1	Immunization and Asthma Quality Improvement in Primary Care AMIA Primary Care Working Group October 22, 2005 Robert Grundmeier, MD The Children’s Hospital of Philadelphia
2	Overview: Immunization Alerts Background Why build immunization alerts? Methods Focus groups Decision support implementation Results Demonstration (connectivity permitting) Discussion
3	Background Timely immunizations are a key element of preventive care for children Underserved populations may be difficult to immunize All immunization opportunities should be captured
4	Quality Improvement Project Started in 2003 Immunization rates and covariates were measured Only 80% of patients were up to date at age 24 months Immunization status at early age (< 6 months) was greatest predictor of immunization status at age 24 months
5	Methods Grant submitted and funded for a decision support intervention in primary care sites American Academy of Pediatrics Young Investigator Award Focus groups to build consensus with physician, nurse, and administrative representation from each site Outcome comparison to historical controls
6	Focus Group Results Recommended Electronic Health Record (EHR) centered intervention with best practice alerts as central element Clarified immunization schedule Resolved differences between CDC, ACIP, and package inserts Recommended workflow for both nurses and physicians
7	Immunization Questions Clarifying intervals How long is 6 months? Local custom vs. standards Do we really want to start immunizations at 6 weeks? Prospective alerts vs. retrospective validation How do we use the “4 day grace period” recommendation? How do we handle product shortages?
8	Special Problem: DTaP #4 Pertussis outbreak occurred in Philadelphia during winter 2003-2004 Philadelphia Department of Public Health (PDPH) investigated Discovered that missed DTaP #4 was a key predictor of disease Recommended DTaP #4 booster at earliest age possible (12 months rather than 15 months)
9	Controversy: Red Book (CDC) vs. PDPH Providers felt uncomfortable with PDPH recommendation National domain expert states: “Immunogenicity of DTaP #4 is better at 15 months than 12 months.” And then: “But it is better to immunize at 12 months than not at all.”
10	DTaP #4 Simulation Retrospective office visit data were analyzed to predict effect on immunization rates if DTaP #4 administered at 12 months
11	DTaP #4 Immunization Opportunities
12	Methods: Best Practice Alert Design for near perfect predictive value Alert behavior for each antigen determined by Current age Number of valid doses on file Time since last dose Age at last dose (Hib and Prevnar) Time since first dose (Hep B) Prior disease history (Varicella) Time of year (Influenza) Product availability and choice (Prevnar, Pediarix) Contraindications (especially Influenza)
13	Immunization Schedule
14	Testing
15
16
17
18	Maintenance Experience
19	Maintenance Experience Prevnar recommendations changed twice during implementation due to shortages Update was made and verified in << 1 hour Influenza vaccine was added to project scope No change in infrastructure required to temporarily handle seasonality
20	Results: Percent Adherence to Immunization Guidelines At Acute Visits
21
22
23	Comparison of Immunization Status at age 2 years (4-3-1-3-3 criteria)
24	Summary Electronic Health Record (EHR) facilitated all aspects of the project Clarifying the problem of poor immunization rates Using relevant data to build consensus Making the intervention Measuring the effect Demo
25	Overview: Asthma Quality Improvement Background Paper version of asthma care plan Integration into Epic Evaluation Ongoing QI project Demonstration Discussion
26	Background Paper-based asthma care plan had been in use sporadically prior to Epic implementation After Epic implementation, virtually no new paper asthma care plans were filled out for patients This was bad, because there was no alternative tool in Epic at that time…
27	Asthma Care Plan on Paper
28	Initiative to Standardize Asthma Care at CHOP Pew Charitable Trusts funded a team of asthma specialists from primary care, allergy, and pulmonary Standardize asthma care “toolkit” within institution including asthma care plan Educate clinicians Integrate with electronic health record Distribute widely
29
30
31
32
33
34	Evaluation Asthma QI project initiated Consistent documentation of asthma severity class Prescription and use of controller medications Consistent use of the Asthma Care Plan Standardized education across the network
35
36
37
38	Next Steps: Translating Research Into Practice Implement an asthma classification and asthma control “coach” Continue audit and feedback strategy Quality of care measures may be included in physician incentives Implement real-time decision support
39	Asthma Control Form
40	Asthma Alerts
41	Asthma Best Practice Smart Set
42	Thank You!