Immunization Strategies for Healthcare Practices and Providers Immunization Reaistries Many recordkeeping tasks,as well as patient reminder/recall activities,can be greatly simplified by participation in a Immunization Registrie 3 population-base Iimmunization registry,also known as an don system.】 dataororall .Reliable immunization history achchild in a give .Produce records for patient use geographic area (e.g.,a state).In some areas,an immunization registry is linked to a child's complete medical record.A Iegpoidatnetedbtnonc心crllcorsfhde mmuni tion pro ing access reliable immunization history for ever enrolled child and can also produce accurate immunization records,if needed for school or summer camp entry. 11 burden n a tlproduceroofmmuni o ohic28。品 thy People 2010 ild opulationtion thi tries.In 2002. state NIP and its parmnersat the eve evels are continuing their effo on ther and maintaining immunization levels and provide benefits for providers,patients,and state and federal immunization More about C.gov/ Recommendations to Parents and Reinforcement of the Need to Return The recommendation of a healthcare provider is a powerful pais ocomlywith vaccina ommendations and mendations Parentsof ped d the powerful motivato of the vaccine was positive. orba Regardless of their child's true status,many ild isitare nece.It is useful for patients to have the next appointment date in hand at the time they leave the 37
3 37 Immunization Strategies for Healthcare Practices and Providers Immunization Registries Many recordkeeping tasks, as well as patient reminder/recall activities, can be greatly simplified by participation in a population-based immunization registry, also known as an immunization information system. An immunization registry is a computerized information system that contains information about the immunization status of each child in a given geographic area (e.g., a state). In some areas, an immunization registry is linked to a child’s complete medical record. A registry provides a single data source for all community immunization providers, enabling access to records of children receiving vaccinations at multiple providers. It provides a reliable immunization history for every enrolled child and can also produce accurate immunization records, if needed for school or summer camp entry. Registries can also generate reminder/recall notices (discussed below), relieving provider staff of an additional burden, and can automatically produce reports of immunization coverage in an individual providers’ practice, or by the child’s age or geographic area. A goal of Healthy People 2010 is to increase to 95% the proportion of children younger than 6 years of age who participate in fully operational, population-based immunization registries. In 2002, approximately 43% of children in this age-group met this participation goal, and NIP and its partners at the federal, state and local levels are continuing their efforts to improve the registries themselves and to increase participation by immunization providers. Registries are a key to increasing and maintaining immunization levels and provide benefits for providers, patients, and state and federal immunization program personnel. More information about immunization registries is available on NIP’s website at http://www.cdc.gov/nip/registry/gen.htm. Recommendations to Parents and Reinforcement of the Need to Return The recommendation of a healthcare provider is a powerful motivator for patients to comply with vaccination recommendations. Parents of pediatric patients are likely to follow vaccine recommendation of the child’s doctor, and even adults who were initially reluctant were likely to receive an influenza vaccination when the healthcare provider’s opinion of the vaccine was positive. Regardless of their child’s true immunization status, many parents believe the child is fully vaccinated. Parents may not have been told or may not have understood that return visits are necessary. It is useful for patients to have the next appointment date in hand at the time they leave the provider’s office. An additional reminder strategy is to link the timing of the return visit to some calendar event, e.g
Immunization Strategies for Healthcare Practices and Providers the child's birthday or an written schedules or rem vethal enco and reminder can be an incentive for a patient's completing cgckneieadanhid水oatnhhr Reminders and Recall to Patients Reminder and Recall Messages to Patients lers and re me ges are me t Remnersoneinsaioehat ninders)or past due (recall messages).The messages vary in their level of (e.g.,postcar e degree o improving vaccination rates in various settings. impleonton ahouoe a ae a re call system. However,a dividers,and these can be adapted to the needs of the provider.The specific type of system is not directly related to its effe eofoaraonstoct mme Both the Standards for Child and Adolescent Immunization Pr upon providers tod : op and implement aeiwg paren ACIP supports the use of reminder/recall svstems by all syst Reminder and Recall Messages to Providers Reminders and Recall to Providers nd r for for remembering for which patients ions are due ast due reminder/recall is different from"feedba 'in which the out c -computer-generated list me mmunzation Due"clip on chart .A computer-generated list that notifies a provider of the 38
3 38 Immunization Strategies for Healthcare Practices and Providers the child’s birthday or an upcoming holiday. Even with written schedules or reminders, a verbal encouragement and reminder can be an incentive for a patient’s completing the immunization series and can ultimately result in higher coverage levels. Reminder and Recall Messages to Patients Patient reminders and recall messages are messages to patients or their parents stating that recommended immunizations are due soon (reminders) or past due (recall messages). The messages vary in their level of personalization and specificity, the mode of communication, (e.g., postcard, letter, telephone), and the degree of automation. Both reminders and recall messages have been found to be effective in increasing attendance at clinics and improving vaccination rates in various settings. Cost is sometimes thought to be a barrier to the implementation of a reminder/recall system. However, a range of options is available, from computer-generated telephone calls and letters to a card file box with weekly dividers, and these can be adapted to the needs of the provider. The specific type of system is not directly related to its effectiveness, and the benefits of having any system can extend beyond immunizations to other preventive services and increase the use of other recommended screenings. Both the Standards for Child and Adolescent Immunization Practices and the Standards for Adult Immunization Practices call upon providers to develop and implement aggressive tracking systems that will both remind parents of upcoming immunizations and recall children who are overdue. ACIP supports the use of reminder/recall systems by all providers. The National Immunization Program provides state and local health departments with ongoing technical support to assist them in implementing reminder and recall systems in public and private provider sites. Reminder and Recall Messages to Providers Providers can create reminder and recall systems for themselves as aids for remembering for which patients routine immunizations are due soon or past due. Provider reminder/recall is different from “feedback,” in which the provider receives a message about overall immunization levels for a group of clients. Examples of reminder/recall messages are • A computer-generated list that notifies a provider of the children to be seen that clinic session whose vaccinations are past due
Immunization Strategies for Healthcare Practices and Providers 3 .An"Immunization Due"clip that a nurse attaches to the chart of an adolescent who has not had hepatitis B vaccine Reminder syst will ver cording to the needs of the provider;in addition to raising immunization rates in the A missed o a persotraio butisot Missed Opportunity routinely or not. Missed A he Frequenty stared re have include conce reduced immune respons oradverse events and parenta dtProvie may be unaware tha cin RepPporised of vaccination (especially if t tion yaecwnegchildneedsaditiona Some of approp elae to laree inanutiona or breauerae as state ins s that deny Several studies have shown that eliminating missed esigned Standing or Exaincude he fol cation with siciar rephysician nvovent at the time of the immunio Standi s are implemente aniadpminediceonnnneaiaasnae 39
3 39 Immunization Strategies for Healthcare Practices and Providers • A stamp with a message such as “No Pneumococcal Vaccine on Record,” that a receptionist or nurse can put on a the chart of a person over age 65. • An “Immunization Due” clip that a nurse attaches to the chart of an adolescent who has not had hepatitis B vaccine. Reminder systems will vary according to the needs of the provider; in addition to raising immunization rates in the practice, they will serve to heighten the awareness of staff members of the continual need to check the immunization status of their patients. Reduction of Missed Opportunities to Vaccinate A missed opportunity is a healthcare encounter in which a person is eligible to receive a vaccination but is not vaccinated completely. Missed opportunities occur in all settings in which immunizations are offered, whether routinely or not. Missed opportunities occur for several reasons. At the provider level, many nurses and physicians avoid simultaneous administration of four or even three injectable vaccines. Frequently stated reasons have included concern about reduced immune response or adverse events, and parental objection. These concerns are not supported by scientific data. Providers also may be unaware that a child is in need of vaccination (especially if the immunization record is not available at the visit) or may follow invalid contraindications (see Chapter 2 for more information). Some of the reasons for missed opportunities relate to larger systems; e.g., a clinic that has a policy of not vaccinating at any visits except well-child care, or not vaccinating siblings. Other reasons relate to large institutional or bureaucratic regulations, such as state insurance laws that deny reimbursement if a vaccine is given during an acute-care visit. The degree of difficulty in eliminating the missed opportunity may vary directly with the size of the system that has to be changed. Several studies have shown that eliminating missed opportunities could increase vaccination coverage by up to 20 percent. Strategies designed to prevent missed opportunities have taken many different forms, used alone or in combination. Examples include the following: • Standing orders. These are protocols whereby nonphysician immunization personnel may vaccinate clients without direct physician involvement at the time of the immunization. Standing orders are implemented in settings such as clinics, hospitals, and nursing homes. When used alone or in combination with other interventions, standing orders have had positive effects on immunization rates among adults
Immunization Strategies for Healthcare Practices and Providers 。Provider education muniations should be eable abour。 of vaccination and vaccination scheduling,to the extent Numerouucational mareriavariety of format ting some principles (iere behavior than an education effort aimed only at increasing knowledge. Provider reminder and recall sy ms.Provider rer inder systems,while effective in increasing immunizatio leves. can also help avoid missed opportunities if they are a ward his goal tly and ational aid in promoting aropriat m can practices. Reduction ers to Immu anization Within t Remoun Despite effo ere to ractice setting ·Physical barriers a exist within the etim to the provider.Barriers to immunization maybe physical or psychological.P might be such things as .Psychological barriers ing pat -unpleasant experience C,or the e their specific patient population and take steps.suchas extending clinic hours or providing some immunization clinics,to address obstacles to immunization. Costsalboabaricrai In addition to such ren and the State Ch ildren's the provisions specific t Psychological barriers to health care are often more subtle 40
3 40 Immunization Strategies for Healthcare Practices and Providers • Provider education. Anyone responsible for administering immunizations should be knowledgeable about principles of vaccination and vaccination scheduling, to the extent required for their position. Providers are largely responsible for educating their patients, so an investment in provider education will result in a higher level of understanding about immunizations among the public in general. Numerous educational materials, in a variety of formats, are available from CDC, the Immunization Action Coalition, and some state health departments, hospitals, or professional organizations. Incorporating some AFIX principles (i.e., assessment, feedback) into a provider education program might have a greater effect on provider behavior than an education effort aimed only at increasing knowledge. • Provider reminder and recall systems. Provider reminder and recall systems are discussed above. These reminder systems, while effective in increasing immunization levels, can also help avoid missed opportunities if they are a component of other practices directed toward this goal. For example, if a reminder system is used consistently and staff members are knowledgeable about vaccination opportunities and valid contraindications, the system can be an additional aid in promoting appropriate immunization practices. Reduction of Barriers to Immunization Within the Practice Despite efforts by providers to adhere to appropriate immunization practices, obstacles to patients’ being vaccinated may exist within the practice setting, sometimes unknown to the provider. Barriers to immunization maybe physical or psychological. Physical barriers might be such things as inconvenient clinic hours for working patients or parents, long waits at the clinic, or the distance patients must travel. Providers should be encouraged to determine the needs of their specific patient population and take steps, such as extending clinic hours or providing some immunization clinics, to address obstacles to immunization. Cost is also a barrier to immunization for many patients. In addition to evaluating their fee schedule for possible adjustments, providers should be knowledgeable about such programs as Vaccines for Children and the State Children’s Health Insurance Program and the provisions specific to their state. Enrollment as a VFC provider is recommended for those with eligible children in their practice. Psychological barriers to health care are often more subtle but may be just as important. Unpleasant experiences (e.g., fear of immunizations, being criticized for previously missed
Immunization Strategies for Healthcare Practices and Providers appointments,or difficulty leaving work for a clinic appointment)may lead clients to postpone receiving needed 3 m edge and inter e a supportive and encouraging environmen Acknowledgments The editors thank Amy Kirsch and Nancy Fenlon of the National Immunization Program,CDC for their updating and critical review of this chapter. Selected References nvnCommiree onPctc of pediatrics.committes and Ambulatory Medicine.Increasing Immunization Coverage.Pediatrics 2003:112:993-996. CDC.Progra coverage information.MMWR 1996;45:219-220. A rica nil Physicians:Use of reminder and recall by vaccination 网catinae0W7 Dietz VJ,Baughman AL,Dini EF,Ste Hersey IC.Vacc Dini fe linkins rw sigafo generated me Am J Prev Med2000,18(2):132-139. i EF Maes E 41
3 41 Immunization Strategies for Healthcare Practices and Providers appointments, or difficulty leaving work for a clinic appointment) may lead clients to postpone receiving needed vaccinations. Concerns about vaccine safety are also preventing some parents from having their children immunized. Overcoming such barriers calls for both knowledge and interpersonal skills on the part of the provider— knowledge of vaccines and updated recommendations and of reliable sources to direct patients to find accurate information, and skills to deal with fears and misconceptions and to provide a supportive and encouraging environment for patients. Acknowledgments The editors thank Amy Kirsch and Nancy Fenlon of the National Immunization Program, CDC for their updating and critical review of this chapter. Selected References American Academy of Pediatrics, Committee on Community Health Services and Committee on Practice and Ambulatory Medicine. Increasing Immunization Coverage. Pediatrics 2003;112:993–996. CDC. Programmatic strategies to increase vaccination rates —assessment and feedback of provider-based vaccination coverage information. MMWR 1996;45:219–220. CDC. Recommendations of the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics, and the American Academy of Family Physicians: Use of reminder and recall by vaccination providers to increase vaccination rates. MMWR 1998;47:715–717. Dietz VJ, Baughman AL, Dini EF, Stevenson JM, Pierce BK, Hersey JC. Vaccination practices, policies, and management factors associated with high vaccination coverage levels in Georgia public clinics. Arch Pediatr Adolesc Med 2000;154:184–189. Dini EF, Linkins RW, Sigafoos, J. The impact of computergenerated messages on childhood immunization coverage. Am J Prev Med 2000;18(2):132–139. LeBaron CW, Chaney M, Baughman AL, Dini EF, Maes E, Dietz V, et al. Impact of measurement and feedback on vaccination coverage in public clinics, 1988–1994. JAMA 1997;277:631–635