Chapter 3: Immunization Strategies for Healthcare Practices and Providers

CDC works with state, local, and territorial public health agencies to administer the Immunization Quality Improvement for Providers (IQIP) program to introduce and sustain new or improved immunization practices. Designed to increase on-time vaccination at the provider level, IQIP strategies are intended to increase vaccine uptake among child and adolescent patients in adherence with the Advisory Committee on Immunization Practices (ACIP) routine immunization schedule. IQIP is targeted toward quality improvement among providers enrolled in the Vaccines for Children (VFC) program.

IQIP Overview

IQIP serves to assist and support providers by identifying opportunities to improve vaccine uptake, determining options for improving immunization delivery practices, and ensuring providers are:

• Aware of and knowledgeable about vaccination coverage within their practices and missed opportunities to vaccinate
• Motivated to try new immunization service delivery strategies and incorporate changes into their practices
• Capable of sustaining changes and improvements to their immunization delivery services

The IQIP Process

IQIP is a 12-month process where public health representatives and VFC providers collaborate to identify strategies to increase vaccine uptake by improving and enhancing immunization workflow. The collaborative process includes vaccination coverage measurement at or near the time of an initial site visit and again one year later to evaluate progress. Technical assistance and support occur at two- and six-month intervals to aid providers in staying on course with implementing strategies to improve vaccine uptake.

IQIP strategies include:

• Scheduling the next immunization visit before the patient leaves the provider site
• Leveraging immunization information system (IIS) functionality to improve immunization practice
• Giving a strong vaccine recommendation for patients
• Optional strategies as defined by the needs of state and local communities

IQIP has replaced CDC's previous Assessment, Feedback, Incentives, and eXchange (AFIX) quality improvement program to better address the current health care environment.

Many record-keeping tasks, as well as patient reminder and recall processes, can be greatly simplified by participation in an IIS. An IIS is a confidential, population-based, electronic database that records all vaccine doses administered by participating providers to persons residing within a given jurisdiction. In some areas, an IIS links to a complete medical record. While electronic health records (EHRs) include vaccination information, they may not provide a consolidated immunization history. An IIS provides a single data source for all community vaccination providers, enabling them to access records of persons receiving vaccinations from multiple providers. Data exchange between IISs, EHRs, and other information systems helps ensure timely vaccinations and records consolidation and allows immunization personnel to work more efficiently.

• At the point of clinical care, an IIS can provide consolidated immunization histories for use by a provider in determining appropriate patient vaccinations.
• At the population level, an IIS provides aggregate data on vaccinations for use in surveillance and program operations and for guiding public health action, with the goals of improving vaccination coverage and reducing rates of vaccine-preventable diseases.

The Guide to Community Preventive Services recommends IISs based on strong evidence that their use increases vaccination coverage. IISs can directly contribute to efforts to increase vaccination coverage through their abilities to:

• Create or support effective interventions such as patient reminder and recall systems, provider assessment and feedback, and provider reminders.
• Generate and evaluate public health responses to outbreaks of vaccine-preventable disease.
• Facilitate vaccine inventory management and accountability.
• Determine patient immunization status to inform decisions made by health care providers, clinicians, health departments, and schools.
• Aid surveillance and investigations of vaccination coverage, missed vaccination opportunities, and invalid dose administration.

Federal, state, and local public health agencies are continuing their efforts to improve IISs and to increase participation by vaccine providers. IISs are a key to increasing and maintaining vaccination coverage, and they offer advantages for providers, patients, and state and federal immunization program staff.

Strong Vaccination Recommendation

A strong recommendation by a health care provider is a powerful motivator for patients to comply with vaccination recommendations. A recommendation from a health care provider remains the number one reason parents decide to vaccinate. Even initially reluctant adults are likely to receive an influenza vaccination when the health care provider's opinion of the vaccine is positive. Studies show a parent who receives a recommendation from their child's health care provider is four to five times more likely to get the HPV vaccine for their child.

Research has also shown the way a recommendation is presented makes a difference. When providers use a presumptive approach (one that assumes parents will choose to vaccinate), parents are more likely to accept vaccines than when a participatory approach (one that presents parents with a decision to make) is used. A research study looking at health care provider's interactions with parents during vaccine visits showed parents were more likely to express concerns when providers used language asking parents about their vaccination plans. In this study, the presumptive approach resulted in significantly more parents accepting vaccines for their children, especially at first-time visits.

In practice, a provider using a presumptive approach might say, "Your child needs DTaP, Hib, and hepatitis B shots today." In contrast, a participatory approach might sound like, "Have you thought about the shots your child needs today?"

Take Time to Answer Questions

A strong recommendation will be enough to persuade many patients and parents to accept vaccines. However, some patients and parents might need more information or additional reassurance. An opportunity for questions should be provided before each vaccination. Discussion of the benefits and risks of vaccination is sound medical practice and providers are required by law to distribute vaccine information statements (VISs) before each dose of vaccine.

Surveys of parents of young children have shown while most parents plan to vaccinate on schedule, many parents still have questions, often related to vaccine ingredients, vaccine safety in general, or side effects. Data from CDC's National Immunization Survey (NIS)-Teen show when parents receive a recommendation for HPV vaccination from their child's health care provider, about a quarter of parents still choose not to have their child vaccinated. These parents may have concerns that need to be addressed about the safety or effectiveness of the vaccine.

If a parent has concerns, resists following the recommended immunization schedule, or questions a provider's strong recommendation, this does not necessarily mean they will not accept vaccines. Sometimes parents simply want to hear their provider's answers to their questions. Providers should be prepared to answer parents' questions succinctly and accurately, using terms parents understand. Effective, empathic vaccine risk communication is essential in responding to misinformation and concerns. It is important to remind parents that state laws for school or child care entry might require unvaccinated children to stay home from school during outbreaks. For patients who question or refuse vaccination, identifying common ground and discussing measures for deferring vaccination are more effective public health strategies than excluding these patients from a practice.

Providers can also train their staff in how to address basic vaccine questions to help save time during vaccine discussions and ensure parents hear consistent messages about vaccines.

For adults, providers can SHARE important information to help patients make informed decisions about vaccinations:

• Share the tailored reasons why the recommended vaccine is right for the patient based on his or her age, health status, lifestyle, occupation, or other risk factors.
• Highlight positive experiences with vaccines (personal or in the practice), as appropriate, to reinforce the benefits and strengthen confidence in vaccination.
• Address patient questions and concerns about the vaccine, including side effects, safety, and vaccine effectiveness in plain and understandable language.
• Remind patients that vaccines protect them and their loved ones from many common and serious diseases.
• Explain the potential costs of getting the disease, including serious health effects, time lost (missing work or family obligations), and financial costs.

When recommending influenza vaccine, it may also be helpful to explain that the vaccine can reduce the severity of illness among those who contract influenza.

Despite efforts by providers to adhere to appropriate immunization practices, there may be unknown obstacles to vaccination within the practice. Barriers to vaccination may be physical or psychological.

Physical barriers might include inconvenient clinic hours for working patients or parents, long waits at a clinic, or transportation issues. Providers are encouraged to determine the needs of their specific patient population and address obstacles to vaccination by taking appropriate actions, such as extending clinic hours or holding special vaccination events.

Psychological barriers to health care are often more subtle but may be just as important. Unpleasant experiences (e.g., fear of injections or difficulty leaving work for an appointment) may lead patients to postpone receiving needed vaccines. Concerns about vaccine safety contribute to some parents delaying or refusing recommended vaccines for their children. Overcoming such barriers calls for both knowledge and interpersonal skills on the part of the provider: knowledge of vaccines, recommendations, and reliable sources of accurate information to provide to patients and parents, as well as communication skills to address fears and misconceptions and provide a supportive and encouraging environment for patients.

Another obstacle to vaccination is a missed opportunity at a health care encounter in which a person is eligible to receive a vaccine but is not vaccinated completely. Missed opportunities can occur in all settings in which vaccines are offered, whether routine or not.

Missed opportunities occur for several reasons. Many health care providers avoid simultaneous administration of multiple injectable vaccines, frequently citing concerns about reduced immune response, adverse events, or perceived parental objections. These concerns are not supported by scientific data. Providers might even be unaware a child or adult needs a vaccination. In addition, providers sometimes follow invalid contraindications. A list of conditions incorrectly perceived as contraindications or precautions can be found in ACIP's General Best Practice Guidelines for Immunization.

Some reasons for missed opportunities relate to larger system issues, such as policies of only vaccinating children at well-care visits or not vaccinating siblings. Other reasons relate to institutional or bureaucratic regulations, such as state insurance laws denying reimbursement if a vaccine is administered during an acute-care visit. Several studies have shown eliminating missed opportunities could increase vaccination coverage by up to 20%.

Providers should implement systems to ensure the practice never misses an opportunity to vaccinate. Establish a policy to vaccinate at every visit, not just well visits, and schedule the next vaccination appointment before the patient leaves.

Recognized barriers to adult vaccination include:

• Limited access to health care
• Multiple competing priorities for providers who care for adult patients
• Low awareness among adults about recommended vaccines and their benefits
• Challenges in coordinating care for adults who often have more than one medical provider
• A complicated adult immunization schedule
• Vaccine cost and reimbursement

Professional societies such as the American College of Physicians and American College of Obstetricians and Gynecologists have developed programs to support providers in improving vaccination coverage among their patients. These organizations and the National Adult and Influenza Immunization Summit offer educational resources, tools, and strategies to overcome challenges to vaccinating adults.

It is an immunization delivery best practice for every provider setting to designate an immunization coordinator. This individual should be the provider site's point person for activities such as:

• Ensuring all vaccines are stored and handled correctly within the practice
• Helping to ensure all staff are trained in their role in immunization delivery and patient education
• Monitoring the practice's vaccination coverage
• Ensuring all staff know how to address questions from patients and parents so there is consistent messaging about vaccines
• Promoting and motivating staff implementation of immunization quality improvement strategies to improve immunization workflow, delivery, and, ultimately, vaccine uptake

By being familiar with the practice's vaccination coverage and understanding more about why some patients are not up-to-date with their vaccines, providers can implement interventions to increase coverage in their practice.

Cost can be a barrier to vaccination for many patients. In addition to evaluating the fee schedules for possible adjustments, providers should be knowledgeable about the VFC program, the state's Children's Health Insurance Program, and other vaccine-focused programs available within their jurisdiction.

A provider should consider participating in the VFC program if the practice sees children and adolescents (age 18 years or younger) who meet one or more of the following criteria:

• Medicaid-eligible
• Uninsured
• American Indian or Alaska Native
• Underinsured (only eligible to receive vaccines in a federally qualified health center or rural health clinic)

Being a VFC provider reduces up-front costs because practices are provided vaccines for VFC-eligible children at no cost. Providers can charge an administrative fee to offset the cost of doing business. VFC-eligible patients benefit because they avoid having to go somewhere else to get the vaccines they need.

Providers can create reminder systems to help them remember which vaccinations a patient needs. Examples of reminder systems are:

• A computer-generated list that notifies a provider which children being seen during the clinic session are past due on vaccinations
• A stamp with a message such as "no pneumococcal vaccine on record" that staff can put on the chart of a person age 65 years or older

• A "vaccination due" clip that staff attaches to the chart of an adolescent who has not had HPV vaccine

• An electronic reminder that appears when a provider accesses an electronic health record

Reminder systems vary according to the needs of the provider. In addition to raising vaccination coverage in the practice, systems serve to heighten staff awareness of the need to continuously check the vaccination status of their patients.

Standing orders are protocols whereby nonphysician medical personnel may vaccinate patients without direct physician involvement at the time of the vaccination. Standing orders are implemented in settings such as clinics, hospitals, and long-term care facilities. Standing orders have had positive effects on vaccination coverage among children and adults.

Standing order protocols should:

• Identify persons eligible for vaccination based on their age, their immunization status, or the presence of a medical condition putting them at high risk.
• Provide adequate information to patients or their parents regarding the risks and benefits of a vaccine and document the delivery of that information.
• Record patient refusals or medical contraindications.
• Record administration of a vaccine(s) and any postvaccination adverse events, according to institution- or physician-approved protocol.
• Provide documentation of vaccine administration to patients and their primary care providers.

Standing order protocols should also specify that vaccines be administered by health care personnel trained in screening patients for contraindications to vaccination, administering vaccines correctly, and monitoring patients for adverse events in accordance with state and local regulations.

Anyone responsible for administering vaccines should be knowledgeable about immunization principles, scheduling, safety and effectiveness, and proper administration techniques. Starting with the front office, each staff member should be aware of the importance of vaccines, educated on proper immunization practices and recommendations, and prepared to answer patient questions as related to their position. Numerous educational materials in a variety of formats are available from CDC and some state, local, and territorial health departments, hospitals, and other professional organizations.

Patient records are essential to a medical practice, and maintaining these records remains a critical part of providing optimal health care. Immunization records in particular must be accurate and meet all applicable legal requirements, as well as requirements of any specific program (such as the VFC program) in which the provider participates. These records should be available for compliance inspections and should be easy to interpret by anyone examining them.

Active medical records must reflect which patients are actually in the practice, and charts of persons who have moved or are obtaining services elsewhere should be clearly marked or removed. Records should be kept up to date as new vaccinations are administered, and all information regarding each vaccine and its administration should be complete.

Because patients often receive vaccines at more than one provider's office, communication between sites is essential for maintaining complete and accurate vaccination records. School-based, public health, and community-based vaccination sites should communicate with primary care personnel through quick and reliable methods. IISs provide the most seamless and comprehensive avenue for sharing information; however, e-mail, telephone, or fax can also be used. Using an IIS or other mechanism is increasingly important as more venues outside the medical home offer vaccinations.