A call for the informatics community to define priority practice and research areas at the intersection of climate and health: report from 2023 mini-summit

Abstract

Objective

Although biomedical informatics has multiple roles to play in addressing the climate crisis, collaborative action and research agendas have yet to be developed. As a first step, AMIA’s new Climate, Health, and Informatics Working Group held a mini-summit entitled Climate and health: How can informatics help? during the AMIA 2023 Fall Symposium to define an initial set of areas of interest and begin mobilizing informaticians to confront the urgent challenges of climate change.

Materials and Methods

The AMIA Climate, Health, and Informatics Working Group (at the time, an AMIA Discussion Forum), the International Medical Informatics Association (IMIA), the International Academy of Health Sciences Informatics (IAHSI), and the Regenstrief Institute hosted a mini-summit entitled Climate and health: How can informatics help? on November 11, 2023, during the AMIA 2023 Annual Symposium (New Orleans, LA, USA). Using an affinity diagramming approach, the mini-summit organizers posed 2 questions to ∼50 attendees (40 in-person, 10 virtual).

Results

Participants expressed a broad array of viewpoints on actions that can be undertaken now and areas needing research to support future actions. Areas of current action ranged from enhanced education to expanded telemedicine to assessment of community vulnerability. Areas of research ranged from emergency preparedness to climate-specific clinical coding to risk prediction models.

Discussion

The mini-summit was intended as a first step in helping the informatics community at large set application and research priorities for climate, health, and informatics.

Conclusion

The working group will use these perspectives as it seeks further input, and begins to establish priorities for climate-related biomedical informatics actions and research.

Background

The climate crisis is an alarming global threat to individual and public health. Intensifying climate-related exposures such as extreme weather events, rising sea levels, and temperature fluctuations have direct and indirect implications for human health.^1,2 More frequent heat waves are associated with greater risks of heat-related illnesses ranging from heat exhaustion to heat stroke.^3,4 Furthermore, worsening air pollution is contributing to increasing numbers of cardiopulmonary and pulmonary complications, and rising cardiovascular-related mortality rates.^5,6 Those risks disproportionately impact vulnerable populations such as children, older adults, individuals with chronic conditions, and people without homes.^7,8 Increased occurrence and severity of extreme weather and other events, including hurricanes, floods, droughts, wildfires, and heatwaves, cause direct physical and/or environmental harm, such as injury, displacement, environmental degradation, and saltwater intrusion.¹ Additional long-term sequelae of climate change are numerous, including the spread of vector-borne diseases such as dengue fever and malaria to areas that were previously non-endemic, alongside the emergence of other pathogenic conditions.^9–12 The most recent Lancet Countdown on Health and Climate Change report presents sobering projections for the health and survival of people worldwide unless “profound and immediate systemic changes” are made.¹ Most notably, the report forecasts a disturbing trajectory in key indicators for global progress, including a 370% increase in heat-related deaths, an additional 525 million individuals facing moderate-to-severe food insecurity, and a ∼36% increase in transmission of dengue disease (given a 2°C surface temperature increase scenario) by 2050.

Because understanding and addressing the impact of climate change on human health depend on the collection and analysis of data,¹ interest in the role of biomedical informatics in addressing climate change has also increased. All of the 2023 Lancet Countdown’s “11 priorities to deliver a healthy, thriving future” rely on climate data-informed surveillance, with 4 priorities specifically calling for strengthened global data collection and analysis, capacity to support climate change research, and knowledge generation.¹ However, given its urgency and public health implications, an undertaking of this magnitude necessitates strategic direction and concerted collaboration in the informatics community. This requires involving key stakeholders in biomedical informatics, healthcare providers, public health, policymakers, community leaders, regulatory bodies, technology developers, and others. At the same time, biomedical informaticians have knowledge about the healthcare system and its operations that can be useful in defining ways for the health profession to contribute to climate change mitigation and adaptation strategies.¹³

Methods

As a first step to that end, the AMIA Climate, Health, and Informatics Working Group (at the time, an AMIA Discussion Forum), the International Medical Informatics Association (IMIA), the International Academy of Health Sciences Informatics (IAHSI), and the Regenstrief Institute hosted a mini-summit entitled Climate and health: How can informatics help? on November 11, 2023, during the AMIA 2023 Annual Symposium (New Orleans, LA, USA). AMIA is the leading professional association for >5500 multidisciplinary subject matter experts committed to the practice of informatics as it relates to clinical care, research, education, and policy.¹⁴ IMIA seeks to grow and nurture a collaborative global biomedical and health informatics community that encourages and supports international initiatives to improve health for all. IAHSI promotes the dissemination of knowledge and best practices, fosters new ideas, and encourages worldwide collaboration and sharing of expertise and resources, by recognizing those who have made key contributions to biomedical informatics internationally. The primary aims of the mini-summit were to (1) initiate dialogue on the impact of climate change on health in the informatics context, and (2) conduct an open forum to identify potential opportunities, solutions, and collaborations at the intersection of climate, health, and informatics.

In-person participants were registered attendees of the AMIA 2023 Annual Symposium. Virtual attendees were also invited to participate. Participants consisted of informaticians from a wide cross-section of disciplines (biomedical informatics, clinical informatics, public health informatics, and others) including academics of various tenures (junior faculty to senior faculty) and in various roles (department chairs, journal editors, and association presidents), students and fellows (PhD, medical and informatics training programs), as well as industry leaders (Table 1). Using an affinity diagramming approach¹⁵ defined a priori (Indiana University IRB Protocol #21183), the mini-summit organizers posed 2 questions to ∼50 attendees (40 in-person, 10 virtual). We focused the questions on actions to support mitigation, that is, making climate change impacts less severe by preventing or reducing greenhouse gas emissions, and adaptation, that is, adjusting to the current and future effects of climate change.¹⁶

Table 1.

Attendee professional demographics.

Academia (n = 40)	Industry (n = 10)
Students	Health IT
Fellows	Insurance carriers
Junior faculty
Senior faculty
Department chairs

1. Current action and implementation: What evidence-based professional practices can individuals, groups, and organizations in healthcare apply or implement now to help (1) mitigate or (2) adapt to climate change?

2. Research: What research (of any kind) should the informatics community conduct to help the healthcare profession (1) mitigate or (2) adapt to climate change? The findings will then form the basis for evidence-based practices for future action and implementation.

The rationale for posing 2 distinct questions was to identify actions that can be taken now while acknowledging that additional approaches and solutions will have to be developed. While we considered the 2 areas as mainly separate, overlap in responses was expected. All responses were recorded by mini-summit organizers (H.C., J.C., M.D., T.S.) and synthesized (M.B., H.C., J.C., M.D., T.S.) to identify current- and future-state priorities for implementation and research.

In this process, we categorized attendees’ responses using affinity diagramming, an inductive exercise in which participants individually first record their own points and insights on Post-it™ notes. Then, participants collaborate to sort the Post-it™ notes into groups that have some similarity in intent, problem, or issue. We then labeled each group with a descriptive, summary note, and continued grouping until each cluster of notes was summarized and all comments represented. Affinity diagramming has several benefits. First, it avoids the danger of the most vocal participants dominating the discussion since each attendee records their own ideas independently. Second, popular ideas are easily discerned by the number of Post-it™ notes they are recorded on.

To check the group output against the current literature, we queried PubMed for the terms “climate change” and “informatics” (both Medical Subject Headings)¹⁷ in July 2024. The exact search was: Search: (climate change) AND (informatics)

(“climate change”[MeSH Terms] OR (“climate”[All Fields] AND “change”[All Fields]) OR “climate change”[All Fields]) AND (“informatics”[MeSH Terms] OR “informatics”[All Fields] OR “informatic”[All Fields] OR “informatization”[All Fields]) Translations

climate change: “climate change”[MeSH Terms] OR (“climate”[All Fields] AND “change”[All Fields]) OR “climate change”[All Fields] informatics: “informatics”[MeSH Terms] OR “informatics”[All Fields] OR “informatic”[All Fields] OR “informatization”[All Fields]

Two authors, T.S. and M.M., reviewed all citations independently and resolved conflicts jointly.

Results

In response to the current action and implementation question, comments clustered into 11 areas: literacy and education, workforce, regulations and policy, healthcare operations, measurement and evaluation, partnerships, community adaptation and resources, analytics, emergency preparedness, finance, and clinical decision support (Table 2). These responses point to the need for a cohesive yet multi-pronged strategy. With respect to education, participants noted that integrating climate literacy into all aspects of healthcare delivery will require that healthcare professionals gain, through a variety of instructional modes, a fundamental understanding of their individual and collective carbon footprints and other climate change impacts. Workforce development, participants said, will involve educating dedicated climate health experts with cross-disciplinary knowledge and expertise, while creative policymaking will be needed to incentivize climate-friendly practices in the healthcare sector and beyond, leading to optimal resource utilization and sustainability-focused practices. Transforming clinical operations will require reducing travel emissions from both health care practitioners and patients, switching from fossil fuel-generated power to renewable energy sources, minimizing resource use on all levels including essential supplies, and modernizing IT to support climate-friendly clinical and administrative operations. Regarding measurement and evaluation, comments emphasized the need to establish real-time monitoring of immediate and short-term climate impacts and resource utilization in the form of actionable dashboards. Participants also described methodologies for predicting long-term climate impacts via advanced predictive modeling techniques. Multisectoral partnerships across governmental agencies, research institutions, community organizations, and business entities, participants noted, will be crucial in addressing climate change and adaptation/mitigation efforts (including how to address resource allocation to those most in need and how to advance predictive modeling techniques to anticipate future resource needs). Furthermore, emergency preparedness and data stewardship (including IT resilience and health record access during natural disasters, crisis response scenarios, and mass human displacement as a result of climate events) are essential, so that clinical decision support and other informatics tools can guide healthcare providers appropriately.

Table 2.

Responses on actions and implementations that could be introduced currently.

Area	Action	Implementation
Literacy and education	Increase awareness of climate change impacts	Locally: Host educational workshops and community events Regionally: Collaborate with public health agencies and NGOs Nationally: Advocate for climate education initiatives Internationally: Support global health partnerships
	Track carbon footprint	Individual: Assess personal and professional carbon footprint Healthcare organization: Conduct carbon footprint audits
	Foster climate-friendly choices	Integrate climate principles into healthcare curricula Partner with vulnerable communities to co-design educational programs Offer just-in-time training for climate-related interventions
Workforce	Build a climate-literate workforce	Upskill existing healthcare professionals in climate science and resilience Educate future healthcare workers on climate-sensitive care Create career pathways for climate-focused healthcare roles
Regulations and policy	Incentivize climate-friendly practices	Advocate for policy changes that reward sustainable healthcare operations Implement internal policies to encourage green choices (eg, telemedicine, renewable energy) Design reimbursement models that promote climate-friendly care
	Enhance EHR sustainability	Develop “green-leafing” features in EHRs to minimize environmental impact Leverage EHR data for sustainable care insights (eg, reducing high-carbon medications) Standardize medical device validation and public health data sharing
Healthcare operations	Reduce patient and provider travel	Promote public transit and bicycle incentives for healthcare providers and patients Expand telemedicine and virtual care options Optimize clinical workflows to minimize travel needs
	Source renewable energy	Invest in on-site renewable energy generation (eg, solar panels) Purchase and advocate for clean energy from local providers Track and report progress toward renewable energy targets
	Prioritize resource efficiency	Reduce dependence on disposables (eg, switch to reusable supplies) Minimize paper and fax usage (eg, digitize processes) Implement waste reduction & recycling programs Extend lifespan of durable medical equipment Design resource-efficient health IT infrastructure
Measurement and evaluation	Monitor climate impacts	Implement real-time monitoring systems for resource consumption and emissions Design feedback loops to continuously improve sustainability performance Integrate climate change metrics into existing healthcare performance models
Partnerships	Foster cross-sector collaboration	Build partnerships with environmental organizations, government agencies, and public health departments Engage with communities most affected by climate change Collaborate with national EHR vendors and technology providers
Community adaptation and resources	Assess community vulnerability	Identify populations at increased risk from climate impacts Develop resource allocation plans based on social vulnerability indices
	Predict resource needs	Use data analytics to predict climate events and associated resource requirements Prepare essential resources (eg, cooling centers, medications) for vulnerable populations
Analytics	Optimize clinical and administrative efficiency	Implement data dashboards to track energy use, resource consumption, and waste production Leverage analytics to identify opportunities for sustainability improvements
Emergency preparedness	Enhance healthcare resilience	Conduct vulnerability assessments for healthcare facilities and IT systems Develop disaster preparedness plans for extreme weather events Establish protocols for minimum health record access during crisis response Prepare for mass displacement and refugee situations
Finance	Make climate action financially viable	Demonstrate the cost-savings potential of sustainable healthcare practices Secure funding and grants for climate-related initiatives Develop innovative financing models for clean energy investments
Clinical decision support	Encourage climate-friendly choices	Integrate climate considerations into clinical decision support systems Develop “nudge” strategies to promote sustainable care options Educate healthcare providers on the environmental implications of clinical decisions

In response to the research question, participants focused on the following areas: (1) emergency preparedness, (2) cost and carbon footprint, (3) sustainability, and (4) finance (Table 3). We put comments that did not fall into these 4 areas in a miscellaneous category. Two key areas identified for emergency preparedness research were IT resilience (to include evaluation of the current state of backup power solutions, data protection strategies, and alternative communication methods), and minimum necessary health and social determinants data collection and formatting to ensure that information is shared among first responders, clinicians, and other stakeholders. To optimize remote patient monitoring and other virtual medicine platforms, participants noted that more research is needed to define the level of electronic support needed, triage those who need in-person assessment from those who do not, and facilitate interoperability in communication streams. Regarding carbon-related research, comments emphasized the need to develop a systematic framework for information sharing and quantify the carbon benefits of a telemedicine platform for executives who would finance such platforms. From a sustainability and data analytics perspective, integrating the climate health informatics framework into the healthcare informatics framework, enhancing and developing new clinical coding standards, and forming a core set of data elements were seen as priorities.

Table 3.

Responses on needed types of research and other longer-term actions.

Area	Research focus	Examples
Emergency preparedness	IT Resilience	Strengthen IT infrastructure against disasters (floods, outages) Define minimum health and social record for crisis response
	Telehealth Optimization	Improve virtual consultations to reduce traffic Optimize telemedicine efficiency and effectiveness Determine optimal levels of electronic support (text, voice, video)
	Remote Examination Solutions	Research methods for remote physical exams or assessments Enhance patient information sharing (images, documents, DICOM files) Explore the use of templates and structured communication formats
	Clinician Workload Management	Investigate clinician capacity for multi-patient management (help desk model) Explore incentives for green transportation options Optimize clinician and patient commuting
Cost and carbon footprint	Resource and Workflow Assessment	Compare carbon footprints of healthcare resources, materials, and workflows Quantify telehealth carbon benefits across different regions Design climate-conscious health interventions Categorize and label energy costs throughout asset lifecycles
	Consumer Preferences and Expectations	Research consumer expectations around virtual care’s carbon footprint Optimize hospital size for minimum climate impact
Sustainability	Resource Reduction Strategies	Develop methods and culture for reduced resource consumption Integrate climate considerations into clinical decision support for sustainable practices
	Climate Informatics Integration	Integrate climate change into healthcare informatics frameworks Develop climate-specific clinical coding for evaluation and measurement Establish core climate health data elements for informatics
	Environmental Justice and Equity	Address challenges of measuring climate impact on Indigenous populations Use novel simulation methods to model health challenges (syndemicity) Build risk prediction models with AI and simulation Research environmental determinants of health
	Geospatial Mapping and Risk Assessment	Establish data vocabulary for spatio-temporal information retrieval and analysis Use GIS for heat island mapping and environmental risk analysis Employ wearables for remote patient monitoring (body temp, sweat, etc.) Leverage NASA/NOAA data for climate health risk indicators Improve surveillance and risk stratification (examples: heat-related conditions in vulnerable populations) Identify mental health impacts of climate change
Finance and ROI	Business Case for Climate Action	Demonstrate how climate measures improve organizational bottom line Research cost incentives for environmental improvement
Miscellaneous	Policy Development for Food Systems	Investigate policies to shift food production away from fat- and sugar-rich options (eg, targeting fast food and manufacturers)

The literature search yielded 1823 raw citations, dating back to 1989. Of those, 126 focused on climate, health, and informatics. Collectively, the papers had a large degree of overlap with the results of the mini-summit, both for current actions and implementations, as well as research. For instance, multiple papers addressed issues of informatics methods and data^18–26; sustainability in healthcare,^27–31 sometimes with a focus on informatics/IT applications^30–33; the role and impact of digital health interventions^34–36; disaster preparedness^37,38; public health surveillance^39–42; measurement and monitoring²⁹; and education,^43–45 awareness,^46,47 and communication.^48,49 Ideas from the summit that appeared be additive to the current literature included a strong focus on broad and inclusive collaboration; career pathways for climate-focused healthcare roles; advocating for policy changes and regulation; systematically and comprehensively assessing the carbon footprint of healthcare diagnostics, procedures, therapies, and clinical and administrative workflows; sourcing energy renewably; improving the management of resources and waste, including developing a more resource-conscious culture; designing feedback loops to continuously improve sustainability performance; integrating climate change metrics into existing healthcare performance models; accommodating environmental determinants of health in terminologies and coding systems; focusing on environmental justice and equity; developing more detailed approaches for disaster preparedness, including how to strengthen resilience of IT infrastructures; addressing the financial viability of sustainability and climate action; building climate considerations into clinical decision support and Electronic Health Records (EHRs); and researching consumer expectations. Many ideas generated at the mini-summit were also consistent with the recommendations made by Coiera and Magrabi⁵⁰ in a seminal editorial suggesting ten action steps that informaticians can take to address climate change.

Discussion

The mini-summit was intended as a first step in helping the informatics community at large set application and research priorities for climate, health, and informatics. While the recruitment of attendees was non-systematic and largely focused on attendees of the 2023 AMIA Annual Symposium, the generated ideas were largely consistent with the current literature, but also yielded some novel ideas and directions focused on informatics. As a result of discussions at the mini-summit, as well as subsequent discussions within the AMIA Climate, Health and Informatics Working Group, and with AMIA leadership, the AMIA Public Policy Committee, and others, we are making the following recommendations:

1. Leadership in climate, health, and informatics: The informatics community should continue to build on its early leadership in climate, health, and informatics to advance the important role of biomedical informatics in coping with the climate crisis. Evidence of AMIA’s early leadership includes JAMIA’s 2021 publication, in parallel with more than 100 health and science journals, of a key editorial⁵¹ that called for emergency action to limit global temperature increases, restore biodiversity and protect health; JAMIA’s December 2022 issue focused on climate change; AMIA’s approval of its Climate, Health and Informatics Working Group in February of 2024; and the increasing number of submissions to AMIA conferences under the heading of “environmental health and climate informatics.” The Working Group co-sponsored the NorCal Symposium on Climate Health and Equity, whose theme is “Climate Health Informatics,” during the AMIA 2024 Annual Symposium. Finally, the IMIA Yearbook of Informatics in 2025 will focus on climate and health, and IMIA is in the process of establishing a climate, health, and informatics working group as of this writing.

2. Partnerships with other efforts at the intersection of climate and health: Addressing the climate crisis requires broad and collective action. Therefore, it is important that the informatics community partner with other initiatives and organizations, such as the Climate and Health Program of the Centers for Disease Control and Prevention; climate and health policy at the federal government level; the Climate and Health Initiative of the National Institutes of Health; the Center for Climate, Health, and Equity of the American Public Health Association; the National Academy of Medicine’s (NAM’s) Action Collaborative on Decarbonizing the US Health Sector; the Medical Society Consortium on Climate and Health (MSCCC); and global efforts such as the Planetary Health Alliance and the Global Consortium on Climate and Health Education. AMIA already has joined the NAM and MSCCC initiatives, and the Working Group has built a strong relationship with the Healthcare Information and Management Systems Society.

3. Connections among scientific and applied communities: Addressing the climate crisis requires collaboration among many scientific and applied fields. Scientific fields include climate science, environmental science, atmospheric science, environmental engineering, geosciences, agricultural science, urban and regional planning, sociology and human behavior, public health, healthcare, biomedical informatics and communications. Applied fields comprise industrial engineering, business, and economics, among others. However, currently few of those fields pursue the robust and energetic collaboration that we need. Because informatics has a large focus on data and information, it can play a key role in helping connect various domains.

4. Partnerships with citizen scientists and patient/caregiver-driven climate-focused research communities: Although scientific and applied communities possess expertise that is critical for a meaningful response to climate-related health concerns, they cannot undertake all needed research and advocacy. Recognition of and engagement with citizen scientists^52,53 and patient/caregiver researchers will advance climate response and resilience by supporting protocol development, data collection, research dissemination, and other efforts.

5. Policy engagement: AMIA has a robust public policy program currently focused on 4 priorities: (1) support the healthcare workforce by advancing the field of informatics and reducing the burden on clinicians; (2) advocate for evidence-based care and decision-support through informatics, including through machine-learning and AI; (3) advocate for health IT solutions that ameliorate systemic biases and discrimination; and (4) advocate for ongoing funding for the field, including informatics research. The area of climate, health, and informatics intersects with all of them, and AMIA should integrate climate-relevant considerations with its public policy positions going forward.

6. Representation, curation, and connection of data and information regarding climate, health, and informatics: The informatics community has a long and impactful history in helping represent and curate data and information in healthcare and biomedicine.⁵⁴ This history should be written forward with regard to climate data. For instance, AMIA could work with the National Library of Medicine and others to ensure that data sets, rapidly growing literature, and practical guidelines, best practices, and implementation approaches are findable, accessible, interoperable, and reusable, in line with the FAIR principles.⁵⁵ In addition, in parallel with bridging the gaps among disciplines described above, we also must connect relevant data sets. For instance, to understand the manifestation, impact, and trajectory of vector-borne disease, we must connect data sets about climate, weather, geography, ecology, entomology, virology and bacteriology, clinical care, and public health. Informatics, with its competence in developing data standards, structures, mappings, and analytical methods, is a key discipline in realizing these connections.

7. Education and training on climate, health, and informatics: The contribution of physicians (and, by inference, all health professionals) to adaptation and mitigation is based on a professional ethos emphasizing their responsibility for the wellbeing of individuals and populations, now and in the future.^50,56 As a result, many initiatives developing competencies and approaches to address the need for education about climate change in the context of human and planetary health have been developed.^43,44 Informatics is not only essential in the delivery of health education⁵⁷ but also as a topic in its own right.⁵⁸ Education about climate and health, and their intersection with informatics, should therefore be integrated in all health science curricula.

While the mini-summit brought together participants from a wide variety of disciplines within the informatics field (such as members of AMIA as well as the International Medical Informatics Association and the International Academy of Health Sciences Informatics) as well as professional connections of the authors themselves, the expert recruitment process for the event was not conducted systematically, possibly leading to selection bias. Defining priority practice and research areas at the intersection of climate, health, and informatics comprehensively and systematically will require a rigorous, long-term, and continually evolving process.

Conclusion

The AMIA 2023 Mini-Summit on Climate, Health, and Informatics was our inaugural initiative to mobilize informaticians to confront the urgent challenges of climate change, laying the groundwork for sustained action and collaboration. The mini-summit discussions and the affinity diagramming exercise were valuable tools to engage and harness the collective expertise within our AMIA membership, and begin to establish priorities for informatics-based research and practical actions for the healthcare profession. The outcomes of the mini-summit will help shape the evolving charter of the AMIA Climate, Health, and Informatics Working Group in creating a strategic roadmap for climate informatics research. This group will serve as a focal point for exchanging knowledge, driving innovative solutions, guiding the development of evidence-based practices, and fostering engagement and mentorship for future informaticians engaged in climate change. Simultaneously, efforts are underway to establish an informatics emphasis area for climate change research, and make the topic an integral part of AMIA conferences and symposia going forward. These collective endeavors are the first of many required to achieve a broader vision to leverage AMIA and its community for heightened awareness and education, partner and community engagement, and public policy in the face of a rapidly changing climate. The AMIA 2023 Mini-Summit laid the groundwork for sustained action in climate health informatics, but the journey is just beginning. As we continue to build on these initial steps, the informatics community must remain at the forefront, driving innovation, research, and inter-disciplinary collaboration to address one of the most critical challenges of our time.

Author contributions

Titus Schleyer contributed to the paper according to the ICMJE guidelines for authorship including: substantial contributions to the conception or design of the work as well as the acquisition, analysis, or interpretation of data for the work; drafting the work and reviewing it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Manijeh Berenji contributed to the paper according to the ICMJE guidelines for authorship including: substantial contributions to the conception or design of the work as well as the acquisition, analysis, or interpretation of data for the work; drafting the work and reviewing it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Monica Deck contributed to the paper according to the ICMJE guidelines for authorship including: substantial contributions to the acquisition of data for the work; drafting the work; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Hana Chung contributed to the paper according to the ICMJE guidelines for authorship including: substantial contributions to the acquisition, analysis, and interpretation of data for the work; drafting the work or reviewing it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Joshua Choi contributed to the paper according to the ICMJE guidelines for authorship including: substantial contributions to the acquisition, analysis, and interpretation of data for the work; drafting the work or reviewing it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Theresa A. Cullen contributed to the paper according to the ICMJE guidelines for authorship including: substantial contributions to the acquisition, analysis, and interpretation of data for the work; drafting the work or reviewing it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Timothy Burdick contributed to the paper according to the ICMJE guidelines for authorship including: substantial contributions to the acquisition, analysis, and interpretation of data for the work; drafting the work or reviewing it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Amanda Zaleski contributed to the paper according to the ICMJE guidelines for authorship including: substantial contributions to the acquisition, analysis, and interpretation of data for the work; drafting the work or reviewing it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Kelly Jean Thomas Craig contributed to the paper according to the ICMJE guidelines for authorship including: substantial contributions to the acquisition, analysis, and interpretation of data for the work; drafting the work or reviewing it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Oluseyi Fayanju contributed to the paper according to the ICMJE guidelines for authorship including: substantial contributions to the acquisition, analysis, and interpretation of data for the work; drafting the work or reviewing it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Muhammad Muinul Islam contributed to the paper according to the ICMJE guidelines for authorship including: substantial contributions to the acquisition, analysis, and interpretation of data for the work; drafting the work or reviewing it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflicts of interest

A.Z. and K.J.T.C are employed by CVS Health^® Corporation and receive equity and own stock.