Quality Improvement and Vaccination (including EHR, Immunization Information System [IIS])

Join Dr. Tim Farrell, from University of Utah and the VA SLC GRECC and Dr. Nuzha Amjad, from UTHealth Houston, McGovern Medical School, as they define Quality and Improvement and for Model for Improvement and various strategies to improve vaccination in older adults. They also discuss the use of Immunization Information systems (IIS) and Electronic Health Records (EHR) and how they interact.

To view a transcript, click here then select the transcript tab.

Transcript

Timothy Farrell, MD, AGSF: Well, hello, I'm Dr. Tim Farrell. I'm a professor of medicine and Geriatrics Division Associate Chief for Age-Friendly Care at the University of Utah. I'm also a physician investigator at the VA, Salt Lake City GRECC, and it is my pleasure to introduce Dr. Nuzha Amjad who with me will be discussing key points from the AGS Older Adult Vaccine Initiative module on Quality Improvement. Dr. Amjad. 

Nuzha Amjad, MD: Hi. Thank you for having me here, Tim. Yes, and thanks for the initial introduction. I'm Nuzha Amjad. I'm a, an assistant professor in the Division of Geriatric and Palliative Medicine here at McGovern Medical School, UT Health Sciences in Houston, Texas. I also serve as the associate program director for the Geriatric Medicine Fellowship program here.

Glad to be with you. 

Timothy Farrell, MD, AGSF: Well, Dr. Amjad, so please, you're joining us and sharing your expertise with us today. I'd like to [00:01:00] begin by asking you to tell us in terms of the Older Adult Vaccine Initiative module and quality improvement just how do you think about quality of improvement and, and not only with QI, could you also speak about the model of improvement more specifically? 

Nuzha Amjad, MD: Thank you for asking that. The older adult vaccination project can be implemented as a quality improvement for health organizations. 

Quality improvement is, basically a systematic way to improve care. If I want to be more precise, I would say that quality improvement is a scientific method to implement interventions, ideas, strategies to make iterative improvements to a process or system and sustain that change long term.

The important thing that I would like to know my audience is there are three key [00:02:00] features of quality improvement. First of all, quality improvement, or QI, is focused on systems and not individuals, which sometimes makes it easier to implement in a health practice. 

Secondly, The ideas and the interventions can come from anybody. They don't necessarily always have to be evidence-based strategies. They can come from frontline staff or the ideas from your patients or clients. 

And the third important thing is it is a never ending process. It is an ongoing process. And I think when you present this to your health practice, it makes it easier for people to be enthusiastic about the quality improvement. Needless to say, quality improvement is essential to strive for excellence and improve our health outcomes for our patients and communities. 

There are several frameworks to implement quality improvement, but the most commonly used one [00:03:00] is the Model for Improvement, which was developed by Associates in Process Improvement, and this provides a roadmap for implementing your project or your QI in your system.

The advantages of using this model for improvement is it'll eliminate any chances of hasty, impulsive decisions, and it'll allow a systematic scientific method to prevail and avoid making us any errors. The model for improvement consists of two basic steps. Step one is asking three fundamental questions, which is then followed by the PDSA Cycle or the Plan, Do, Study, Act Cycles, which is really when you are testing the changes. 

I am gonna take a minute here and go over the three fundamental questions. Question number one is our aims question, and this is when we [00:04:00] ask ourselves what are we trying to achieve here? This will set our overall goals. The important thing here to remember is make sure our aims are time specific and measurable.

As Dr. Donald Berwick, who's the founder of IHI Institute, but he said that "some is not a number, and soon is not a time." This allows us to help ourselves accountable that we are going to achieve something in a dedicated time. Also in our aims statement, this is when we are going to define that what percentage population we are going to be including in this project and what specific part of our organization, what systems will be impacted.

The second question is the measures, and here we ask ourselves that, how will we note that a specific change is an improvement? And this step will include defining specific quantitative [00:05:00] measures that will indicate the improvement. 

And the third or the last question is our ideas question, and where we ask ourselves that, what changes can we make that will result in improvement? And this question will specify the interventions and strategies that we are trying to achieve through our aims. Again, these interventions can come from somebody from the administration, or it could also be coming from your frontline staff, or the ideas that your patients may have brought up. They could also be imported from other people who have done these projects and learned from their wisdom.

Then we proceed to the next step, which is the PDSA Cycle, or the Plan, Do, Study, Act Cycle. This is when we are going to put our changes to a test in the real work setting. PDSA Cycles are also called cycles for [00:06:00] improvement. 

To enable my audience to understand PDSA Cycles, I would give us an example from our daily routine. I think we use PDSA Cycles every day. Let me give you an example. Let's say we start going to work in the morning and you're driving to work and you're listening to radio and you know this is the way you're gonna take to work. But on your way there, you find out that there is a traffic accident. You then stop, you analyze this information and change your plan accordingly, and then take a detour to achieve your initial goal, which was to get to work.

This is how a PDSA Cycle will also work. When you're implementing a QI project that you plan, then you do the change or implement the strategies, and then you analyze the results, and then you act on what is learned. And if you feel like that that change or that strategy did not work, you can [00:07:00] accordingly adapt before applying it to a larger scale.

So it is really important to use the PDSA Cycle because it will help us move towards the improvement and monitor our performance at the same time in a very systematic manner. 

Timothy Farrell, MD, AGSF: Well, that's fantastic, Dr. Amjad, and I love the analogy about readjusting your, your route on the way home from work. I also was struck by what you mentioned about quality improvement being a team sport. This is not just for researchers or clinicians. It, it really can be expanded, if I understand you correctly, Dr. Amjad, to include virtually everyone on the healthcare team. 

Nuzha Amjad, MD: Exactly. That's the reason when we do it this way, it becomes a responsibility and you can expect the enthusiasm and participation from everybody in your office.

Timothy Farrell, MD, AGSF: I'd like to move on to another key point regarding [00:08:00] quality improvement as it relates to vaccination, and that would be the IIS or Immunization Information Systems s. So, Dr. Amjad, could you tell us about. The IIS and also how they interact with electronic health records. 

Nuzha Amjad, MD: Thank you so much and I think this is very important to understand, IIS if you want to improve the immunization coverage for our patient population. The Immunization Information Systems are defined as the confidential, population based computerized databases that record all immunization doses administered by participating providers to persons residing within a given geopolitical area, that is a specific city or state.

And at this point, pretty much every state has their own Immunization Information System. [00:09:00] And the system we have here in Texas is called ImmTrac2. IIS are very important public health databases, and the good news is they do have the capability to interact directly with our EHR or electronic medical records.

IIS provide us with accurate, timely, and complete information in one place, which is absolutely crucial for high immunization coverage. When I'd like to describe the functions and capabilities of IIS, I like to divide them into two broad categories. 

The first category is its functions at the level of point of clinical care, and in the second category would be its capabilities and functions at a public health level or a larger population level.

So when we are talking about a point of clinical care, IIS is very [00:10:00] useful to provide consolidated immunization histories. They can actually help generate reminder and recall notices to our patients, and they also provide assessment and feedback for any interventions that we may be doing. At the population level, they help us in assessing the local vaccination coverage and identified target population. They assist during public health emergencies by they can assess the vaccine shortage situations. They can also help us in tracking the vaccine safety issues and then eventually evaluate the vaccine effectiveness. 

As I mentioned earlier, IIS have the capacity to electronically exchange data with the clinical systems, including electronic medical records if your organization is planning to do that. I would like to introduce [00:11:00] that most state and local IIS use the industry standard Health Level Seven protocol to exchange this type of patient's immunization information. So we, here at my organization, we have Epic and our informatics team help us establish that connection. And just to, for our audience, HL7 or Health Level Seven is actually a not-for-profit organization, which was founded in 1987, and it is dedicated to providing a comprehensive framework and related standards for the exchange integration and sharing and retrieval of electronic health information between systems. Another important thing that I would like to mention here, that the practices will have to be aware of, that the state policies differ when it comes to IIS programs, [00:12:00] and they can be either opt in or opt out. 

So here in Texas, our state policy is opt in, which means that the EMRs must acquire the required consent forms to establish the electronic exchange. And these documents can be made part of your EMR. And once the patient sign that consent, then you have the capability to pull in the information in a bidirectional way directly from the IIS.

Timothy Farrell, MD, AGSF: So Dr. Amjad, thank you for walking us through what the Immunization Information Systems, or IIS, are and sort of helping us understand how they interface with electronic health records. And I think it seems like there is some local variability, but overall it's an extremely useful resource and really important to know for anybody who's contemplating a QI initiative focused on, on vaccination. And I think from my perspective [00:13:00] as a geriatrician, something I never really thought too much about. I knew that there were, there was sort of a repository of vaccination immunization data in our electronic health record, but to know that there's sort of this backend infrastructure and standards such as the HL7 protocol that you mentioned to sort of make this all you know, compliant and as accurate as possible and, and so forth. 

Nuzha Amjad, MD: Definitely, yes. It, it was amazing to me also that once everything falls in place, it makes it very easy for the clinician to pull in the data and the ISS information can be part of your actual record. It's quite easy to me. I compare it to almost what I think most people are familiar with, the medicine reconciliation that you get from pharmacies. Once the patient has consented, you would just click on that button, but it'll be a consolation - or reconciliation from IIS [00:14:00] and very helpful for sure. 

Timothy Farrell, MD, AGSF: Yeah, that's a, a wonderful analogy.

And, and I've been, I've been impressed at just how well the IS, does pull in information from local pharmacies that, I mean, there are some times where things are not always pulled in, but I think in general it, it works quite well and is really important resource to know about within individual health systems and and practices.

So I'm just gonna move on to the third item which is to ask you, Dr. Amjad about some tips and strategies that our listeners can use to incorporate QI vaccine projects in their existing clinic flows and other resources that they may have available in their local environments to try to try to make this really highly effective in, in their individual settings.

Nuzha Amjad, MD: Thank you so much for asking this question because like any other [00:15:00] QI project, I think we wanna first look and utilize our existing resources to the maximum so we are not overburdening our system with requirements for having new staff and a lot of new strategies, which sometimes the administration may not look down as favorably.

And this is definitely a question which is very open to the audience. And they can definitely adapt it according to their local clinical practices and environment. But some of the things that we have been doing in our clinic and I think have helped us in the workflow is number one, asking the medical assistants to ask patients about their COVID vaccination status at the beginning of the visit, and this has the added benefit of building in the 15 minute observation period into the visit itself, which helps the clinic workflow because you don't have to keep the patients in rooms after the visit just to [00:16:00] observe them for receiving the COVID booster.

The second thing which we have been doing, because we are in a state where consent has to be opt in, that we have made the consent form for the IIS part of the existing registration packet, and here I would like to elaborate that it's good to look at the consent document because especially for older adults, the consent document here in Texas does require the patient to provide their mother's maiden name. And this is something sometimes if our older adults are coming in with a caregiver and they may have some cognitive impairment, they may not be noticed. So when the front desk calls them for their initial visit, they can let the family members know and ask for that information so they are ready to fill that when they're doing the registration packet. 

The third thing which I wanted to emphasize is a lot of the electronic health records already have inbuilt reminders [00:17:00] for patients regarding their upcoming vaccines. So learning more about them and utilizing those is something like a, a resource we already have and we probably may not have gone into it as much. So that could come in very handy when we are trying to implement the vaccination QI project. 

And lastly, for those practices that currently have NCQA Patient-Centered Medical Home Certification, or if they plan to obtain PCMH image certification, a vaccine QI project can satisfy one of the requirements for this certification.

So presenting the vaccine QI project to the organization leadership as a means to get the. PCMH certification might result in a more favorable response because you know your goals are aligned with their goals, and this always is helpful. 

Timothy Farrell, MD, AGSF: Yeah. Thank you Dr. Amjad. I I would also [00:18:00] say that, you know, vaccination can be considered an age-friendly initiative. So for those health systems, I know there are many out there that are engaging in age-friendly work. You know, this certainly aligns with the medication M and so it's always good to pair an effort like this with something that you're already doing. And I think that, you know, particularly in an era where health systems are stressed from a workforce perspective and, and other perspectives, being able to make meaningful change in improving vaccination rates doesn't need to be hard. And I think you've, you've outlined some strategies for, for doing that. Dr. Amjad, was there anything else you'd like to mention before we conclude our discussion today? 

Nuzha Amjad, MD: No. I'm just thankful for the opportunity and would like to just emphasize that doing this project as a quality improvement, I think will definitely help us increase the immunization coverage for our older adults, as we all know that they're one of our [00:19:00] more vulnerable populations, so definitely hope to achieve that. 

Timothy Farrell, MD, AGSF: Thank you, Dr. Amjad, for sharing your expertise. It was my pleasure to moderate this session. This concludes a discussion of key points from the AGS Older Adult Vaccine Initiative module on Quality Improvement.

Thank you for your time. 

Nuzha Amjad, MD: Thank you so much.