The software design that allowed hundreds of people who weren’t eligible to get vaccination appointments at FEMA’s mass clinic in Philadelphia this week wasn’t a glitch, said the woman who founded the company behind the technology.

Far from it; the design was entirely intentional.

Tiffany Tate, CEO of Maryland Partnership for Prevention, said the shareable computer links that have been such a problem at COVID-19 vaccine sites were a feature meant to make them easier to disseminate in schools, senior centers, and other facilities. It’s not the software’s job to make people obey the rules, she said.

“You’re sharing it and showing up at a clinic you know you shouldn’t be showing up for, that’s a real problem,” said Tate. “No one would have known that people would abuse the link as they’ve been abusing them.”

The nonprofit’s software, PrepMod, has been criticized all over the country by governments who used it at the recommendation of the U.S. Centers for Disease Control and Prevention. PrepMod has handled five million individual vaccination records nationwide, and is the most widely used such software in the country, she said, managing COVID-19 vaccine registration in half of the top performing states in the country.

“The demand has been great and it’s been bigger than anybody anticipated,” she said, adding that public health officials are trying to manage a crisis on a scale no one has experienced before.

Plus, she noted, funding for public health departments has been slashed for decades, which may mean the tech savvy needed to use the software properly is out of reach at many agencies.

» READ MORE: Pa. counties are blaming ‘cumbersome’ state-provided software for vaccine registration problems

PrepMod’s local users have been asking the company to fix the unrestricted links for weeks, health officials have said. And while they agree with her assessment of declining budgets, they balked at the suggestion that its lack of know-how is behind any problems.

“I don’t think it’s a fair assumption to say because we’re underfunded we’re not tech-savvy,” said Megan Young, Montgomery County’s public health emergency preparedness coordinator. “It’s also a little frustrating that when we reach out for help or identify issues, we’re not getting the support we need.”

Small organization, big task

Maryland Partnership for Prevention began 21 years ago as a coalition to provide education and technical assistance to immunization providers. The Owings Mills, Md., nonprofit designed PrepMod to help schools coordinate immunization, Tate said, but when the pandemic struck, the organization was one of the only ones in the country with software capable of managing the information and record-keeping necessary for large-scale vaccination. PrepMod handles every task from finding a clinic with vaccine doses, to reporting a completed vaccination to state and federal governments, she said.

The fact that the CDC last year identified this organization as having the only end-to-end vaccine management software in the country speaks to how ill-prepared governments were for the pandemic. Others have since debuted.

Spending for state public health departments shrunk by 16% per capita in the last 11 years, and money for local health departments declined by 18%, a July analysis from Kaiser Health News and the Associated Press found.

“It makes no sense whatsoever that a tiny nonprofit like ours has the nation’s only solution to the biggest problem of our lifetime,” Tate said.

Her firm is engaged in a legal battle with the CDC and Deloitte, contending they stole her intellectual property to give Deloitte a template for its own software system, VAMS. The firm and agency have denied those claims.

Tate’s software is significantly more effective than VAMS, said Tinglong Dai, a professor of operations management and business analytics at the Johns Hopkins Carey Business School.

“I think that there are issues, but the issues are fixable issues,” Dai said. “Overall I feel like they do a really good job and some things can certainly be improved.”

Pandemic learning curve

Philadelphia officials backed up Tate’s statement that, for the issue with links, the software itself is not to blame, agreeing they too had no idea the links would help ineligible people make appointments.

» READ MORE: Philadelphia COVID-19 vaccine registration can finally keep out line jumpers, officials say

Pennsylvania health officials agreed some state and local public health personnel have required additional training to use PrepMod properly.

“On-boarding new staff to a system requires training, which the department has made a priority for internal staff and local partners,” said state Department of Health spokesperson Barry Ciccocioppo. “With any new technology, there is a learning curve that may take time to fully implement across all partners.”

The department paid $852,000 for the software, and shared it free with local governments. That too has created problems. In Allentown, for example, officials reported overbooking for vaccine clinics. Tate said she had not heard of that complaint, and a spokesperson for the Allentown mayor’s office said complaints were routed through the state Health Department, not to Tate’s nonprofit directly.

In Bucks County, officials contended with appointment reminders showing incorrect times, officials said, and ultimately switched to a different system.

“PrepMod proved to have far too many shortcomings,” said Diane Ellis-Marseglia, chair of the Bucks County Board of Commissioners. “In 2021 there should have been a better option, and the experiences and needs of the counties should have been consulted before an ongoing commitment to this program was made.”

The nonprofit offers two training sessions a week, Tate said, but she acknowledged health officials have a lot of work to do.

“They’re saving lives,” she said. “People are busy saving lives.”

Design flaws

There are design choices in PrepMod that have made using it more cumbersome or confusing, too. Dai thought a simple warning that links should not be shared or used except by the recipient might have helped.

“Eighty percent to 90% of the people are honest people, but we have a very small fraction of people who decide they want to jump the line,” he said. “That shouldn’t be the reason that things are not working.”

Montgomery County officials found that people who think they are canceling text-message notifications actually cancel their vaccination appointments. And users aren’t given enough time to enter insurance information.

If software is confusing and user errors are cropping up, Dai said, that indicates problems with its design.

“It should be very intuitive and actually have a very easy user interface,” he said.

The Health Department spent $15,000 for a temporary solution to the unrestricted links problem — but it made the sign-up process even more complicated.

Maryland Partnership for Prevention added 35 workers since April to manage the wide adoption of PrepMod, Tate said, but building new software is a painstaking process requiring rigorous quality testing to ensure the fixes don’t create other problems.

And, Tate said, she is prepared for the possibility that all the software’s problems have not yet been identified.

“It would be ignorant for me to say we worked it all out,” she said, “because I have no clue how this pandemic is going to pan out.”