The whole world watched in awe as Israel became the first country to vaccinate most of its citizens against Covid-19. And decision makers globally waited with bated breath for the results of Clalit Health Services’ study on the effectiveness of the Pfizer vaccine. When the results were published in The New England Journal of Medicine on February 24, 2021, confirming the vaccine’s efficacy, the article was the top news story all over the world and received an Altmetric Attention Score ranking it among the top 100 published medical pieces of all times, out of over 17 million papers!
Prof. Ran Balicer, the article’s lead author and the Chief Innovation Officer for Clalit and head of its Research Institute, explains that the study was groundbreaking for many reasons. “Our research was innovative because of the methodology, the data use and the data analysis that was done in near real time,” he points out. “We were able to match 600,000 vaccinated individuals with 600,000 ‘identical twins’ who were not vaccinated. For example, a 56-year old vaccinated man who lives in a specific neighborhood and has three pre-existing conditions was matched with one of his neighbors of the same age and identical health history who was not vaccinated. It’s the first time anything like this was done.” Clalit’s servers worked around the clock for five days straight in order to find non-vaccinated matches for all the vaccinated people in their database.
The extraordinary vaccine study reflects Clalit’s leadership role in innovation and healthcare research. These efforts are spearheaded by Clalit’s Innovation Division under the leadership of Prof. Balicer. During the pandemic, the Innovation Division conducted intensive research on many vitally important questions, enabling Clalit to implement a series of transformative initiatives. These included predicting the deterioration of specific Covid-19 patients and proactively contacting them in order to prevent their health from worsening; identifying patients who are at high risk to become infected with the virus when they come to a clinic and intervening in real time; predicting area-level morbidity trends and, as a result, warning about potential overcrowding in each hospital; and monitoring the effect of virus variants on morbidity.
Prof. Balicer explains that in the beginning of 2020 his team collected publicly available data mainly from China and Italy, where the virus was already rampant, and adapted an existing influenza complication prediction to build a model that would forecast who is most vulnerable to become sick with the coronavirus. “We developed a model which predicted who will most likely develop Covid-19 complications and we gave that information to our doctors back in March-April 2020, and they called each and every one of them. This is a good example of Clalit’s predictive proactive care approach. During Covid, we simply did what we always do – we created high-level models to help us care for our patients proactively,” he says.
The Innovation Division is now working on important follow-up studies on vaccine effectiveness and safety, including a clinical study which will determine to what extent vaccinated people can still infect others. The results, which will be published soon, will surely reverberate around the world – as many millions of people are eagerly waiting to hear the answer to this question.
Even before Covid-19, Clalit was a trailblazer in the field of information systems and digitization. The health fund’s state-of-the-art database includes detailed demographic and clinical data about all of its members, including their age, address and complete medical history. The data also includes information about next of kin for those aged 60 and older – their name, relationship and contact details. “This was especially important during Covid-19,” says Calanit Key, Clalit’s Head of Community Nursing division. “The relationship between the community nurse and the frail elderly patients is continuous and we knew how to reach out to them even through their son or wife.”
Throughout the pandemic, the health fund was able to proactively reach out to everyone in high risk groups thanks to its sophisticated information systems, to make sure that they were taking care of themselves and staying safe. “We were able to determine who was at high risk for developing complications and our teams, who personally knew these patients for years, contacted each one of them and instructed them on how they should comport themselves to avoid being infected. For example, we told people with certain chronic diseases not to see their grandchildren and to stay home as much as possible,” Key elaborates.
Clalit Research Institute defined five levels of risk for Covid-19. Approximately 200,000 of their members were in the highest risk category and another 300,000 were in the next two risk levels. In the first stage, all 200,000 people at the highest risk level were contacted directly by the nurse on their care team. “We checked on our patients and made sure everyone continued receiving their medications and the care they required for their medical conditions. Sometimes, we brought their medication to their homes and even arranged for some people to receive daily hot meals,” says Key. All 300,000 people in the next two risk levels were also contacted by their nurses. This initiative, which helped many people endure this difficult period, was facilitated by Clalit’s advanced computer capabilities.
“In parallel, we have worked with leading Israeli start-ups to create, adapt and integrate their solutions for use at Clalit during this time of crisis,” adds Prof. Balicer. “These tools were used to collect data about symptoms from our patients, to support monitoring of our patients in inpatient and outpatient settings, and improve our laboratory efficiency in testing for Covid.”
Holistic healthcare teams
Clalit’s innovative approach begins with the multidisciplinary, holistic manner in which it provides healthcare to its nearly 4.7 million members. Calanit Key explains that each Clalit member is attached to a family team who remains with them throughout their lives and oversees all their medical needs. In addition to doctors, each team includes a nurse, a pharmacist, a social worker if needed, and other professionals.
The team system has proven itself over the years, and even more so during the coronavirus. Since members know their doctors and nurses very well, the level of trust is high and people were more likely to accept the nurses’ guidelines and advice during the pandemic.
Thanks to its comprehensive, nation-wide network of community clinics and its strong presence in communities of all sizes throughout Israel, Clalit is able to provide a uniquely wide range of services, many of which are based on close relationships with resources in each community. For example, if a patient in a small town in the Negev requires a wheelchair, his care team will know who to talk to in order to help him obtain a wheelchair as quickly as possible.
Clalit employs approximately 3,000 community nurses throughout the country. These nurses, who are accustomed to caring for patients in an empathetic and personal manner, stepped up to the challenge presented by Covid-19 and came through with flying colors. They are the ones who called each high-risk patient and made sure they were okay. They also were in contact with each person who tested positive for the coronavirus – calling them twice a day and monitoring their symptoms. When necessary, they arranged for their patients to receive kits at their home through the subsidiary Clalit Handasa Refuit. These kits include an oxygen saturation monitor and other home care devices.
“Some people were really scared and didn’t know what to do. There were many difficult human situations we helped deal with, such as people who tested positive and didn’t know how to isolate themselves from their family members,” recalls Key.
In addition to caring for Covid-19 patients in their communities, Clalit also took on the virus in its 14 hospitals, which include general, geriatric, rehabilitation and mental health hospitals. As soon as the first wave of Covid-19 struck, the general hospitals opened special Covid-19 wards and ICUs to care for those with medium to severe symptoms. Covid-19 wards were also opened in geriatric hospitals.
Clalit also set up an impressive Covid-19 testing operation, with testing sites all over the country. In addition to community nurses and hospital nurses, the testing sites are staffed with various Clalit employees who volunteered to join the effort and underwent a two-day training program.
Triumphant vaccine rollout
Although it has clearly proven itself to be an innovative and resourceful organization, Clalit was put to the ultimate test on December 22, 2020. That was the day when the health fund was informed that in exactly one week it would start administering the Pfizer vaccine to the population of Israel. Working 24/7, Clalit successful built an impressive vaccination operation that included the physical sites as well as a convenient online appointment system. “We were able to do it because everyone knew what to do and everyone joined the effort with all their heart,” says Key, who headed Clalit’s vaccine rollout, adding that the health fund’s existing infrastructure enabled them to organize so quickly and efficiently.
Clalit set up 200 large vaccination sites near their clinics, some of which were located in stadiums, event halls and other large venues, as well as additional sites in smaller communities. Each vaccination site consisted of dozens of vaccination stations that were open seven days a week from 8:00 until midnight. At first, Clalit’s community nurses were tasked with the job of vaccinating. Later, when demand grew as those who received a first shot came back for a second dose, IDF medics and hospital nurses joined the nurses.
Key explains that ‘war rooms’ were set up to make sure that the enormous logistic operation ran as smoothly as possible and that no precious doses were wasted. The operation’s success is also due to the massive information campaigns that Clalit directed at the Israeli public, advising them about how to behave during the pandemic and, later, reassuring them about the vaccine. Both Key and Prof. Balicer made numerous appearances in the media and devoted much of their time to communicating information.
Clalit is rightfully proud of its remarkable achievements during the past year. Without a doubt, its longstanding commitment to innovation has allowed Israel’s premier health fund to uphold its position as a leader in cutting-edge research and advanced medical care during the Covid-19 pandemic.
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