The US healthcare system is moving from volume-based care to one focused on value, forcing providers to shift their focus to efficiency and quality instead of patient quantity. As a result, health organizations are developing new systems to address issues resulting from this paradigm shift.
Sponsored by: Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., has paid for and provided editorial input on this material.
These trends are evidenced in the concerns of CEOs. In a May 2017 survey of 20 health system CEOs conducted by consulting firm Deloitte, respondents cited the move toward population health management, a component of value-based care, as one of the top-of-mind concerns.
One CEO survey participant described the shift toward population health- and value-based care as "a concern, but also a huge opportunity for our country to provide better healthcare."
Population health management can be defined as efforts made to prevent illness and improve healthcare outcomes among a defined set of people by monitoring and identifying individuals within the group. Vaccination is a core component of any preventive services package. In 2011, the CDC identified vaccines as one of the 10 public health achievements of the 20th century.
Improving vaccination rates is an important area of focus.
The persistence of vaccination myths
The popularization of the Internet at the beginning of the 21st century has offered an unprecedented opportunity for antivaccination activists to disseminate their messages to a wider audience. For example, individuals who are opposed to vaccination are very active in news forums, resulting in a minority of users generating a disproportionate amount of anti-vaccination content. The Internet enables scientific abstracts and articles to be shared outside of the scientific community, often without presenting the details of the scientific information or context, which can lead to misinterpretation. Studies examining vaccination-related content on websites or social media platforms have shown that the quality of information was highly variable, with a substantial amount of inaccurate information. Vaccination experts have indicated they are concerned that as the vaccination debate on the Internet intensifies, "many parents may shift from vaccine hesitancy to vaccine resistance, and from vaccine resistance to outright opposition."
Parental concerns about vaccine safety and efficacy are resulting in many families choosing to decline required school vaccinations for their children by obtaining religious- or philosophical-based exemptions. In 2016, exemptions based on philosophical beliefs were permitted by 18 states. These findings indicate that new foci of antivaccine activities are being established in major metropolitan areas, rendering select cities vulnerable for certain vaccine-preventable diseases.
In fact, approximately 72 percent of children aged 19 to 35 months were fully vaccinated in accordance with guidelines issued by the Advisory Committee on Immunization Practices, according to the National Immunization 2015 survey.
According to the American Academy of Pediatrics (AAP), the single most important factor in getting parents to accept vaccines remains the one-on-one contact with an informed, caring, and concerned pediatrician. In a study reported in Pediatrics, parents of more than 7000 children 19 to 35 months of age were surveyed to determine what influence their primary care providers had on their decisions to vaccinate. Nearly 80 percent of parents stated that their decision to vaccinate was positively influenced by their primary care provider.
As pediatricians encounter parental resistance to vaccination, parental concerns must be addressed. La Crosse, Wisconsin-based Gundersen Health System has developed an approach to address parental concerns in order to increase vaccination rates.
Rajiv Naik, MD, an Onalaska-Wisconsin-based pediatrician with Gundersen, recently spoke with Becker's Hospital Review about how Gundersen leveraged the electronic health record (EHR) to help providers address vaccination myths and vaccinate more adolescent patients.
"Regarding healthcare for children, immunizing them is the most important thing we can do," Dr. Naik said.
To improve vaccination rates among its pediatric patient population, Gundersen initiated an EHR-based solution based on the Plan-Do-Study-Act (PDSA) model created by the Institute for Healthcare Improvement (IHI). Over a 3-year period that started in March 2015, Gundersen tracked how the initiative influenced vaccination rates for a specific adolescent vaccine in March 2015, observing a 48 percent increase in vaccination for that particular virus over the span of two years.
Make the CASE for vaccination
The IHI's PDSA model consists of 2 parts: 3 fundamental questions and the PDSA cycle. The fundamental questions ask the initiators of a potential solution to identify 1) what they hope to accomplish, 2) how they will know that observed change is actually an improvement, and 3) what specific change will result in concrete improvement. After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the change may be implemented on a broader scale.
Gundersen implemented 5 specific PDSA changes involving both EHR and provider education to facilitate improvements in vaccination coverage among children and adolescents 11-18 years of age:
- Create electronic alerts and reminders to notify clinicians when a patient is due or overdue for a vaccine.
- Create a centralized process for electronic alerts and reminders.
- Electronically schedule follow-up vaccine doses to eliminate missed vaccination opportunities.
- Conduct system-wide provider education on addressing vaccination misperceptions among parents and patients.
- Create real-time prompts in the EHR with educational information for providers to share during patient visits.
For the provider education component, Dr. Naik assembled a small team of clinicians, which included 3 pediatricians and 1 family medicine physician, to travel to different care sites in the area served by Gundersen Health System. These physicians trained their fellow providers to address vaccine hesitancy by using the CASE methodology:
- Corroborate: Acknowledge parental concern and find points of agreement to set the tone for a respectful conversation.
- About me: Describe what efforts you have made to improve your knowledge and expertise on the issue.
- Science: Describe what the science says regarding the importance of vaccination and any vaccination concerns.
- Explain/Advise: Give the patient science-based advice.
The educational sessions were well-received by Gundersen staff, according to Dr. Naik. The sessions also allowed the team to address another hindrance to vaccination — clinician hesitancy. Other studies have corroborated Dr. Naik's findings. In a review of 185 previously published studies examining healthcare provider vaccine hesitancy, researchers found providers often had limited resources and inadequate information to address patients' vaccine concerns. This lack of resources can inhibit a provider's inclination to recommend vaccination. Several studies also found that healthcare providers who were vaccinated themselves (or who intended to be vaccinated) were more likely to recommend vaccination to their patients.
According to Dr. Naik, "The single factor that's most important in whether or not a family accepts a vaccine has to do with the strength of the provider recommendation."
The effort at Gundersen yielded improvements in adolescent vaccine coverage. For one adolescent vaccine, the health system increased vaccination rates among its male pediatric patient population from 30.9 percent in 2015 to 55.4 percent by the end of 2017, a rate that is substantially higher than the 31.4 percent national average.
The Gundersen roadmap
During the implementation of the initiative, Dr. Naik and colleagues identified potential hindrances to the program and devised strategies to address them. For example, the vaccine champion team found hands-on training was necessary for members of staff beyond frontline providers.
The Gundersen team also discovered that continuous analysis of vaccination data and the identification of new opportunities within the EHR to enhance and sustain documented improvements were essential components of the program's success.
Dr. Naik said Gundersen's culture, which places an emphasis on launching initiatives designed to improve the well-being of its patients and community, specifically contributed to the program's success. However, he noted that the program was designed to be replicable and other health systems can follow the Gundersen "roadmap."
Dr. Naik also cautioned that culture alone is not enough to ensure significant improvements. For other organizations to "truly move the needle" on vaccine acceptance, they must implement quality improvement methodologies and identify provider vaccine champions internally. Once champions are identified, individuals tasked with leading the initiative need to monitor the implementation of the initiative and make a conscious effort to learn what works and what falls short.
For its part, Gundersen is happy to spread the word. Dr. Naik has shared information on his organization's program in a number of venues. Additionally, other hospitals and health systems can access the Gundersen clinical program through Epic EHR.
"The work that we've done from a health information technology standpoint has been turned into a clinical program," Dr. Naik said. "It's certainly possible for other organizations to have similar success."
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