As a pediatric healthcare organization, Boston Children’s Hospital provides huge numbers of immunizations to patients. Clinicians were figuring out immunization due dates manually using CDC references.
One reason Boston Children’s Hospital had not previously implemented any sort of electronic forecasting is because of the need to support catch-up scheduling for patients who have fallen behind in routine immunizations. Previously available electronic health record integrated systems did not support catch-up scheduling and could have made it more confusing to properly assess immunization needs.
Additionally, from a documentation perspective, it was a struggle to accurately document all of the information required by the state vaccine program – each dose must be accompanied by manufacturer, lot number, expiration date and funding source. The documentation burden and effort was very high and as a result sometimes not accurate.
“Boston Children’s Hospital implemented a homegrown labeling solution to help mitigate, but this required large amounts of staff time to complete,” said Brenda Dodson, PharmD, clinical integration architect, information services department, Children’s Hospital Applications Maximizing Patient Safety (CHAMPS), at Boston Children’s Hospital.
“The other challenge we faced was Vaccine for Children status documentation required for state-supplied doses, which is most difficult in the inpatient venue, so we ended up using all hospital-purchased supply for inpatient doses,” she said.
Boston Children’s Hospital worked with EHR vendor Cerner to identify a number of functional gaps in its immunization processes.
“The proposed solutions the hospital and Cerner collaborated on included accurate immunization forecasting leveraging Clinical Decision Support for Immunization (CDSi) content, including catch-up scheduling,” she explained.
“Also, leveraging information printed by the immunization manufacturers on the immunization vials and syringes to lessen preparation and documentation burden. Automation of the funding source determination – state versus privately funded vaccine. Implementation of an inventory-aware documentation system that could help separate out state and privately funded supplies of vaccines and let bedside clinicians know if they were using the wrong one.
"After a few week period of lots of questions and learning, trust began to build in the forecasting module. There are actually a lot of very nuanced recommendations for immunizations."
Brenda Dodson, PharmD, Boston Children’s Hospital
“Also, automation of immunization charge capture. And automation of Vaccine For Children status determination. Lastly, as a follow-on proposal, Boston Children’s Hospital was keen to implement immunization query and import from our state registry to reduce historical immunization documentation burden.”
The goal was to implement in stages, adding on as each piece of functionality was adopted by clinicians. The hospital worked with Cerner to design an implementation strategy that supported this goal and ensured it had the right technology implemented at the right time in the process for success.
There are many vendors with electronic health records systems on the health IT market today. Some of these vendors include Allscripts, Cerner, eClinicalWorks, Epic, Greenway Health, HCS, Meditech and NextGen Healthcare.
MEETING THE CHALLENGE
Immunization forecasting was implemented first. After extensive testing and validation, this went live in August 2018.
“Our clinicians were appropriately skeptical at the beginning – nothing had worked quite like this in the past,” Dodson noted. “After a few week period of lots of questions and learning, trust began to build in the forecasting module.
“There are actually a lot of very nuanced recommendations for immunizations,” she added. “CDSi serves to distill the Advisory Committee on Immunization Practices (ACIP) recommendations into very discrete and uniform recommendations – so much so that it sometimes seems to differ from what you see in the colored graphical and footnoted schedules that are often used in the absence of a formal forecasting function.”
With one or two exceptions, each time a question came up, staff reviewed the specific antigen/immunization CDSi recommendation and found that it was exact and correct, she added.
“Our next step was to start scanning the manufacturer barcodes that in most cases have embedded in them the manufacturer name, lot number and expiration date,” she continued. “To facilitate documentation of funding source, we enabled a solution to pre-populate the funding source automatically at the point of order entry by prescribers.
“Then, based on that ordered funding source, our system can now check the scanned product at the point of care to ensure it is the right immunization from the right funding source as well as automate documentation of that funding source,” said Dodson.
By having all of this in place, the hospital also has been able to move the charge capture point to be a direct result of documentation of the administration in the patient’s medical record, she added.
Recently, the hospital enabled the automated VFC status determination. VFC status must be documented for vaccines administered to patients under 19 years of age.
“It is often challenging for clinical staff to be able to do this because it requires knowledge and review of insurance information,” Dodson said. “Now VFC status is determined and displayed for each visit and this can be referenced to help meet the documentation requirements of Massachusetts. This has allowed us to move from using hospital-purchased supply for inpatients requiring vaccines to using state-supplied vaccine when appropriate.”
Most recently, the hospital has implemented immunization query and import. This enables clinicians to review immunization history that has been documented outside of the hospital’s system, recognize any missing information, and import it with just a few clicks.
“It is simply mind-blowing to do this for a patient who is new to our organization, but who is well on their way with routine immunizations,” she said. “A documentation task that used to take a lot of time and effort has been made more efficient and can be done with a few simple clicks.”
The system has been integrated with the Massachusetts Immunization Information System (MIIS). Documentation done in the electronic health record flows to the state registry. During this process, the state-based inventory – Massachusetts knows what they sent to the hospital based on the monthly shipments – is decremented automatically when administrations are documented in the record.
“This works ideally when all of the information about a particular immunization – for example, lot number, expiration – is an exact match to what the state has on record as having been sent,” Dodson said. “Our information match and auto-decrement rate has improved since implementing the new system because there are fewer manual steps involved in getting that information documented thanks to the inventory-aware documentation at the point of care.”
Another point of integration with MIIS is for the immunization query and import. In this process, clinicians initiate a request out to MIIS for the patient records. After clinician confirmation of the patient match to the MIIS record, previously administered and documented immunizations that are not in the hospital’s EHR can be reviewed and imported.
“Having this historical documentation is an important step in the process since future forecasting depends on previous administrations – what immunization, what dose number, timing between doses, etc.,” she said.
From a process perspective, prior to implementation of all of this functionality, there were at least 15 steps required across departments and clinicians to complete the full process around immunizations. This was reduced to 11 steps, five of which were made more efficient with automation.
“Overall immunization process time – inventory reconciliation, ordering, inventory intake, cross-charting – for the pharmacy department was reduced from about 48 hours per month to 2.5 hours per month after implementation of these technologies,” Dodson reported. “The largest time savings came from no longer applying labels to each immunization in an effort to reduce documentation burden at the point of care.”
Now that Boston Children’s Hospital can leverage manufacturer barcodes and inventory to get the same information automatically at the point of care, that process is no longer necessary.
“Boston Children’s Hospital has been able to reduce costs associated with supplying immunizations for our patients,” she said. “Previously, we had to use hospital purchased supply for all inpatients due to challenges with assessment of VFC status by bedside clinicians. The hospital is now able to use state supply – when appropriate – for inpatient doses thanks to the automated VFC status determination and inventory-aware documentation. From the year prior to the year after implementation, our savings in vaccine supply was roughly $36,500.”
From a patient care standpoint, prior to implementation of the forecasting, there was about a 7.5% occurrence of not having the complete recommended interval between live vaccine administrations met. This has been reduced to 2.1% post-implementation.
“Additionally, the forecaster has helped to highlight additional immunization needs such as additional doses of hepatitis B that are sometimes caused by having to use alternate products – for example, Pediarix instead of Pentacel – during back orders,” she said.
ADVICE FOR OTHERS
The entire process involved with immunizations is quite complex. At Boston Children’s Hospital, it involves multiple departments and many clinicians as well as the state.
“Analyzing process and clinical needs at each point of the process was a very important step in our process so that we were able to understand where we needed to have changes,” Dodson advised. “Some of those changes required patience as we anxiously awaited technology changes that would allow workflow and process changes.”
Ultimately, implementing the full suite of what was available has been welcomed by all involved in the overall immunization process, she said. Organizationally, she cautioned, it has required changes in several departments and workflows and many opportunities to collaborate.