Standing Orders to Boost Adult Immunizations August 17, 2016

Transcription

1 WEBINAR: Standing Orders to Boost Adult Immunizations August 17, 2016 >> Hello everyone. Thank you for joining us today and welcome to today's webinar. We are very happy to have Doctor LJ Tan joining us to talk about our topic how to use standing orders to boost adult immunization rates. He is a key strategy officer of the Immunization Action Coalition. If you've joined Qualis Health I'm sure you've seen this slide before. We are a population health management organization. We working quality improvements and all kinds of practice settings, home healthcare, hospitals. We are the Medicare quality improvement organization for the states of Idaho and Washington. We work quite a bit in various settings to help people improve their practice and improve their workflow. Also working on Medicare quality reporting programs. Which brings me to this slide which is something we've create a recently which we hope you will take a look at which is called the MIPS minutes. MIPS is a new version of meaningful use and all kinds of quality improvement rolled into one thing and the proposed final rule is out. It's 962 pages. We assumed nobody felt like reading that. We have broken it down into a number of bite-size bits all available on our YouTube channel. All named by what the topic is. If you're curious about MIPS you can pour yourself a cup of coffee and pick and choose and begin to get to new -- know the new program. We also have some other events coming up. These are free webinars that are coming up on a variety of topics about strategies to strengthen patient engagement. That is September 13. Transitions of care medication reconciliation. And also the outcomes Congress celebration webinar for the nursing home quality care collaborative. We hope you'll join us for any of those. Pass it on to colleagues if you think someone else to work with might be interested. Now a quick look of a topic at hand which is adult immunization. Part of I Medicare work that follows Harold reforms and -- health reforms. We're looking at flu and pneumonia immunization for the over 65 population. A lot of what Doctor Tan talks about has to do with other immunizations as well. I was reminded that I have not introduced myself. My name is Mary Franzen I am the moderator. I'm a QI consultant here at Qualis Health. I did not put my own photo here so I forgot to remind myself to introduce myself. Here is a quick snapshot of where we are. This is data from last fall. Idaho and Washington rates for flu in pneumonia. -- And pneumonia. Were falling short of the healthy people 2020 goals. Nationally the pneumonia rate is about 50% and flu is 48%. We all have progress to be made here. Here is Doctor Tan. Doctor Tan is the chief strategy officer for the Immunization Action Coalition and the cochair of the United States adult in influenza immunization Summit he joined the Immunization Action Coalition in January Before that he was the director of medicine at public health at the American Medical Association for 15 years. The national adults in influenza immunization Summit is a joint project with the CDC and the national vaccine program office. Doctor Tan recently served on the national quality reforms adult -- is currently met -- thank you very much Doctor Tan. I will turn the present at -- presentation over to you.

2 Thank you Mary and thanks to everybody for this opportunity. Hope the seriousness will get implemented across the country. I am specifically focusing on adult immunization I think if you talk to the pediatric colleagues I think they will tell you this will indeed work in the pediatric practices. Just to highlight I know Mary talked about the rates -- I will point out that those turn out to be the two adult vaccines we are doing well in. I will focus on that and use it as a rationale for why we need to think about standing orders. Before I do that let me go ahead and show you a couple quick disclosures. The content of a lot of the work that I'm going to present is an initiative that's called take a stand. It was a project where we are trying to implement standing orders nationally for adult immunizations. As part of that project we launched into 23 workshops across the country. The 23 workshops are completing. -- Completed. Right now we are in the second phase of this project which is where we will begin to come back and reapproach networks and other practices as to the best ways I which we can continue to assist folks in terms of implementation of standing orders. I say that to plant the seed in your head that as you go forward and if you find an opportunity where you think standing orders are not being implemented and you need guidance, please think about us at the take a stand initiative and we will be happy to work with you all to figure ways to do this. Where it could be simply a repeat of a four-hour workshop, we can do webinars and so forth. That gets into the nittygritty of implementing standing orders. As I say that, the content of the entire initiative is immunization action coalitions. It is funded by Pfizer but Pfizer's funding has no consequence on the creation of the content. Just to let people know the independence of the content. This is what I will hope to do in the next 45 minutes and leave room for questions and answers. To discuss standing orders and discuss what are the components of a standing order next hopefully I will show you some evidence that standing orders include vacuum -- improve vaccination coverage rates. And discuss quickly how standing orders benefit the medical practices that you will be talking to as well. The problem and why we want to have standing orders is very clear. Besides flu and pneumococcal vaccination rates for adults all adult immunization rates are appallingly low. Not only are they appallingly low that they also exist huge disparities in terms of the immunization coverage rates as well. Many patients do not receive recommended vaccines during office visits. The assessment component is lacking. The patients come in for acute care for adults which we know happens. We have a great pediatric well care model and that's where pediatric populations are so well vaccinated. Somehow through adolescence we lose that and what we become adults we switch to acute care model. Our providers do not have a lot of opportunities to assess and make recommendations for adult vaccines even though they are being asked to do so. The newly redone -- revised adult standards for immunization practice. Of course as we all know, if you don't assess the patient for vaccinations there is no way you're going to be giving vaccines. If you did assess, -- if you can assess, you can give. Assessment is lacking which leads to missed opportunities for vaccinations.

3 The reason is clear, clinicians have to address all of those a key problems. The chronic medical issues. That's what they're being asked to take care of. As a result, they don't have a lot of time to prioritize vaccinations. Not just vaccinations but other preventive health issues. That leads to the missed opportunities which leads to the fact that a lot of patients are not protected against adult vaccine preventable diseases. We have a solution. It's a solution that is not well implemented and its standing orders. To summarize what we think standing orders can day. They can increase vaccination coverage because it reduces the missed opportunities in your practice. The way does that is it routinized is -- recognizes instead of having the physician meet every individual patient and prescribed an individual vaccine every single time for the patient in the practice it routinized visit so you do not have to rely on that physician order for every dose of the vaccine. Because of that you transformed the program and the immunization concept to a program. You can actually then empower nurses or other legally qualified individuals in the practice to manage that vaccination program. Legally qualified is important because depending on the state, you will have a very -- people who can administer a standing order and administer it. If you have freed the clinician from having to do this individual reaction and prescribed every single dose of vaccine you can imagine how that physician time can be -- acute-care situations and so on. We think standing orders are and exclusive solution to these problems of assessment and administration. Let's set the stage and talk about what are standing orders. I think many of you know that the definition of standing orders are written protocols that are approved by a position -- physician or some other authorized practitioner. That varies from state to state. In some states there's practitioners are giving the prescription authority and they can be the ones that also sign a standing order. It does vary from state to state. These written protocols when they have been approved authorized a nurse, pharmacist or other nonphysician healthcare personnel as allowed by state law to assess the patient's needs for vaccination. They can follow the standing order template and assess. And they can then give the vaccine and the clinician's direct involvement with that patient is not needed. You can see it really does transform it into a program whereby the practice is routinized. Who recommends the use of standing orders? I will mention two here. The community preventive services task force which is the US equivalent -- the parallel to the United States preventive services task force it gives recommendations and guidance to preventive services. This task force gives rapid -- recommendation and guidance to community preventive services. What the task force recommends are testing -- standing orders to increase vaccination coverage rates. They recommend standing orders on the basis of strong evidence of effectiveness. They have found in their review of 29 different studies that not only as -- is a standing order able to increase immunization rates in adults and children. In addition to the community preventive services task force the advisory

4 community immunization practices also recommends standing orders to improve adult immunization coverage rates. Specifically for pneumococcal and other adult vaccines. >> To talk a little bit about what we know about standing orders. This is from a paper by Rick Zimmerman who is one of the godfathers of standing orders. He's been studying and researching it and trying to implement them for several years. These made multiple publications. He took a look and -- trying to understand who is using them and how are they being used in 2011 he showed that only 42% of physicians reported using standing orders for flu. Which is one of the big adult vaccines. When you ask in that same study what happens if you ask them are you giving flu but are you giving them pneumococcal polysaccharide vaccine it drops to 23%. Only one in four physicians reported consistently using standing orders for both influenza vaccination as well as pneumococcal polysaccharide vaccination. When he took a look at this and said what are the factors associated with the practice being more successful. These are some of the things he found. I want to point out that while these are factors that are associated with improving use of standing orders they are not prerequisites. Your physician practices do not have to have these in order to be successful. These are factors that make it easy. The big one is that these are physician practices that are very aware of ACIP recommendations as well as Medicare regulations regarding adult immunizations. Specifically encouraging the use of standing orders. I showed you the ACIP recommendation and I will show you the Medicare recommendation shortly. The practice also has a strong philosophy that standing orders do work if you believe that standing orders are effective you will make a much -- implement them. The other factor that seems to be associated with success is having two or more clinical staff per physician because that allows the delegation of the standing order to more staff. Here are some of those documents that I was talking about. Here is the ACIP recommendation to use standing orders to increase vaccination rates. And here is a memo that was issued in 2002 from CMS that basically asserted the use of standing orders for influenza and pneumococcal vaccinations. Recommended by the ACIP. Recommended by CMS. Recommended by the United States community services task force. >> Taking a look at standing orders again here are other factors that have been associated with the use of standing orders. When it's interesting is the practice is a family physician practice. They tend to be more competent in using standing orders. Reason for that is probably because family physicians vaccinate across the lifespan. They have huge experience vaccinating pediatrics and as part of that the use standing orders for their pediatric patients. If you going to a pediatrician's office physicians are rarely the ones giving the vaccine it's a nurse or medical assistant or physician assistant. As a result the pediatric power -- practices are very versed in using the standing orders. If your family doctor and you see that it works in the pediatric population you will tried with the adult population. The second point is the idea of having a staff that is open to innovation and works well together. It is to the job of the standing order -- the implementation component of standing orders to emphasize collaboration and bringing in all members of the office staff to get them to work together into implement the standing order and to be open to the innovation of using

5 it as well. Having an EMR makes it easy because you can obviously pull a lot of that information directly into your standing orders. There are a lot of systems out there were standing orders are part of the module. When the patient's record pulls up the standing order to do the vaccinations pulls up so the patient -- the person looking at the medical record they can see the standing order. That makes it easier. In addition to the office staff that works well together having someone in that office staff that is passionate about giving vaccines and giving vaccines under standing orders is a six -- successful portion as well. We encourage them to develop an immunization champion. None of these are prerequisites. You do not have to have these 268. These are things that will help success. What are the things that seem to get in the way of using standing orders. We have lack of standing orders can be due to things such as no organizational support or weak organizational support. Many practices now exist in what we call integrative delivery systems or clinically integrated networks where they are employees within a larger system. If a practice says I want to do a standing order and the leadership says no. It will be harder. If within the physician practice a champion comes in and says I really want to implement the standing order but the physician is not convinced that will create a hindrance. These are not prerequisites. These are not things that apply to all practices. The other one I want to point out is concerns about legal ramifications of standing orders. When Rick took a look at this and ask what are you concerned about standing orders? One popped up which is the fear of malpractice. There was a concern that what happens if I implement a standing order and a nurse gives the vaccine and gives it poorly and there is a liability issue. I am here to basically take that off the table. To tell you that this fear of malpractice especially for liability is -- it has been relieved. The reason is because we have the vaccine injury compensation program. The program was established in 1986 and basically it provides no-fault compensation for injuries that are related to specify vaccinations. There is a table that's been created. In the table you have different vaccinations. You have event that are associated with those vaccinations. If those event occur, no questions asked, the patient is reimbursed or given compensation out of the vaccine injury compensation program. If it's not on the table, then you still cannot see the provider. You cannot see the manufacturers or the distributors of the vaccine. You have to go through the vaccine injury compensation court which is a special court that's run by three special masters. They will adjudicate whether that specific event that you are associating with immunizations is indeed an adverse event that should be compensated. You probably heard of this happening with autism. When they found that autism is not related to vaccinations and therefore was not compensated bill under the vaccine injury compensation program. Finally all routinely recommended childhood vaccinations because that's where it started. If a child vaccine is being administered to an adult it's covered. There's one vaccine that's administered to adults that's not administered to children and that is not included in the vaccine injury compensation program. The vaccine is zoster. That's only giving to adults. >> Let's take that off the table. Liability, not an issue. The other

6 thing that we hear as we went for our workshop entering across the country is what is the number one challenge of implement a standing order? We don't know what they look like. We don't have a protocol. Since we don't have a protocol it makes it hard. I will takes that barrier immediately off the table again. The Immunization Action Coalition shows an example of flu, indeed has templates for standing orders for every single ACIP routinely recommended vaccine. If it's ACIP routinely recommended vaccines you don't have to create your own templates or standing order protocol. Come to IAC and we have them done for you. I will take that off the table as well. I will spend some time now trying to show you what's in a typical standing order template that we have that IAC. I will run through the different components of the standing order protocol. I also want to emphasize that our templates are there for you to utilize as you see fit. If there is a component that I will talk about that you don't think needs to be in your protocol, it does not have to be. This is what we consider a best practice protocol. That's what I will use to walk through. I will walk through the component of a protocol using influenza as an example. This is a flu protocol that you see in front of you. These are the things that your protocol should have. If you think about it 80 follow the chain of immunization behavior it makes sense. First thing is the assessment. It is now part of the standing order protocol. We can reduce -- who is targeted to receive the vaccine? What you find out who is targeted to receive the vaccine then you need to take a look at the patient and say is that patient eligible to receive the vaccine? Is it indicated? Once you've determined that the patient can receive the vaccine the protocol will take you through the provision of the federal required information. There is one piece of federally required information and that's the VIS. Then the next step is you've given up the VAS and you've got the patient in the standing order protocol should talk about the procedures for comparing -- preparing and administrating the vaccine. You should check the vaccine name, schedule and needle size. Now you're at that point you've given the vaccine and you've done all of that properly. Now you've got to document the vaccine. Your standing order protocol should talk about how to document the patient record. You can do EMR, registry and you could also provide the patient their own individual records. Now you documented the vaccine and the next step is you had an adverse reaction that was related to that vaccination process. Then you should having your standing order a protocol that the person can look at to manage any medical emergency that might be related to that adverse event if you had the adverse event then you want to make sure that you report it. Finally at the bottom of that immunization journey you should have a box that is signed by a physician that says I offer -- authorized this standing protocol. Those are the necessary components -- those are the component that we consider best practice for your protocol. I want to give you more detail about each of them. I'm going to take a quick break. There are a lot of folks using standard orders. Our templates are used across the nation. The Department of Defense in particular uses our standing order protocol. Let's take a look at the different components in her standing order protocol. First the assessment. We are taking assessment and routinizing because we know that is a missed opportunity. Assess adult the need for vaccination against flu. You can see with flu

7 it's easy. The assessment process is easy. All adults are recommended to receive flu vaccine. The other component is there are protocol is that people do not recall if they have received it. They should just be vaccinated anyway. You have assessed and you know the patient in front of you can get the flu vaccine. The second component should be canned the person get that flu vaccine because of contraindications or precautions. This is the second box we have a and are protocol. We have a little box that says these are the contraindications for flu vaccine that is injectable. Then they precautions as well. We put it in her standing order protocol for you to take a look at but if you don't want to have this entire boxing your protocol you can say screen for contraindications and precautions by using our checklist. This is a checklist that -- to simplify the screening for contraindications. You can attack this component multiple ways and put it in the standing order itself or you can refer them to a checklist. The patient has been screened and the patient can receive the vaccine. Third component, got to give that VIS. This is the box that reminds a person to give out the VIS because it's federally required. IAC has VIS is for all the vaccines. You don't have to work too hard to get them. If you have a diverse population that your vaccinating, IACs has translations in over 32 different languages. Take a look at our website. This is the flu VIS a note of information for everybody if you're beginning to give flu vaccines, you don't have to wait for a revised VIS. CDC last year made a universal VIS that they intend for everybody to use throughout the different seasons. Reminder -- remember how we had to wait for the next season VIS. You do not anymore. You can use last year's VIS it's applicable for this coming season and for the following season as well. CDC has announced that. You've given up the VAS and the patient is ready. Now you will prepare the vaccine. We've got a couple components I want to run through. If you believe you've got really competent staff you can basically say consider the appropriate -- make sure you check the product and needle size. If you want to make sure that people are double checking look at the table we have here. This is specific to intramuscular injections for flu you can see we have a table that talks about body weight and talks about the needle gauge and also he tells you the injection site. We also have at the bottom for nasal as well. A little component to make sure that the vaccine is identified and you know the best way to administer it properly. We talk about the administration component and this is important has recently there's been an uptake in vaccine administration errors. The vaccinating injury compensation program has actually introduced a new adverse event that is compensated bill. This new adverse event that compensated bill is something called shoulder injury related to vaccine administration. This is because vaccines supposedly even in the deltoid muscle and not given appropriately were given in the capsule of the shoulder and cause injury. It's been happening frequently enough that the vaccine injury compensation program has said that this is something we will compensate this is not a license to go administer vaccines wrong. It's a license to go and make sure we do it right. We have a box in her standing order protocol that talks about doing it right.

8 Folks should recognize that you have the right patient, right vaccine, right age group, right dose and right route. We need to make sure that we treat our patients appropriately. This is something to keep in mind. I say this because I'm going to show you some pictures that tell you that this is happening. If I could pull these pictures up -- this is not an I am injection. This is definitely not an I am injection into the deltoid muscle. And this is wrong. You do not ever do flu vaccine into the glutinous. If I could pull up pictures clearly we have a problem. Our idea is we need to eliminate this problem and the way we do this is to take a look again at the protocol and make sure your staff think about this as well. >> Now this is the right way you're supposed to give the flu vaccine and you've now given the flu vaccine you've given it right now you need to document. We want to remind people that you are not supposed to document the vaccine in the medical record of the -- as by they will be talking to each other and that will be easier to do. Until that back and flow happens between medical records and the information immunization system there is a gap is specifically for adults. One thing we recommend is our template -- in our template is to give a personal immunization record card to the patient as well. There are many ways you can do that. IAC has one and this is virtually indestructible. If you write with it on good ballpoint pen you can throw it in the laundry and it does not wash off. You cannot rip it. It will help the patient keep track of his or her own immunizations at least until our adult lifespan registries catch up. That the documentation component. Now that you've documented there should be a trigger inside your standing order to help the person in doing it that they need to be prepared in case there is that rare adverse event that follows the vaccination process. There should be a protocol of how you will manage it. We have multiple ways you can do that. We recommend to give out this flyer from IAC. There are many of them out there. This is something that the administrator of the standing order protocol can take a look at in say I know what I have to do for all of these vaccine reactions. They are rare but they could happen. You want to make sure your standing order protocol informs the person who's doing that that they should be aware of this. If you've got an adverse event the next step is that you need to make sure you report it. You should report all adverse events to VAERS I want to remind everyone it's a passive reporting site. Anybody and everybody can report an event that's associated with vaccine administration to this database. There is no requirement for verification or validation. All that happens later after the documentation process. This is a signal generator. It does not validate the signal. It does not show causation. It just generates the signal. That's the reason I want to make sure everyone remembers that Now were done. We have gone through the vaccine administration journey. At the very bottom of your standing order protocol should be this box where the patient -- where the physician can sign off and say here is the standing order protocol and my nurses or my PA or MA can uses

9 protocol to vaccinate my patients. We recommend a rescission date. The reason we recommend that is because we don't want standing orders to sit perpetuated. Because recommendations change. Your stander -- standing order should change as well. With flu we think it's actually a good time every year that the flu has to be revisited. Having this rescission date allows you to come back every year and make sure that your people -- your staff who are administering vaccinations with standing orders are doing it right. One of the things that a colleague likes to say is every time flu season comes around the flu -- first bought the flu vaccinees -- vaccination to get should be for you and your staff. By putting a rescission date it makes you come back and revisit this and revisit your protocols as well. I will wrap up with a couple slides to talk about why we do this. Our standing orders -- our standing orders effective? The community guide to look at studies. When you use standing orders alone and have nothing else and increased vaccination coverage in adults by 17 points. When you use them with other interventions. Something like client reminder recalls or improving access, clinic-based education or provider education. If you use those things the association with standing order this shows the coverage rates go up by 31 points. Standing orders work. If you take a look at that same study they showed that it works not only in physician practices but in a range of clinical settings among a variety of provider patient populations both inpatient and outpatient. They found that it works not justfor children but also adults. Here some data. It's an older study that shows to practices with specific to influenza vaccination. They did not use standing orders and to practices that did. You can see there is a 27% improvement in terms of standing orders. With the implementing of standing orders for influenza. 27%. Here is more recent data. Data presented at the 2015 and if ID clinical vaccination course. This is standing orders with adolescents. It's out of a large healthcare system in Colorado Denver health were not satisfied with their Atul -- adolescent immunization rates. They implemented standing orders. If you look at the right-hand side of the table you see the the -- the immunization coverage rates followed the implementation of standing orders take a look at those rates. Compare those to the Colorado average and compare those to the national average. You can see how incredibly effective standing orders are in terms of complete -- improving immunization rates. Standing orders work. Not only do they work, there is a lot of information that supports that they benefit medical practices just a few points as you go to your practices. Efficiency. Now the clinician is freed up. They don't need to assess vaccination needs or issue written orders for every single patient to vaccinate. You can reach nice it into a program and allow nurses to take charge of that program. Increases your clinical efficiency and less you to vaccinate more people if you vaccinate more people, you can reduce the cost of the vaccine because you can buy it in bigger numbers. And you can increase your income flow. If those two reasons are not reasons for you to vaccinate using standing orders, we believe patient safety should be the number one reason. If you get better vaccine coverage you get less vaccine preventable diseases and you decrease opportunities for transmission of those diseases. For all

10 those reasons implementation of standing orders to improve immunization coverage makes a lot of sense. Here's a summary. I want to point out it works. I showed you data that it works. It's been endorsed by major major vaccine policymaking institutions. They are not difficult to implement. You've got to get everybody on board. If you have that immunization champion it's each the year -- easier. >> IAC decided to create what I call a cookbook but it's a protocol for step-by-step how do you implement standing orders in a system or practice. We created brand-new guidance for this. This was introduced this year in It's 10 steps for implementing standing orders and systems or practices. It's brand-new. It's on our website now. I will not walk through this six page guidance because this six page guidance in detail because it's the focus of our workshops. If we can do a whole workshop on every single component obviously I don't have time to do that now. I will show you the 10 steps that we have identified in our guidance and that we work through the details for each of these steps. Step one, discuss the benefits of implementing standing order protocols. Here is the leadership. We have a recommended if you're going to do this the first thing you should do is audit your current immunization rates. When you do that you will find that you're not doing as well as you thought you were. When that happens, leadership -- leadership by in happens quicker. We also talking our guidance about the person who will take the lead. This is the program that drives the program through. You have to identify the person that will be the champion. And you want to reach agreement within your practice and staff. This is the team getting together and thinking about what vaccines do you want to do? I would recommend at least doing more beyond flu and Nemo. What you do that you come to IAC and you can create your own standing protocol. At this point you are ready to think about how to move forward. Now you want to hold the staff meeting and bring everybody in. Explaining of standing orders and you will do them for these vaccines. Get everybody to buy in. As part of that volume in we have created a card that is on our website that provides talking points for why a practice needs to do standing orders. Things that are more nitty-gritty villa rent -- relevant to staff members. Once you've done that staff meeting this as an opportunity to use that staff meeting to determine step six which is the role they will play in the implementation. You will have administrators of the vaccines but at the same time you need to think also for example while standing orders are great and you can vaccinate a large number of your patients it cannot and will not be able to be used to vaccinate 100% of your patients. There will be that funky patient that come through the standing order process that will have to be pulled out and evaluated by another care -- healthcare personnel inside the office. This is why you identify those roles. This is why you identify that profit -- process you want to sit together and say if we have that patient we will pull that patient out and nurse Jones you are next and you will be the one that talks to the person about whether they can get vaccinated. Those are things you want to determine as step five, six and seven. So your whole team buys in. Once you're done, you've got a standing order program that can be used to vaccinate all the adults in your practice. Now you need to think about how do

11 increase vaccinates -- vaccination coverage. Think of ways to publicize the program to your patients. Put a sign in the waiting room. Advertise if you have electronic new -- newsletters. Think of ways to make it possible to improve your vaccination coverage rates. You want to start vaccinating. Finally, we recommend you come back and review your progress. You want to go back to leadership and say I implemented these standing orders and look the numbers have gone up. A great way to get people to buy yen. That's something you want to think about. I will leave you now and say no liability. Templates are available. Here is the website. How to implement X we have a guidance. Come talk to us. Go out there and get your practices putting in standing orders because as I showed you they work. They protect patients and that's what we should be doing. I will and you with this resource page. There are multiple places in IAC to get information. I want to thank you for your time and thank you for your attention and for the opportunity to present to you a topic that's passionate to me. Thank you Doctor Tan. This is Mary Franzen. I want to wrap up a little bit with a few more resources. Some places you might want to look for additional information and we will open it up to -- for questions. If you could chat your questions that was probably the easiest way. There is one link listed on the slide but that link is a landing page that takes you into a number of different resources. There is a number of things there including information about Medicare billing processes and Medicare regulation. Both flu and pneumonia our billable up -- among -- billable on Medicare part D. A little bit about vaccine hesitancy in adults. Probably the practitioners on the line have heard every reason in the world why someone does not need a shot. This first link is the CDC link, strategies for increasing adult vaccination rates. It talks about overcoming hesitancy. Standards for adult practice these bullet points mere what Doctor Tan was talking about. The there last one, document. Here are the links to the two state immunization registries. There is a perception that these are childhood registries. They are actually lifetime registries. We can help you figure out how to use the registries or put you in touch with the statement -- Department of Health. Whatever you need. That is the end of our section. We welcome questions. >> How do you suggest addressing patient fears about shots? >> I think it's interesting because one of the things we are figuring out is the adult population is different from the pediatric. We know that the vaccine and vaccine confidence is something we have to address with parents in the pediatric population. We do have a lot of information on the IAC website. There's a lot of talking points you can pull down to address specific questions that people can ask. You have to address the patient at the patient's fear. You do have to do that. This is one of those question points that you can put into your discussion on standing orders because that question will come out at the very beginning when the patient is being assessed. This is where the team discussion has to happen. You have to ask if they are comfortable at -- answering questions about the adults fear. The adult population have a couple of very specific questions they want answered and if they're done they tend to get vaccinated. You can say Doctor Jones recommends you get the flu vaccine because of your heart

12 condition. If you can provide an answer specific to that question meeting the patient at the patient's need they tend to get vaccinated. I can't go through every single possible fear that we could address but I do think it's important to address the patient's fear at the patient's fear level. Do not talk around the fear. Do not try to bypass that conversation. You want to address it and there are a lot of resources to pull up. Have that discussion with your staff before you implement the standing order to find out their confidence level to address the fierce. Patient to decline, if someone decides that they don't want to vaccinate today that's not a reason to not come back and ask again the next time. A person may decline because they don't feel well. It's not because they're resistant to vaccinations. Those are things we want to make sure we are aware of as well. I hope that addresses the question. Thank you. We have a question on the phone line. >> My question is is there any plan in the future for Washington and Idaho to be able to share information that are in the registries -- in the databases since we have so much common -- workers that go back and forth and patience? Thank you for that question. I will and by my colleague Chanda to -- the answer is not as far as I know. I recently tried to answer this question with Washington and Oregon. It doesn't seem to be too high on the registries list at the moment. That's something that we will look into with the IAS and it's something I hope we have. It's not something that I know of at the moment >> Also just to point out there is a pilot study that's been organized by the offices of national coordinator where they are looking at five states and trying to connect the five states systems or registries through a cloud. I don't know if you've heard of it. Washington was actually a participant in that pilot but I don't think Idaho was. There looking at the data and hopefully this will lead to a new way for interoperability between all the states. Thank you. >> Is a possible for us to get the links to that? So we can find out more about it. I will send you the link to the presentation where they talked about that pilot. Thank you. I have another question. You do have some -- I appreciate the way in which you presented it it was very clear and concrete. I'm aware of the fact that some of [ Indiscernible ] are not from physician offices but are from home health agencies or skilled nursing facilities. To have any recommendations for these other sites? While the data is not as -- it hasn't been studied. The data is not as robust. There is no expectation why standing orders would not work to facilitate immunizations for home health agencies. The challenge is going to be at the state level the so-called supervision requirements that are associated with different people vaccinating. What do I mean by that? Estate for example may have very specific supervision

13 requirements for a medical assistant who is providing a vaccine. That supervision will make it such that a home health agency that that medical assistance -- assistant cannot travel -- those do vary from state to state. I don't know the laws around Washington or Idaho. To tell you that there is no reason to say why standing orders cannot work but you need to check that your state legislation level to see whether there is something else that might prevent a standing order from being put -- implemented easily. You may not be able to use the MA or you may have to use a nurse. There is no -- it's data state to state. Otherwise I think it's worth exploring. >> It's nurses that are usually doing it from the home health standpoint and from a skilled nursing facility standpoint. >> That would go back to the state legislation as to how much supervision a nurse is required and I think that will vary from state to state as well. I would argue that if it's a nurse that's doing it in Washington, I think the ability of a physician to sign a standing order and authorize a home health agency to go out and provide that under the standing order would be strong. It looks like we have a question -- maybe you can text it into all participants. You talked a lot about having an immunization champion within the practice. The first day your the champion and you want to go in and start the standing orders. No one else is on board. Where would you recommend that person start to try to win people over? It depends on whether you're talking about a large system or this. Look for the person that is the most influential in your practice. Don't call that team meeting yet. You've come to one of our workshops and your gung [ NULL ]. I would look for that one person that you know in your practice who is the most influential. The person that's respected and people say you need to go ask him or her. I would look for that person and have a sitdown lunch. Or have coffee. I think one-onone you can make a very argument -- you can use all the materials I presented today. It talks about not just the benefits of standing orders in terms of efficiency and improved coverage rate and quality gap but also talk in terms of things like the idea of fiscal responsibility because you're making things more efficient and you can bring in more resources and more income. You will have to find that person and who that person is. I can push almost any lever that you want. If you have a quality person that's interested in quality I can push quality. If you have a patient safety person, I can person safety. I would say that, that is what you need to do. Find that person who's respected and said that person down and argue the point. Once that happens then you approach the leadership and make sure that the leadership can support the team meeting. Tell everybody in the team meeting what you intend to do and you will still have to be the driver. You will have to be the one that goes up and pushes people along. If you find a standing order protocol person who's using standing orders, you will find -- they will find it works and makes their life easier after the initial startup. Those are some point I would suggest especially when talking about a small price there other attack points you can use for

14 healthcare systems. I would be happy to talk off-line on those as well. Thank you. Are there any questions -- other questions? You can type them into all participants Thank you for sharing that interim rule. >> What Sherry typed in is in 2002 CMS published interim final rules that removes the physician signature requirements for influenza and pneumococcal vaccinations [ Indiscernible ] home health agencies [ Indiscernible ]. We have something that came into Q&A. Where the egg free vaccines and nasal spray vaccines can be purchased? >> The egg free vaccine which would be blue block is purchased through several different distributors. I do not know the names of all of them. I think triple F Enterprises is one. They are entirely through a distribution system. There are two or three distributors that carry flu block. They will be at market and they are by distributors only. LA IV is going to be in the market it was approved by the FDA. There was a publication that essentially said LA IV was as effective as IAD. FluMist will be brought into the market. It will not be brought in [ Indiscernible ] as soon as a recommendation was announced they stop production. What is available on the market will be what was made before they stop production. They were -- those -- the FluMist will be available -- hopefully that addresses some of the questions. Thank you. We have come to the end of our our. It has been a very informative our. Thanks so much Doctor Tan. Are very last slide is some contact information. We would like you to take this survey. We love feedback and we would love to hear what worked and what didn't. The URL at the bottom is the Medicare Quality Improvement Organization in the work we do here Qualis Health. Thank you all very much. Thank you again for the opportunity. >>