? Having access to the brain power and creative energy of the world, via communication technologies like TikTok and other Social media tools, is, I think, a wonderful antidote to our recent experiences, and the best expression of humanism. How can we design to augment this, the better angels of our nature?
Turns out, those of us in healthcare informatics and in the midst of the pandemic think the world has come to a halt. But no, WIRED magazine reports that robots and other tech development have not slowed down. Awesome reporting.
Why make folks go to training or read a tip sheet if you could guide them just-in-time as they do their work?
Here’s a lovely example of our Physician Informatics Group (Large PIG) evolving as we improve the “intelligence” that our Electronic Health Record (EHR) supplies to our hardworking providers (physicians and advanced practice providers).
In the past
clinicians might have pulled up an app on their smartphone dedicated to the ASCVD: atherosclerotic cardiovascular disease RISK CALCULATOR, punch in some numbers and get a result to type back into the EHR.
Later on, some well known national websites would do the calculation for you. Still requires finding the website and typing in numbers.
Even later, we would put hyperlinks within the EHR to link you automatically, but the typing was still required to get an answer.
we have built a smartphrase (while using the EHR, in any text field, type “.ASCVDRISK”, hit the RETURN key, and Voila, the answer above:
Risk calculated based on what the EHR knows about your patient: age, sex, diabetes, smoking, blood pressure, cholesterol. AND THE ANSWER: 9.1%. FURTHERMORE, disappearing help text guides you to use this information appropriately, and only saves the relevant info to keep in your progress note.
My colleague’s wonderful metaphor for Clinical Decision Support like this?
Put the road signs on the road, not in the garage.
It is already hard enough to use an EHR with patients. Don’t make me go looking for that training document from weeks or months ago, don’t make me think. Make it easy to do the right thing. It is a small celebration every time we can do this right.
CMIO’s take? Thanks to Rich Altman MD for a beautiful new tool in our system. What road signs can YOU take out of the garage and put on the road?
I love these stories about entrepreneurs coloring outside the lines. “That can’t be done” or “There is a big gulf between theory and reality”. These are statements everyone faces when trying to change the status quo, including in healthcare.
The proposal in brief, use a massive centrifuge to speed a rocket up to 5000 mph and launch it like a slingshot so that it can coast up to the stratosphere and then a tiny rocket pushes it into orbit: it avoids the Tyranny of the Rocket Equation – that most of the mass of a rocket is dedicated to massive engine and the fuel it must burn to put a relatively tiny payload into space.
More power to folks like these. Yes, they might flame out as they get closer to a real trial, but imagine if they succeed:
- Launch costs of $400k, instead of 10x as much
- Being able to launch 5x month instead of 5x a year
- Commoditizing access to space without massive rockets
CMIO’s take? Color outside the lines! I give it a 50:50 chance this is viable as a commercial enterprise after vaulting all the potential hurdles.
Billie, Alex, and some crazy doctor, newly recruited Pit Crew. Biggest innovation? Billie’s smiling face on her button! Why haven’t we all done this!?
Our team is at it again!
The Rockies and Coors Field welcomed the UCHealth crew, this time for a 2-day, 10,000 vaccine event Jan 30 and 31. It was a smashing success, and tremendous fun, to boot.
Our fearless leader, Ali Hererra, giving last-minute tips to an eager 630am crew.
The new kid on the block
The new kid on the block: a neck-lanyard, battery-pack augmented iPhone with the EHR mobile app installed for on-the-fly vaccine documentation from QR bar-codes.
Our vaccine clients show tremendous gratitude; we love the spontaneous cheering and applause that break out at times while the cars are moving through. One even handed us an unexpected gratitude card today!
What’s the count?
Here’s my tally for one day of vaccination: 150 for each day, 300 for the weekend. Unanticipated outcome? Donning and doffing gloves 150 times in quick succession causes some hand irritation and a need for heavy doses of vaseline petroleum jelly at the end of the day.
I proudly showed my clinical informatics colleague my collection of vaccine caps in my pocket (see how clever I was to keep track of my productivity?), and she promptly told me: Well, it is easier just to run a report (Thanks, Kristin). Um-hm. And I call myself a CMIO.
Efficiency tip? Here’s the latest: Non-dominant hand: bandaid on the thumb, half peeled. Vaccine, ready to go. Pre-peeled alcohol swab. Dominant hand: Mobile device on a lanyard or in a coat-pocket, QR code scanner ready, some quick screening questions and screen-taps, vaccine documented in EHR, give vaccine, walk back to tent and re-supply while our student hands out the vaccine card and follow-up instructions. Rock-and-Roll.
First of all, our team CRUSHED the scheduled volume today. At our peak, we vaccinated more than 1000 people per hour, with average throughput times of 22.5 minutes (that’s INCLUDING the 15 minute observation).
To say that another way: we timed cars arriving at Check-in Registration at time ZERO, got screened, registered, consented, and vaccinated in about EIGHT MINUTES. And 15 minutes after that, they were rolling out of the observation area. WAT?!
We had numerous people exclaiming: “This is unreal, how smooth it is.” With masks on, we’re getting good at reading the smiling eyes. Wave after wave of grateful vaccine recipients.
Current Vaccine Tent workflow
The Tent 8 “A-team.” Billie Martinez, medical assistant, Brittney Poggiogalle, PA student, Alexander Jimenez, medical assistant (working hard). Thanks for making us all look good!
Turns out it is easy to “infect” colleagues with the enthusiasm I have for optimizing our workflow, which is now:
- Vaccinator sets up the non-dominant hand with vaccine, bandaid and swab (see above)
- Patient arrives with QR bar code ready on their phone (from My Health Connection or a printout). No Bar code? No problem, a last name search is only a few seconds more. Beep! 3 screening questions, done!
- Vaccinate! (previously described)
- Pivot our positions, and our student volunteer steps up and hands the vaccine card with followup instructions to proceed to observation area and to NOT MISS their next appointment (already booked for 3 weeks from now).
- DONE! our best cycle time: ABOUT 70 SECONDS INCLUDING DOCUMENTATION.
- Perhaps even more exciting, talking to each other about Lean process, discussing throughout the morning, how to stay safer: remember to tell drivers to put it in Park! Remind each other as we walk up and down, to stay out of the driving lane! When standing at your work table, prep your supplies with your body turned facing the line to be aware of your environment. Tell each other if you see something to improve.
- All 3 vaccinators have their own neck-lanyard mobile documentation tool, and we can give about a vaccine every 1.5 to 2 minutes including drive-up time, and one student keeps us supplied with peeled bandaids, filled-out vaccine cards, and explains next steps to the drivers, allowing the vaccinators time to re-set for the next care. It is a beautiful dance.
A Lean Lecture?
Talking with a colleague later, I reflected that I got so excited about our efficiency, that I gave a mini-lecture during the morning to our team and student volunteer on Lean process. My colleague then replied: “Oh no, Student! Wrong Tent! Wrong Tent!” implying that no student needs a lecture from an over-enthusiastic CMIO on a weekend. (Thanks for the commentary, Dr. Bajaj).
Our previous worries about backlog of paper charting needing later data entry?Gone!
The cool thing about this setup is: we did not pre-identify which cars had slow-down factors like: more than one scheduled vaccine recipient per car, no bar-code, occasional technical glitch, or lots of clinical questions. Occasionally, if one car took a little longer, the other 2 vaccinators would walk up the line and greet the next car. Once the line opened up, everyone slid forward easily. A handheld mobile and a one-hand vaccine supply made us nimble. None of us was waiting around, unless our line of cars emptied out entirely.
I enjoyed hearing the pharmacists on-site, who were mixing up batches in real-time (the Pfizer: needing to defrost and reconstitute from -70!), on the walkie-talkies discussing which tents needed more vaccine: “We’re almost out again at Tent 8.” “Okay, on the way with another batch of 25.” With our throughput (3 vaccinators, cycle time about 2 minutes simultaneously), that batch would only last us about 18 minutes. Loved every minute of it.
The CMIO in me wanted up-to-the-minute vaccine stats from the other tents. Not that I was feeling competitive. No. Not me.
The Pit Crew
Not being satisfied with even this, mid-morning we were asked to transition to a Pit-Crew method being piloted by our Clinical Informatics nurses. In our standard lanes, cars would pause at one of 6 Registration lines, drive down a lane and then be split into 16 vaccine tents. The Pit Crew were doing both Registration AND Vaccination in the Registration (big white) tent. Then, no second stop, straight to Observation. It was going so well, we recruited additional people to run a second line.
INSIDE the big tent. Four cars in a row. One stop to do it all. We don’t have all the timing numbers yet, but we believe this may take additional seconds or minutes out of our cycle time. There are some potential downsides to this configuration VERSUS our vaccine tent configuration; the registration workstations on wheels (WOWs) aren’t as nimble in traffic compared to our handhelds, so walking upstream when there is a delay is not practical, and if one car takes longer inside the tent, there is more potential delay. The upside: one stop could make the transit time much shorter per vehicle.
At the end of the weekend, ZERO DOSES WASTED. 10,000 given. ZERO significant complications in the observation area. Dr. Richard Zane calculates that the 10,000 vaccinated patients means that 157 fewer people will die of Covid as a result of our actions this weekend. Wow.
Stay tuned! We’re already performing at a high level, but we think there are yet improvements to make, while keeping patient and team safety our top priority. The work of our Incident Command structure has been a joy to watch, with team leads in constant communication with the Rockies, the Denver Police, the State, County and City.
Here’s a CBS Denver news article about us, with more photos from a drone.
CMIO’s take. Who knew that Toyota Lean Process could help vaccine administration? Furthermore, I’ll say it again: Get us more vaccine! We can handle it.
Outdoor vaccine guy says: come along, I’ll show you what I learned.
The UCHealth team held its first Mass Vaccination trial at Coors Field on Sunday 1/24. This was the first Mass Vaccine effort in Colorado, and was coordinated with the City and County of Denver, CDPHE (Colorado Department of Public Health and Environment), Denver Police, Verizon, Denver Health, Stadium Medical and the Governor’s Office. Weeks in the planning, dozens of clinicians, staff and coordinators swarmed the location assembling, arranging, tweaking.
2 hours: 1000 vaccines?
For this event, we planned to give 1000 vaccines in 2 hours to stress-test our design plan and to see if we could maintain or exceed this pace for future events. This was an invite-only event with 500 patients selected from UCHealth existing patients and 500 from newly-signed-up for vaccine from the UCHealth website for the general public aged 70+ per State current guidelines.
Between 6 and 7am, we assembled, got last-minute instructions for our many roles: runners, flaggers, registrars, traffic control, vaccinators, timers, process engineers, clinical observers, flow coordinators, etc etc. Here, I’m standing under a heat lamp, warming my hands for the day to come. The big white tent is registration-confirmation. Sorry, no drop-ins.
Team Number ONE!
With Dr. Jenny Bajaj, CMO of UCHealth Medical Group and Andrew Mariotti, medical student and process timer. We, of course, snagged Vaccine Tent #1. For work like this, snow pants recommended.
The UCHealth team set up a small batch of cars to arrive between 8 and 9am, to work out the kinks at every vaccine station; each station received 2-4 cars to test our supplies and workflow, and see if the runners, pharmacists, flaggers, observers had any questions about their jobs.
We then huddled between 9-10am to debrief questions from the team, then BOOM. Our full-speed test was from 10-12am with 1000 cars to come through in that time.
From the fourth floor of the Coors lot parking garage, the command center station. The RTD commuter trains run along the left, Blake Street on the right, the big white registration tent, where we catch and release any folks without appointment. The Mass Vaccine event (like EVERY Covid vaccine clinic) is highly calibrated down to our last vaccine. If we accepted drop-ins or family members, we would run out for our scheduled patients.
In the right row of tents, the first (most distant from us) tent is for registrations taking longer than usual, so that no registration line gets held up. Vaccine Tent 1 is thus the second (tiny) tent on the right. See me waving? No? No.
Our observation area (not shown) is actually behind the photographer, on the other side of the parking garage, with flaggers guiding the way.
Work station setup.
We re-arranged our area to be increasingly efficient. Working in teams of 2 allowed us to iteratively reduce our cycle time for each vaccination. Orange bucket 1: our vaccine supply (closely guarded by pharmacy and defrosted just-in-time). Orange bucket 2: pre-opened bandaids. Nothing is harder than cold, gloved hands opening bandaid packets when in a rush. Supply of gloves, alcohol swabs, gauze if needed. Raise the Yellow laminated card to indicate to runners if we needed supplies. Red card: help needed. Pink ribbon: attach to drivers side mirror for those warranting extended observation (eg previous history of anaphylaxis).
*One person waves down the car, checks “Please put it in Park!” (about 1/3 don’t unless asked!) asks the screening questions, confirms which arm, which passenger.
*Simultaneously, second person (vaccinator) doffs/dons gloves, opens alcohol swab, snags a pre-peeled bandaid, grabs a syringe
*Pivot! first person files the screening paper with identity and signatures for later data entry and grabs the vaccine card
*Simultaneously, vaccinator: Swab, Pre-attach 1/2 bandaid, Vaccinate in one motion, auto-retract needle (more on this below), Swipe bandaid across, Done!
*Pivot! first person explains the card, answers any questions, reinforces importance of second appointment, directs driver to proceed to next flagger to wait for the standard 15 minute observation time.
*Simultaneously, vaccinator disposes the syringe, clears trash, dons/doffs gloves and preps the next setup.
With this setup, Dr. Bajaj and I started with about a 90 second cycle time, and with iterative adjustments, pushed our best time down to 59 seconds, with our average running 1:15 to 1:20, if no questions (or profuse thankfulness) from the patients.
On debriefing this, we had several thoughts: the time it takes to chat and manage paper is about the same amount of time to swap gloves, manage supplies, setup. Seems like the 2-person team is, at present, an optimal setup.
In the coming weeks, it may be possible to incorporate a clinician-mobile-app adjunct to our Electronic Health Record that would allow on-the-fly documentation that would take the place of paper questionnaires and signatures when in the field.
Paper is fast, but…
From an informatics perspective, the paper process was a win from a through-put perspective, but an opportunity to streamline data-flow. We had runners taking our paper to the Documentation Tent to be keyed into the EHR in near-real-time.
Contrast that with our in-hospital based vaccine clinic (see my last post) where vaccination and documentation occur in real-time, the EHR and the State Vaccine Registry being updated almost immediately, and with a cycle-time (with one vaccinator/documentor) at about 3 minutes.
as my sister is fond of saying. At the end of our time, Vaccine Station 1 reported 67 vaccines given in 90 minutes. That is EIGHTY (80) seconds per shot. Taking into account the times when our station did not have a car, we think we could have completed 10-20% more shots. We are NOT Throwin’ Away OUR SHOT.
Here’s our high-level debrief. Team leaders from each of our major roles reported in: paramedics, police, City and County and State leaders, the Rockies (THANK YOU FOR OUR USE OF YOUR MASSIVE PARKING LOT AND TRAFFIC EXPERTISE). Very smooth. We think we could increase the pace beyond 1000 per 2 hours. We are targeting 5000 vaccines per day for 2 days next weekend. We’ll see!
Total throughput time per car?
Measured another way, we found that cars moved from Arrival at the Registration Tent to Leaving the 15-min Observation Area: 21-27 minutes. TOTAL.
Zero anaphylaxis events. No paramedic transports. There were very infrequent side effects observed in the observation lots. Everyone drove away successfully.
Local news coverage of our event
Sky9 aerial footage (about half way down the linked article). Tent 1 and my white coat is visible at 20 minutes. Woo!
Oh, and here’s a gif of the auto-retracting needle. So cool. How did they even fit a spring into the barrel of this tiny thing?
When done correctly, depressing the plunger completely means that the needle retracts from the patient, completely into the barrel of the syringe, eliminating the chance of unintentional needle-stick. Innovation FTW!
CMIO’s take? Mass Vaccination: another chance to innovate, another chance to take a chunk out of the Covid pandemic. Send us more vaccine. We can handle it.