A guest column by the American College of Physicians, exclusive to KevinMD.com.

When I entered practice over 25 years ago, planning for influenza vaccination season was straightforward. Every late spring, we looked at how many doses we gave out the previous year, added a few doses, ordered the vaccine, and immunized our patients in the fall. If we came up short, we could usually find more vials of vaccine. If we overestimated, the distributor would take back the surplus and credit us for next year.

Things have gotten much more complicated since then. What was an orderly process is no longer that way. While I will focus on the new challenges, I don’t want to overlook the many practices that are still providing influenza vaccine to their patients the old fashioned way. The American College of Physicians has tools to help members with their immunization programs. In 2012, I wrote on this blog about making immunization a team effort.

One of the most significant trends in immunization is the expanding role of pharmacists in administering vaccines. This topic could take up a couple of columns. It pits increasing access against decreasing fragmentation of care. Many physicians oppose this broadening of pharmacy practice (which varies by state). On the other hand, having someone else take care of it can relieve an office of the burdens of purchasing, administering, billing, and getting paid for immunizations. Regardless of how one feels about the phenomenon, it is not going away.

The increasing number of options for patients (let’s not also forget community centers, home health agencies, employers, and others) makes planning for the flu vaccine season a challenge in my office. No longer is last year’s count a reliable predictor of the upcoming year’s total, since many patients choose to get their vaccines elsewhere. Nowadays, if we overestimate, we’re stuck with the extras. If we underestimate, it’s not always easy to find additional vaccine.

Because of the increased hassle and the growing number of alternate sources, some offices no longer provide influenza immunization and instead direct their patients to other providers. We came close after last year’s season but found a way to continue providing the service to our patients.

This diversification creates another difficulty, tracking and documenting patients’ influenza immunizations from various locations. If we’re committed to providing the best possible care, we should know how many of our patients have been immunized (and which ones haven’t). If that isn’t enough of a motivation, the use of influenza immunization rates as a performance measure by many organizations might be, especially if it is tied into payment.

We will be scored on how well our practices do immunizing our patients at a time when more and more get their vaccines outside our offices. That doesn’t seem fair, given the huge gap in information exchange that still exists despite widespread adoption of health information technology (HIT) by health care stakeholders. This makes it hard for physicians to keep track of care that is not provided in the office.

Until HIT solves this problem, there are a few tools and practices that can fill some of the gaps. One source of data is the notifications that pharmacies and others should send to the primary care physician when they administer a vaccine. Sadly, that communication doesn’t always occur. It might be worth a phone call by one of your staff to the local pharmacies where most of your patients go for their vaccines to stress the importance of that notification. Your state may require reporting and documenting of immunizations by pharmacies. If so, your health department might be able to intervene. Unfortunately, if you receive the notifications, someone on your staff will need to enter them manually, since they usually arrive by fax or paper mail.

You can also increase your capture of your patients’ immunizations by having staff members ask them if they received their influenza vaccine when checking in or rooming. Most of the performance measures count “self-reported” in the numerator. Posting signs and including a request that patients inform the practice when they are vaccinated at an outside location in your “on hold” message and web page will reinforce this.

Since we’re discussing incentives, one idea that I haven’t tried yet is to give patients who come to the office a self-addressed foldable postcard that they can mail to us if they get their flu vaccine elsewhere. The incentive is that the cards would be entered in a drawing for a gift card or some other prize. If any of you try this (or do this already), let me know how it works.

Our EHR can access an external prescription database, which can tell us if a patient was vaccinated at a pharmacy when a prescription was generated. Your state-wide health information exchange (HIE) is another potential source of documentation, if it provides prescription records, as Rhode Island’s does. A future enhancement that I would like to see is practice-level data made available from HIEs, populating the EHR.

While getting as many patients as possible to receive their flu vaccine is the top priority, having an accurate picture of immunization rates is also important. Until the payment system supports the work of gathering the information, it will be viewed as an additional uncompensated burden on already overburdened practices. While some of the newer payment models in use reward the investment of time and effort, more needs to be done.

Using other members of the team and HIT (if available) to collect the information can lessen the load on the physician, but regardless, someone has to do the work. Eventually, more robust regional HIE and improved interoperability of information systems will streamline the process, although it will never be as simple as it was 25 years ago.

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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