In Practice: Handling Immunization Record Requests

When Susan Kressly started her own practice in 2004, she invested in an electronic medical records system designed for pediatricians.

It works like this: As the nurse administers a vaccine, the system “subtracts” a dose from the inventory, records the immunization in the patient’s chart, and automatically adds the correct reimbursement code to the electronic superbill. “With a few clicks of a button, the patient’s immunization history and chart can be printed and handed to the parents,” says Kressly, who practices in Warrington, Pa.

High-volume acquisition, storage, and administration of vaccines - along with tedious record keeping and retrieval - have become a hot topic for pediatricians. The good news is that a well-organized practice, with policies and systems in place, can weather the flurry of requests for immunizations even in the busiest of seasons.

Charging for records

Of key concern is whether or not to charge families for these immunization record requests. Most practices still supply the records at no cost while absorbing the expense of office productivity used to furnish this information, sometimes more than once to the same person.

Kressly Pediatrics P.C. gives an immunization history free of charge at the time of the office visit. At any other time, there is a $5 or $10 fee, but Kressly rarely collects it unless someone acts unusually demanding. However, as more and more schools, camps, sports leagues, and other venues require proof of immunization, she plans to institute a processing fee for all requests made outside the context of an office visit.

“Our profit margin in pediatrics is shrinking every day, which is why there are very few independent practices remaining. Physicians are beginning to think the only way to stay alive is to join a larger group or sell out to a hospital-based organization,” says Kressly, who launched her own practice after 15 years in a big group. In 2006, she hired another female pediatrician who became her business partner in January.

Louis A. DiNicola, pediatrician and associate medical director at Gifford Medical Center in Randolph, Vt. says that it costs at least $5 to $7 worth of a nurse’s time to handle an immunization record request. “This dollar figure is something that we looked at a few years ago,” says DiNicola, who is also vice president of the American Academy of Pediatrics Vermont Chapter.

“It represents the time to field the phone call, pull the chart, review the chart, call, fax, or mail the information, and refile the chart.” The turnaround time is the same day or immediately, especially if the record is needed for school, camp, or other urgent reasons, DiNicola says, while admitting, “This does put a significant amount of pressure on a busy day.”

Managing the time spent

Despite the time-consuming nature of filling immunization record requests, some outpatient clinics are able to produce immunization records quickly and without a fee. “It is a free service, and yes, people can ask for it as many times as they want,” says Susan Meedon, practice manager of the Primary Care Clinic at Lucile Packard Children’s Hospital at Stanford in Palo Alto, Calif.

“We have a little promise that all requests are filled within five to 10 business days,” she adds. But usually, the immunization card is furnished on the spot, especially if needed in a hurry. “For some people, it really is a crisis, meaning they’re leaving the country tomorrow and they need their shot record to fly to certain countries.”

The key to avoiding cost and time inefficiencies due to handling record requests is to streamline the process as much as possible. At Meedon’s clinic, one office employee is designated to handle these requests along with other duties. All calls regarding forms for immunization records, sports physicals, daycare, and supplemental nutrition for Women, Infants, and Children are transferred directly to her.

For walk-in requests, parents are asked to fill out a form with their name, the patient’s name, date of birth, and medical record number (if they know it), Meedon says. Then they sign it and put a checkmark beside what they need - a replacement immunization card or one of the other records, some of which require a physician’s review and signature and often cannot be provided immediately.

The immunization record is inserted in a protective plastic cover. “It’s an actual yellow cardboard type of card that California issues,” Meedon says. Clinic employees urge parents to keep it in a safe place. Suggested places include a diaper bag, mother’s purse, or a filing cabinet at home. “All Social Security cards for children could be kept along with the immunization records,” she says.

Privacy provisions under HIPAA should not be taken lightly in dispensing immunization records. Kristan Collins, a pediatrics partner at Broadway Medical Clinic in Portland, Ore., says parents who phone in a request must present proper identification upon pickup. They also can mail, fax, or bring a written release for the records to be sent or faxed to their home. In both situations, documentation of a parent’s signature is kept on file, and a notation of record release is made in the chart.

“We tell them that it can be available in 24 hours, but it’s usually available in a couple hours,” says Collins, who is president of the North Pacific Pediatric Society, which covers Oregon, Washington, Montana, Idaho, Alaska, Alberta, and British Columbia. The service is initially provided at no cost. After the third time in a calendar year, families are reminded that additional requests will incur a $25 fee. That usually keeps them from losing the records again. “I’ve probably only had to charge one or two parents in my 18-year career,” Collins says.

Oregon uses a special form for immunizations. It can be filled out by parents, medical personnel, or school staff. “This form is relatively straightforward to complete; however, some parents find it confusing and may need assistance,” Collins says. “When we complete the form for a parent, it usually takes three to four minutes. Providing a Xerox copy of the immunization record is a quicker process if the parent is able to fill out the state of Oregon form.”

Selecting efficient technologies

The technology that allows for quick access to records comes at a significant investment not only financially, but also in revamping practice operations. Physicians acquiring an EMR system incur startup costs as well as fees for on-going maintenance and technical support. But the eventual payoff in lowered overhead and easier access to records can be substantial.

One technology company catering to pediatricians is Connexin Software Inc., which has locations in New York and Pennsylvania. Its Office Practicum includes an immunization management module that physicians use to track vaccine inventory, enter immunizations, document vaccine administration, forecast shots, and receive alerts when shots are due or past-due, says Connexin account manager Louise Aronowitz.

The company charges between $4,000 and $10,000 per provider (depending on full- or part-time status) to use its full EMR, plus a one-time $500 fee to set up the optional module that reports vaccination records to the state’s immunization registry. Doctors also pay between $500 and $2,000 for an online patient portal and a monthly usage fee ranging from $150 to $250.

Using statewide resources

Some states are also providing helpful technologies. A program called Oregon Immunization Alert assists with the immunization request process. The statewide registry compiles all immunizations into one record, saving medical staff and parents the time and effort it would take to contact multiple offices and sift through paperwork to update a child’s record and administer missing vaccinations. Also, by quickly verifying a child’s immunization status, it prevents unnecessary vaccinations, reducing pain and costs, Collins says.

Vermont also established an online electronic immunization record. In development for about eight years, it has been extended to most practices in the last few years. “We are using one person a day, three days a week, to enter all the old information from the charts. This part is expensive,” says DiNicola of his medical center in Randolph, Vt. “In general, what we have done to date has worked but is inefficient. The new electronic record should improve this overall.”

Some pediatricians shy away from relying on a state’s vaccine registry to generate records. “I found it very cumbersome outside of my electronic health record and have discontinued use of that system because it requires reluctant time-intense service,” says Mark Simonian, a pediatrician in Clovis, Calif., and chair of the Council on Clinical Information Technology for the American Academy of Pediatrics. While he looks forward to someday linking to the state’s registry, “the accuracy of the information is not there today or in the foreseeable future.”

What Simonian has found helpful is sharing secure information through a Web site called the Patient Portal. Parents log in using their telephone and insurance policy numbers. They can access any of their child’s past vaccinations that they have shared with the practice. The Web portal may become unavailable to patients after they leave Simonian’s practice, but parents can create a portable history at www.ihealthrecord.com.

William Zurhellen, a pediatrician in Putnam Valley, N.Y., and a member of the same AAP council as Simonian, also has an interactive Web site through which parents can request records. But due to privacy concerns, it does not offer direct access to clinical information. “Since we can produce [immunization records] on the spot, there has not been a tremendous need to put them on the site,” says Zurhellen, who embraced EMR technology in the late 1980s.

The practice follows a policy to print at least one copy during an annual appointment. Then “we can print any number of copies, at any time, with little effort or cost to us,” he says. Parents “can call, write in, or show up at the front desk.”

While Zurhellen views computerized solutions as the only answer to retrieving immunization records efficiently, he laments that current “state-of-the-art” electronic systems “are not designed properly to assess clinical outcome and perform true quality improvement, nor does a national health information network yet exist,” he says. “These two issues are the major roadblocks to the deployment of electronic health record technology in primary-care practice.”

An optimal solution would give patients access to their personal data through state registries. Scientific Technologies Corporation, based in Tucson, is trying something new in Arizona: Patient immunization records that are furnished to the state are available to health insurers for their enrolled members to pull up through secure online portals, says Michael Popovich, president and chief executive officer.

“Empowering the individual with information, which can mitigate the risk of vaccine preventable diseases,” he says, “is a win-win for all - from both a health and economic standpoint.” And it could save your practice time and money.

Susan Kreimer is a New York-based freelance medical and business writer. She can be reached via bkeaveney@physicianspractice.com.

This article originally appeared in the May 2008 issue of Your Best Practice: A Practice Management Supplement for Pediatricians.