PIC Education Committee- Online Educational Modules
Missed Opportunities and Registries
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Immunization schedules are designed to standardize which vaccines are given to different age groups of people and when they are given. There are two commonly recommended schedules: a childhood and adolescent schedule and an adult schedule. There is also a catch-up schedule for children who fall behind on their immunizations.
Missed opportunities occur when someone who needs a vaccine comes into contact with the healthcare system, but is not offered the vaccine. Healthcare providers should be in the habit of checking every patient’s immunization status at every visit. A good motto for this is “Every patient, every time.” There are several reasons why missed opportunities occur including healthcare providers not checking immunization status, inappropriate clinic policies, limiting number of vaccines given in a single visit, unawareness of the immunization schedule by the public, invalid contraindications, and reimbursement issues. Providers can reduce missed opportunities by using standing orders, educating their staff and patients, expanding hours, and/or instituting reminder/recall systems. There are several different types of reminder/recall systems, including chart reminders, mail/telephone/email systems, and computerized or registry based systems.
Vaccine shortages occur when the demand for a vaccine exceeds the supply. Shortages can vary in length, geographical region and cause. There are several different reasons why shortages occur. Some of these include decrease in number of manufacturers; increased demand for the vaccine due to recommendation changes, disease outbreaks, or sudden increase in public awareness; manufacturing or production problems; or insufficient stockpiles or extra doses of vaccine that are stored for such occasions. Sometimes multiple factors contribute to shortages.
Immunization registries, also known as immunization information systems, are computerized information systems that contain information about the immunization status of a population or a subset of the population in a given geographic area. Registries are beneficial because they improve office efficiency, centralize records, and allow for both ease of identification of high-risk populations and program evaluations. Limitations of registries include concerns about confidentiality of data, training of personnel, change to existing systems, and problematic integration with other systems. These limitations have been addressed by the Immunization Registry Association in order to streamline development and use of registries among providers.
Community-based initiatives can be important in addressing missed opportunities and use of registries. Stakeholders such as coalitions, departments of health, providers, and national organizations can work together to make progress in these areas. Efforts can include education, idea sharing, and mutual support.
TO LEARN MORE ABOUT THE IDEAS COVERED IN THIS SECTION, VISIT THE FOLLOWING:
Childhood and adolescent schedule:
Childhood and adolescent schedule:
Immunization schedules are designed to standardize which vaccines are given to different age groups of people and when they are given. There are two commonly recommended schedules: a childhood and adolescent schedule and an adult schedule. To learn more, please refer to Immunization Schedules and Recommendations module (link to ISR module).
Catch-up immunization schedules are specific schedules designed to bring children up-to-date on their immunizations if they have fallen behind. Catch-up recommendations take into account which immunizations have been missed, the current age of the child, and the time interval between doses.
A minimum interval is the shortest amount of time that must pass before an additional dose of the same immunization is recommended for a person. Minimum intervals are important because if vaccines are given too close together in time, the most protective immune response may not be generated. If vaccines are given in more than two doses, there my also be minimum intervals between the first and last dose.
A missed opportunity occurs when a patient comes into contact with the healthcare system for some other reason (a physical exam, mild illness, or emergency room visit) and he/she is in need of an immunization, but is it not offered during that visit. As a healthcare professional, it is imperative to be in the habit of checking each patient’s immunization status to minimize the missed opportunities in a healthcare setting. “Every patient, every time” is a good motto to follow- check every patient’s immunization status at every visit.
Reasons for missed opportunities include:
- Not checking immunization status and administering all needed vaccines at every visit
- Lack of simultaneous administration of all recommended vaccines or having an arbitrary maximum number of injections or antigens that are provided at one visit (on the part of either the healthcare provider or the patient/parent/guardian)
- Parental lack of awareness regarding vaccine needs
- Invalid contraindications
- Inappropriate clinic policies
- Reimbursement deficiencies
Strategies for reducing missed opportunities include:
- Standing orders: protocols whereby nonphysician immunization personnel may immunize clients without direct physician involvement at the time of immunization; can be implemented in clinics, hospitals, and nursing homes.
- Patient and public education: increases understanding about the important benefits of immunizations among the public and healthcare providers. There are several educational materials available from the CDC, the Immunization Action Coalition, Vaccine Education Center at The Children’s Hospital of Philadelphia and some state health departments, hospitals and professional organizations.
- Expanding clinic hours
- Reminder/recall systems: help to inform those who administer immunizations that individual patients are due (reminder) or overdue (recall) for specific immunizations.
Types of reminder/recall systems:
- Chart reminders can be as simple as a colorful sticker on the chart or as comprehensive as a checklist of preventive services including immunizations. These reminders tend to be more effective when they require acknowledgement by the healthcare provider, such as initials or a signature. Chart reminders are inexpensive, efficient and only require staff time and chart reminders in order to implement. However, it only reaches patients with scheduled office visits.
- Mail/telephone reminder/recall systems prompt the staff to telephone patients or send a postcard/letter/email reminding them that a vaccination is due or overdue. Some systems offer the opportunity for the patient to schedule an appointment. Reminder/recall systems can reach patients who may otherwise not have scheduled visits. Reminder/ recall systems can be as simple as picking one age or risk group for focused outreach. The ease of implementation and amount of staff time needed depend on the complexity of the effort and the availability of computer systems that can make reminder/recall “automatic.” Electronic medical record systems increasingly incorporate these types of systems.
- Computerized reminders involve a computer that prints a list of possible reminders that appear on a patient’s record. The software can be programmed to determine the dates that certain preventive procedures are due or past due and then print computer-generated reminder messages, usually overnight, for patients with visits schedules for the next day. Software can be stand-alone or part of an Electronic Medical Record (EMR). This system is effective, efficient, and inexpensive once the computerized system is in place. This system can only reach patients with office visits and requires a computer program linked to an immunization registry, medical records or billing data to generate reminders.
Vaccine shortages occur when the demand for a vaccine exceeds the supply. Shortages can affect certain areas of the country or the country as whole and may last a few days to several months. When a vaccine shortage occurs, local and state health departments and professional organizations try to notify all providers about the shortage, how long it is expected to last, interim recommendations for prioritizing allocation of available vaccine, and suggestions for tracking patients affected by the shortage. During this time, doctors are typically instructed to give immunizations to the people who need them the most. Other people are placed on a waiting list. It is important that providers have methods in place to call patients back after a shortage.
Reasons for vaccine shortages:
- Companies leaving the vaccine-manufacturing market
- Increased demand due to new or expanded recommendations, outbreaks, or highly publicized events increasing patient/family demand for a vaccine
- Manufacturing or production problems
- Insufficient stockpiles
- Stockpiles are extra doses of vaccines that are stored for use in the event of a vaccine shortage or disease outbreak. Doses of vaccine are not wasted as they rotate out of the stockpile for use before they expire and new doses are added as replacements. Stockpiles are controlled by the CDC. Not all vaccines are stockpiled.
- May be multi-factorial
Immunization registries, also known as Immunization Information Systems (IIS), are computerized information systems that contain information about the immunization status of a population or subset of the population (e.g., children) in a given geographic area. In some areas, the immunization registry may be linked to the 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 locations. It provides current immunization status of enrollees, contraindications to vaccines, and can also produce immunization records for school, work, summer camp or other programs. Many immunization registries also provide federally-required reports, such as stocks and inventories related to the Vaccines for Children (VFC) program.
How registries work: An immunization registry can be started at birth or at the time of a child’s first immunization. If a registry includes all children in a given geographical area and all providers report reliable immunization information, it provides a single data source for all community immunization partners, increasing effectiveness of immunization strategies by targeting underimmunized populations and helping evaluate interventions. Registries can maximize efficient use of resources needed to achieve and maintain high levels of coverage. Registry data can also be used to generate reports on any of the variables included in the dataset as needs arise.
Benefits of registries:
- Improvement of office efficiency
- Centralization of records from multiple providers
- Easier identification of high-risk populations
- Program evaluation
Limitations of registries:
- Concerns about confidentiality of data
- Training personnel
- Changing established office systems or starting new systems
- Integration with other systems
The Immunization Registry Association identified practices to help overcome these barriers. These practices include: using a web-based system; identifying a key person in the office to develop process improvements; providing opportunities for training; providing access to toll-free help desks; including a parent notification system; and working closely with billing vendors to verify that the registry data is compatible with their systems.
Community Initiatives and Missed Opportunities: Missed opportunities can be addressed by various members of the community:
- Coalitions and departments of health can undertake initiatives that:
- Educate providers- These groups can work together to create and distribute educational materials; hold continuing education events, such as dinners or workshops; reward providers who decrease missed opportunities in their practices; hold conference calls; or visit provider offices and help them implement best practices.
- Educate the public: These groups can work together to create and distribute educational materials; attend health fairs; work with the media through provision of spokespersons and media campaigns; give talks to local community groups; keep an up-to-date Web site; and provide question-and-answer opportunities.
Promote the use of registries by educating about their utility in decreasing missed opportunities.
- Providers can help reduce missed opportunities by:
- Using registries
- Sharing ideas for decreasing missed opportunities with other providers
- Educating staff to help identify missed opportunities
- Educating patients about immunizations and the immunization schedule
Community Initiatives and Registries: Registries are being developed and implemented at various levels in health care.
- National Organizations
- National Vaccine Advisory Committee (NVAC): In 1998, NVAC launched the Initiative on Immunization Registries to facilitate community and state based immunization registry development in the U.S. Through public hearings and parent focus groups, NVAC’s members and consultants prepared a report resulting from the Initiative on Immunization Registries. The CDC along with representatives from the National Vaccine Program Office (NVPO), state health departments, and the All Kids Count (AKC) program, developed minimum specifications for protecting the privacy of registry participants and the confidentiality of registry data.
- Center for Disease Control and Prevention (CDC): The CDC has several initiatives related to registries including:
- Funding research projects to identify strategies to encourage provider participation, improve registry data quality, and assess the feasibility of avoiding duplicate data entry in provider offices by enabling preexisting billing or patient management systems to report immunizations directly to an immunization registry.
- Developing a computerized tool to help examine registry data accuracy and completeness by comparing registry records with immunization provider records.
- Surveying state vaccination projects to identify provider recruitment activities and determine the best practices.
- Developing a technical working group to develop standard vocabularies and protocols for data transfer, assist in determining registry accreditation or certification methods and provide ongoing quality assurance monitoring.
- The Immunization Action Coalition (IAC) and Every Child by Two (ECBT) promote the use of registries through educational and media campaigns and maintains a national database of immunization coalitions.
- The Immunization Coalitions Technical Assistance Network (IZTA) is an excellent resource for immunization coalition members and advocates. The IZTA website provides resources for starting and sustaining successful immunization collations as well as exchanging information and ideas.
- Coalitions and health departments can help with registries by:
- Educating providers about the importance of registries, how to introduce them into their practices, and how to use them. These groups can also provide services such as training of staff and resources for help.
- Educating the public about the importance of registries and answering questions about privacy.
- Helping to implement registries in communities that do not have them and working with neighboring communities to have registries work together.
- Providers can help with registries by:
- Using the local registry
- Educating staff and patients about the importance and benefits of registries.
To learn more about the ideas covered in this section, visit the following:
Childhood and adolescent schedule:
Childhood and adolescent schedule:
Sample standing Orders:
http://www.immregistries.org/ (American Immunization Registry Association)
Immunization Action Coalition
Immunization Coalitions Directory
Immunization Coalitions Technical Assistance Network (IZTA)
UPDATED: July 2009