Protection Keeping vaccines top-of-mind among competing priorities

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1 Prioritizing Protection Keeping vaccines top-of-mind among competing priorities By Suzanne Wolfe At Novant Health, continuous quality improvement is central to enhancing patient care across the organization s multistate footprint. Consistent with this mandate, Novant Health launched a quality improvement initiative to prioritize immunizations throughout its extensive network of clinics with impressive results. Based in North Carolina and extending into Virginia, South Carolina, and Georgia, the not-for-profit, integrated healthcare system includes 15 medical centers with a workforce of more than 24,000. Some 2,300 healthcare providers work in 471 clinics, about half of which are primary care sites. The medical group (ambulatory care) handles more than 4 million patient visits annually. Novant Health s 23-person Quality Operations team meets monthly to share initiatives and operationalize strategic goals established by the group. These goals relate to all aspects of safety and quality improvement as well as antimicrobial stewardship. The group includes the director of quality, seven physician leaders, and representatives from the departments of population health, nursing, pharmacy, clinic resources, clinic operations, and Care Connections, which provides nurse triage and other clinic support services. For 2016, the Quality Operations team set its sights on enhancing the medical group s vaccine safety program and soon found that improving [immunization rates] in our clinics became a natural part of that effort, says Herbert Clegg, M.D., Novant Health s senior vice president of clinical excellence. By focusing on immunizations within the constellation of clinical practice, Novant Health was responding not only to its internal mandate for quality, but also reflecting national standards. The Department of Health and Human Services (HHS) National Vaccine Advisory Committee s standards for immunization of children, adolescents, and adults call on healthcare professionals to incorporate an immunization needs assessment into every clinical encounter and to either administer vaccines or refer the patient to a provider who can immunize. 1,2 Novant Health s challenge was to elevate the profile of immunizations so they would not be overlooked among the many demands competing for clinicians time and attention from mammography and colonoscopy screenings to hemoglobin tests for patients with diabetes. What s more important, vaccinations or mammograms? asks Nikki Nissen, R.N., M.S.N., chief nurse of the medical group. It s all important, so we try to make balancing priorities as easy as we can for our physicians. Novant Health set its sights on enhancing the medical group s vaccine safety program by prioritizing immunizations. 10

2 Five Best Practices Charged with leading the immunization initiative, Nissen and Aaron West, Novant Health s director of safety, analyzed performance reports pulled from the electronic health records (EHR) system (Epic Healthy Planet) which showed which clinics had the highest immunization rates. Once they identified the top 10 sites, Nissen and West held conference calls and webinars with those sites to understand what they were doing to produce such positive results. From these meetings, five best practices emerged: Address gaps in care at every visit. If a 1 patient comes in with, say, a hurt ankle, and the EHR indicates that a vaccination is due, notify the physician and place the vaccination order, if appropriate. In contrast, low-performing clinics neither immunized during sick visits nor scheduled follow-up visits to administer vaccines. Use a team approach. Improving immunization rates is everyone s job, from the 2 appointment scheduler to the medical assistant to the physician. For example, top-performing clinics encourage all staff to remind patients of the importance of vaccination. If a patient declines a vaccine, the physician will then have an additional conversation with that patient. Engage in pre-visit planning. For well-child 3 visits and annual physicals, do not wait until the patient s arrival to determine which immunizations are needed. Pre-visit planning includes reviewing the patient s record in the state immunization registry. Use EHR Best Practice Alerts (BPAs) 4 consistently. Paying attention to BPAs coupled with health maintenance topics is standard practice to identify the patient s immunization needs. Use the EHR registry to bring in attributed 5 patients. Remind patients who are due and recall patients who are overdue for a well visit, and get those patients immunized. 11

3 The Quality Operations team shared these best demonstrated practices (BDPs) in a digital newsletter with all Novant Health clinics and encouraged each site to take a close look at their own immunization rates while keeping the BDPs top-of-mind. At the same time, Bradley Willis, M.H.A., CPHQ, Novant Health s director of quality improvement, shared reports of clinic-specific immunization rates for each specialty segment family medicine, pediatrics, internal medicine, etc. allowing each site to compare itself to an immunization benchmark. We re large enough that we can benchmark against ourselves, Nissen notes. Because we re 471 silos, Nissen explains, providers at clinics with less-than-optimal immunization rates may think they are doing a good job or believe they face unique barriers. But when one family practice sees that another office with the same barriers has better rates, they can no longer say, It s because we only see 5% pediatrics or We re rural. Giving clinics access to immunization data allows for easy comparisons between sites and even engenders a feeling of friendly competition among locations. Questions bubbled up from the clinics. Why were their rates lower than their peers? How could they overcome a particular problem? The Quality Operations team was quick to offer answers and possible solutions. For example, hands-on clinical education was provided during site visits, and additional metrics for providers to consider were shared. Clinic administrators in the medical specialty segments also scheduled meetings to discuss how to improve immunization rates. The overarching message: giving the right vaccine to the right patient at the right time is the right thing to do. Optimizing Technology Novant Health s EHR system includes more than 90 BPAs and health maintenance topics that activate (or fire ) for a range of health needs. We ve got a lot of BPAs, and it can be overwhelming, acknowledges Keith Griffin, M.D., chief medical information officer for Novant Health. When you build out a decision-support tool, a lot of things come up in the doctor s workflow. We try to be thoughtful and intentional about which BPAs we use. In the pre-ehr world, it was dependent on me to have a little buzz in my head saying, Remember to talk to this patient about immunizations, Dr. Griffin observes. As part of its 2016 Figure 1 Tdap Immunizations in Adult Patients in Novant Health Medical Group 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Nov ,019 New tetanus BPA implemented Dec ,971 Jan ,980 2,931 Feb 2016 Mar ,167 Apr ,500 5,693 May 2016 Jun 2016 Tdap = Tetanus, diphtheria, and acellular pertussis BPA = Best practice alert Lead physicians who are not huge fans of BPAs, the pop-ups, and the extra clicks have recognized that BPA support has improved the care of their patients. Nikki Nissen, R.N., M.S.N. 6,389 Jul ,904 6,634 Aug 2016 immunization initiative, Novant Health expanded or refined its electronic decision-support tools for most vaccines, including pneumococcal, zoster, and tetanus, diphtheria, and acellular pertussis (Tdap). As far as adult immunizations go, Tdap is the vaccine that s probably thought about least, Dr. Griffin says. Nationwide, the Tdap immunization rate among adults 19 years of age and older was 23% in The rate is low despite the fact that the Centers for Disease Control and Prevention (CDC) has recommended a dose of Tdap vaccine for all eligible adults 19 through 64 years of age since 2006, 4 expanding that recommendation in 2012 to include senior adults. 5 We put a decision-support tool directly in the EHR in our ambulatory clinics that incorporated immunization for tetanus [and pertussis] from birth to death, says Dr. Griffin. Before that 12

4 time, BPAs for diphtheria, tetanus, and acellular pertussis (DTaP), Tdap, and tetanus-diphtheria (Td) vaccines were segmented by age group and did not reflect the fact that more than one type of tetanus vaccine may be appropriate across a patient s life span. In the case of adults, the BPA was satisfied if the patient received either Tdap or Td vaccine. Now, if an adult has had Td but no Tdap vaccine, the system continues to suggest Tdap until the immunization is addressed. Clinics that were used to administering just Td to their adult patients are now giving more Tdap because the BPA for Tdap fires if the patient has not received their one-time dose, says Caitlin Dupont, R.N., B.S.N., application analyst with the EHR team. The team also combined the separate BPAs for Tdap, DTaP, and Td vaccines into one BPA that tells the user the patient is due for one of the three vaccines and instructs them to see the Health Maintenance topic. That topic displays the patient s immunization history for all three vaccines from childhood to adulthood and notes the specific vaccine the patient is due to receive. Although using the 3-in-1 BPA required a learning curve, clinics benefited in the long run from the streamlined workflow, Dupont says. The tool gives providers clinical support at their fingertips without having to dig for it such as the ability to order vaccine administration from directly within the BPA, as well as links to UpToDate articles on each vaccine. The entire workflow, from recognizing the need for vaccination through documenting vaccine administration, is completed in a single place. The combined BPA also lessens BPA fatigue by trimming the number of alerts that fire. Moreover, the new tool displays for all clinical users, including nurses and certified medical assistants, so they can actively participate in the process of satisfying the BPA. Achieving Measurable Results Within a few months of the tool s implementation in January 2016, the number of routine Tdap immunizations administered to adult patients per month increased sharply from roughly 3,000 to more than 5,500 doses. Figure 1 shows these data; the analytics were performed using Slicer Dicer. As Novant Health clinics began using the new BPA and focusing on best immunization practices, immunization rates at the low-performing clinics improved (Table 1). By the end of 2016, the adolescent immunization rate (1 dose of meningococcal vaccine + 1 dose of Tdap vaccine) in the Novant Health Medical Group as a whole had increased from 79% to 88%. The adult immunization rate for pneumococcal vaccines rose from 77% to 81%. Increases in rates spurred further compliance with the electronic decision-support tools for vaccines. Such buy-in, particularly from individual physicians and the medical group leadership, Table 1 Implementation Challenges and Responses Challenge Elevate the importance of immunizations in the face of competing care demands. Raise awareness and educate all clinical staff throughout a large healthcare system. Medicare does not reimburse for routine Tdap or Td immunization. has been key. Lead physicians who are not huge fans of BPAs, the pop-ups, and the extra clicks have recognized that BPA support has improved the care of their patients, Nissen says. One physician announced to colleagues at a department meeting that, although he initially had reservations, the BPA support is what drove these immunization rates up, and that s a good thing, according to Nissen. That message cascading from him to other lead physicians who then take that message back to their offices is part of why we ve been so successful. Tackling Challenges Success also depended on overcoming certain challenges (Table 2). In addition to finding a way to elevate the importance of immunizations to clinicians amid competing demands, the Quality Operations team tackled the issue of communication. Because the medical group is so large, and different people like different methods of Response Provide electronic decision-support tool to make implementation easy; share best immunization practices; incentivize by enabling clinics to benchmark their immunization rates; provide educational support and training. Provide ongoing communications in multiple formats and media. Be up front with patients about the need for the vaccine and what reimbursement obstacles exist; try to immunize before patient turns

5 Table 2 Rates for Pneumococcal Vaccination in Patients 65 Years and Older at Selected Novant Health Family Medicine Clinics Family Medicine Clinic 01/16 12/16 Clinic A, Virginia 42% 60% Clinic B, Virginia 32% 50% Clinic C, Virginia 47% 57% Clinic D, Winston-Salem 70% 79% Clinic E, Winston-Salem 50% 65% Clinic F, Winston-Salem 60% 71% Clinic G, Winston-Salem 44% 58% Clinic H, Charlotte 62% 72% Clinic I, Charlotte 70% 79% communicating, communication is always a challenge when rolling out an initiative, Nissen observes. Repetition and variation were required: delivering the same message multiple times in varied formats (e.g., print, group meetings, oneon-ones) and media (e.g., , webinars). Another challenge was posed by the fact that Medicare does not fully reimburse for tetanus boosters outside of wound management, providing only limited payment through pharmacy benefits, depending on the state. 2 We tell Medicare patients that the immunization recommendations say they need [the vaccine] but that it s not covered, and that creates some drama and angst, Dr. Griffin says. When refining the decision-support tool for tetanus immunization, We had a long discussion about whether we should hide [the BPA] for Medicare patients to avoid having those difficult conversations. We landed on the fact that it should be visible. Increasing the number of people immunized before they enter the Medicare program is one way to lessen the need to have conversations about reimbursement, Dr. Griffin notes. References 1. National Vaccine Advisory Committee Standards for Child and Adolescent Immunization Practices. Pediatrics, 112(4): National Vaccine Advisory Committee Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice. Public Health Report, 129(2): Centers for Disease Control and Prevention Surveillance of Vaccination Coverage Among Adult Populations United States, MMWR, 66(11): Centers for Disease Control and Prevention Preventing Tetanus, Diphtheria, and Pertussis Among Adults: Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and Recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for Use of Tdap Among Health- Care Personnel. MMWR, 55(RR-17): Moving Forward In early 2017, Novant Health rolled out a Tdap BPA to its obstetrics group to enhance compliance with CDC recommendations to immunize pregnant women with Tdap vaccine during each pregnancy. 6 With implementation of the decision-support tool, rates for the pregnancy dose of Tdap vaccine increased from 63% to 83% in one quarter. In continuing to drive improvements in immunization performance, a robust interface between Novant Health s EHR system and the North Carolina Immunization Registry is a hope for the near future. Such an interface would provide a full picture of a patient s immunization history. Novant Health is working with participating retail pharmacies to implement technology that would automatically update a patient s history in Novant Health s EHR whenever a local pharmacy administers a vaccine. While building a team-based, best-practice approach, We try to make sure that providers have a feeling of ownership, Dr. Griffin says. By focusing the entire care team on the same goal and expanding a decision-support tool to help accomplish that objective, Novant Health s immunization efforts have yielded impressive results. To keep vaccines top-of-mind among its clinicians, Novant Health plans to continue using EHR-generated data to pinpoint areas for improvement and to offer educational support to clinics in need. By creating an environment in which a deliberate and proactive immunization approach exists, Novant Health has demonstrated that all patients have the opportunity to receive the right vaccine at the right time. Suzanne Wolfe is a scientific director at PRI Healthcare Solutions, a medical communications company based in New York City. This article is an adapted and expanded version of a paper previously published by Sanofi Pasteur. 5. Centers for Disease Control and Prevention Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis (Tdap) Vaccine in Adults Aged 65 Years and Older Advisory Committee on Immunization Practices (ACIP). MMWR, 61(25): Centers for Disease Control and Prevention Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine (Tdap) in Pregnant Women Advisory Committee on Immunization Practices, MMWR, 62(7):