1. RPMS Immunization Program OVERVIEW Scott Hamstra, MD Pediatrician, Sells Indian Hospital, Tucson Area Immunization Coordinator

2. What is the RPMS Immunization Package? RPMS computer software tool used to: –Provide care for individual patients –Provide public health for a community –Provide information (reports) –Account for vaccines Using the RPMS Immunization software improves: –Patient Care –Data Quality –Reporting

3. IMM software works for all ages across the Entire Life Spectrum

4. Public Health Function = Community Views/Reports Who Counts? MOGE ACTIVE

5. What we’ll cover today RPMS Immunization Package –Setting Site Parameters –Adding Data vaccines you give today past vaccines (history not in Electronic Record) –Running Reports Birds eye view: overall vaccine rate in community How to think about and use effectively –Best Practice – Pursuing Excellence Team members and functions

6. RPMS Immunization Package MENU SYSTEM –PATPatient Menu … –REPReport Menu … –MGR Manager Menu …

7. ERREdit Patient Errors CMG Add/Edit Case Manager CMTTransfer a Case Manager’s patients SCN Scan For Patients -------------------------- ESPSite Parameters Edit PKGPackage Setup Information LETForm Letters Add/Edit LOTLot Number Add/Edit VACVaccine Table Edit RESRestandardize vaccine table EXPExport Immunizations KEYAllocate/Deallocate Imm Menu Keys Manager’s Menu …

8. Site Parameters – 19! Edit Site Parameters for: SELLS HOSP 1) Default Case Manager.........: 2) Other Location...............: TUCSON, AZ 3) Standard Imm Due Letter.....: DUE 4) Official Imm Record Letter...: Official Immunization Letter 5) Facility Report Header.........: SELLS HOSP 6) Host File Server Path.........: c:\export\requests\ 7) Minimum Days Last Letter.....: 30 days 8) Minimum vs Recommended Age...: Recommended Age 9) ImmServe Forecasting Option.: #3, WITH 4-Day Grace, HPV thru 18 10) Lot Number Options..........: Required, Low Supply Alert=5 11) Age Appropriate for Pneumo..: 65 years old, one time only. 12) Forecasting (Imms Due)......: Enabled 13) Chart# with dashes.......: No Dashes (123456) 14) User as Default Provider....: Yes 15) ImmServe Directory..........: C:\Program Files\Immserve821\ 16) GPRA Communities........: 60 Communities selected for GPRA 17) Inpatient Visit Check.......: Enabled 18) High Risk Factor Check......: Enabled 1 9) Import CPT-coded Visits....: Disabled

9. Version 8.3 Forecasting Options All options are VALID – meet the ACIP guidelines. Built options to meet standards AND give “wiggle” room to account for some regional/local practice variance. The 2-4-6 month vaccines are ~standard to all options, do have option to begin at 6 weeks vs 2 months of age. Influenza between Sept & March for 6 mo–18 yo children. Option 11 = special case: does not forecast Hep A or Hep B in persons over 18 years, regardless of prior doses. All forecast Tdap, MCV4, and HPV for adolescents.

10. Version 8.3 Forecasting Options with and without the 4 day grace period Option 6 Mths 12 Mths 15 Mths ------ ------ ----------------------------- --------- 1)...... IPV Hib, MMR, Pn, Var..... DTaP 2).......... Hib, IPV, MMR, Pn, Var...... DTaP 3)...... IPV DTaP, Hib, MMR, Pn, Var..... 4).......... DTaP, Hib, IPV, MMR, Pn, Var. 5)...... IPV Hib, MMR, Var............... DTaP, Pn 7) Comvax IPV DTap, HepB, Hib, MMR, Pn, Var 9) Comvax IPV HepB, Hib, Var, MMR......... DTaP, Pn 11)..... IPV Hib, MMR, Pn, Var..... DTaP

11. Forecasting: Adult Pneumococcal Vaccine “Pneumovax” Automatically forecast at age 65 –except in Alaska – forecast early at age 55 Forecast another dose if... –dose #1 given before age 65 Forecasts for High Risk patients –19-65 year olds with 2 high risk condition visits in past 3 years Stop forecast if 2 doses given before age 65 (except in Alaska)

12. Flu (Influenza) Forecasting too! = Young (6m-18y) & Old (>65 y) and High Risk ICD-9 Taxonomy 042.0-043.09, 044.9HIV infection 250.00-250.93Diabetes 393.-398.99Rheumatic Heart D. 402.00-402.91Hypertensive H.D. 404.00-404.93Hypertensive Heart/Renal 410.00-414.9Ischemic H.D 415.0-416.9Pulmonary H.D 424.0-424.9Other endocardial H.D 425.0-425.9Cardiomyopathy 428.0-428.9, 429.2CHF 491.0-491.9Chronic Bronchitis 492.0-492.8Emphysema 493.00-493.91Asthma 494.0-496.Bronchiectasis, CLD, COPD 501-505Pneumoconioses 571.0-571.9Chronic Liver Dis. 581.0-581.9Nephrotic Syndrome 585.Renal Failure 996.80-996.89Transplant V42.0-V42.89Kidney Transplant V58.1Chemotherapy V67.2Chemotherapy f/u

13. Setting Up Form Letters 2 templates: Standard Due & Official Form Letter: Standard Due Letter ------------------------------------------------------------------- top: Anchorage Primary Care Center 4320 Diplomacy Dr. Anchorage, AK 99508 |BI TODAY| Date of Birth: |BI DATE OF BIRTH| Chart#: |BI CHART NUMBER| + Scroll down to view more. Type ?? for more action T Top F Forecast C Closing H History B Bottom P Print Sample Letter M Middle D Date/Loc X Delete Form Letter Select Action: Quit// *** Use Screen Editor – go to TBOX and change from Line Editor

14. Adding Lot Numbers EDIT IMMUNIZATION LOT NUMBERS * –At the prompts, enter the Lot #, Manufacturer, Status, and Vaccine. When a Lot Number is "Inactive“ you can’t select it. Select LOT NUMBER: 11759 Are you adding '11759' as a new IMMUNIZATION LOT (the 927TH)? No// y (Yes) IMMUNIZATION LOT MANUFACTURER: merck & CO. MSD * IMMUNIZATION LOT VACCINE: mmr MMR 3 IMMUNIZATION LOT VACCINE #2: IMMUNIZATION LOT VACCINE #3: IMMUNIZATION LOT VACCINE #4: LOT NUMBER: 11759// MANUFACTURER: MERCK & CO.// Note: The Manufacturer Table is standard –press ?? to see the list

15. # Vaccine HL7 Active Default Lot# VIS Default Forecast 6 DTaP........ (20)....Active......................30-Jul-2001..... YES 7 HBIG........ (30)....Active...................... YES 8 HEP A....... (85)....Active......................25-Aug-1998..... YES 9 HEP B.NOS (45)....Inactive......................11-Jul-2001..... YES 10 HEP B ADLT..(43)..Active......................11-Jul-2001..... YES + Scroll down to view more. Type ?? for more actions E Edit a Vaccine P Print List F Forecast 1. This is a standard list with standard HL7 codes 2. Inactivate vaccines that you do not use makes it easier to see choices of available vaccines. 3. Set default VIS dates 4. Set default lot numbers Edit Vaccine Table

16. How does Immunization Data get into RPMS? –Types of Immunizations: Ambulatory (Clinic) Immunizations (#1) –Inpatient Immunizations, –PHN Immunizations, –Historical Immunizations (given elsewhere) –How does it get entered into RPMS? Paper record goes to Data Entry clerk Direct data entry by Nurse/CMA at “point of service” = BEST PRACTICE !

17. Point of Service Data Entry Nurse gives vaccines Nurse enters vaccine directly into computer : –Vaccine name –Date –Lot number/ manufacturer –Dose/amount –Injection site –Facility –Person administering vaccine –VIS date Advantages: 1.Accurate data 2.Accurate forecasting 3.Appropriate administration 4.Timely data entry 5.Ends duplicate data entry 6.Decreases charting 7.Print out Official Record 8.Increased data access

18. RPMS Immunization Package MENU SYSTEM –PATPatient Menu … –REPReport Menu … –MGR Manager Menu …

19. RPMS – Patient Menu PATPatient Menu SGLSingle Patient Immunization Record LETPrint Individual Patient Letter LLSDue Lists and Letters The immunization record with forecasting you need when you walk into a patient’s room. - also in the Health Summary - also is what you see in EHR

20. Patient: DEMO,PATIENT DOB: 27-Jul-2002 (6 months) Chart#: 999998 at ANCH MED CTR Inactive Female M HBsAg: U # Immunization History | Immunizations DUE on 01/22/2003 1 09/30/2002 DTaPAnch| HIB past due 2 12/01/2002 DTaPAnch| IPV 3 09/30/2002 HEP B PED Anch | PNEUM-CONJ past due 4 12/01/2002 HEP B PEDAnch| DTaPpast due 5 09/30/2002 IPV Anch | 612/01/2002 IPVAnch Contraindications: VARICELLA +Scroll down to view more. Type ?? or Q to QUIT. A Add Immunization D Delete Visit P Patient Edit S Skin Test Add I ImmServe Profile C Contraindications E Edit Visit H Health Summary L Letter Print

21. IF DATE = TODAY – then Default Category is “Ambulatory” Recommend that ALL require lot #s for Ambulatory vaccines. Press F1-e to save and exit. Direct Data Entry of Immunizations * * * ADD IMMUNIZATION VISIT * * * Patient: SINGLETON,COLIN DOB: 05-Sep-1989 (14 yrs) Chart#: 107560 at ANCH MED CTR Active Male ______________________________________________________________ Date: JAN 29,2004 Category: Ambulatory Vaccine: Td Lot#: ***???*** Inj Site: R thigh IM Vol: 0.5 ml Location Type: IHS Location: ANCH MED CTR Provider: SINGLETON,ROSALYN J MD VIS Date: 6/19/2008 __________________________________________________________________________________________________

22. CONTRAIND (IMM v8.0) Mar 26, 2003 12:21:12 Page: 1 of 1 Patient: DEMO, PATIENT DOB: 14-Feb-1986 (17 years) Chart#: 104079 at ANCH MED CTR Active Male # Vaccine Reason Date Noted --------------------------------------------------------------------- 1 VARICELLA: Hx of Chicken Pox 23-Aug-1999 --------------------------------------------------------------------- Enter ?? for more actions. A Add Contraindication D Delete Contraindication ADDING CONTRAINDICATIONS

23. Adding Contraindications Choose from: –Anaphylaxis –Carrier –Convulsion –Egg Allergy –Fever>104F –Hx of Chicken Pox –Immune –Immune Deficiency ( adds contraindication to all live vaccines) –Immune Deficient Household –Lethargy/Hypotonic Episode –Neomycin Allergy –Other Allergy –Parent Refusal (vaccine will still be forecast) –Patient Refusal (vaccine will still be forecast) –Persistent Crying –Reason not recorded

24. RPMS Immunization Package PATPatient Menu… –SGLSingle Patient Record –LETPrint Individual Patient Letter rarely use in this IMM menu but used in EHR daily –LLSDue Lists and Letters

25. Patient Menu Lists and Letters Feature 1 Date of Forecast/Clinic.: TODAY (or date in future) 2 Age Range...............: 12-72 Months (Can change to Years) 3 Patient Group...........: Active (Inactive, other choics) 4 Communities..............: ALL 5 Case Managers............: ALL 6 Immunizations Received...: ALL 7 Immunizations Due........: MMR 8 Health Care Facilities...: ALL 9 Lot Numbers..............: ALL 10 Additional Information...: Forecast (history, more) 11 Order of Listing.........: by Patient Age Select a left column number to change an item. List of Patients Print Due Letters To print a simple list choose Option 10 - “No additional info”.

26. Reports Menu Two Year Old Report Quarterly Report Vaccine Accountability Report Adult Report Adolescent Report Influenza Report

27. Two Year Old Report = 19-35 month olds Designed to match –CDC National Immunization Survey –Healthy People 2010 format Used to compare to all other organizations! Provides Rates for –a single vaccine (2010 Goal is >90% for each one) DTaP –groups of vaccines 4 DTaP, 3 Polio, 1 MMR, 3 Hib, 3 HepB The 43133 standard in 2008 Moving to include –Varicella = 431331 –Pneumococcal conjugate 4313313 This report’s 43133 measure is the used for 2008 GPRA in the CRS package..

28. Quarterly Report – “worksheet” Age-appropriate Vaccines 3-27 months –“snapshot” of the community –Doing well on this >80% -- will ~ENSURE that your Two Year Old 19-35 month old report will be >90% STANDARD REPORT –breakdown by age groups – “Up to Date” changes –3-4 months#1 DTaP, IPV, Hib, HBV –5-6 months#2 DTaP, IPV, Hib, HBV –7-15 months#3 DTaP, #2 IPV, Hib, HBV –16-18 months#3 DTaP, Hib, #2 IPV, HBV #1 MMR –19-23 months#4 DTaP, #3 Polio, IPV, HBV #1 MMR –24-27 months#4 DTaP, #3 Polio, IPV, HBV #1 MMR

29. Adolescent Report denominator similar CRS logic includes those with 2 visits in past 3 years New --- for the United States – not really sure what the levels will be and how to best measure.

30. Adolescent Report IHS Adolescent Immunization Rates For patients 11 through 17 Years of Age As of: 20-Jan-2009 Total Patients: 724 Total Females: 381 ------------------------------------------------------------------------------- Age Group | 11-12yrs 13yrs 13-17yrs Denominators | 239 99 485 =============================================================================== 1-HEPB | 233 98 473 | 97% 99% 98% |-------------------------------------------------------------- 2-HEPB | 231 98 472 | 97% 99% 97% |-------------------------------------------------------------- 3-HEPB | 230 98 471 | 96% 99% 97% ------------------------------------------------------------------------------- 1-MMR | 233 99 474 | 97% 100% 98% |-------------------------------------------------------------- 2-MMR | 233 97 470 | 97% 98% 97% ------------------------------------------------------------------------------- 1-VAR | 203 74 230 | 85% 75% 47% |-------------------------------------------------------------- 2-VAR | 151 50 148 | 63% 51% 31% ------------------------------------------------------------------------------- Hx of Chickenpox| 54 38 252 (Immune) | 23% 38% 52%

31. Adolescent Report cont’ 1-Tdap | 142 88 248 | 59% 89% 51% |----------------------------------------------------- 1-Tdap/Td | 154 91 467 | 64% 92% 96% ------------------------------------------------------------------------ 1-HEPA | 233 99 473 | 97% 100% 98% |------------------------------------------------------ 2-HEPA | 230 98 468 | 96% 99% 96% ----------------------------------------------------------------------- 1-MEN | 147 87 429 | 62% 88% 88% ------------------------------------------------------------------------ 1-FLU | 30 12 34 | 13% 12% 7% ------------------------------------------------------------------------ 1-TD_B 3-HEPB | 150 87 420 2-MMR 1-VAR | 63% 88% 87% ------------------------------------------------------------------------ 1-TD_B 3-HEPB | 97 45 138 2-MMR 1-MEN | 41% 45% 28% 2-VAR |

32. Adolescent – Female portion Female | 11-12yrs 13yrs 13-17yrs Denominators | 128 56 253 --------------------------------------------------------------- 1-HPV | 77 49 220 | 60% 88% 87% |-------------------------------------------------------------- 2-HPV | 44 37 158 | 34% 66% 62% |-------------------------------------------------------------- 3-HPV | 22 24 89 | 17% 43% 35% ------------------------------------------------------------------------------- 1-TD_B 3-HEPB | 17 13 33 2-MMR 1-MEN | 13% 23% 13% 2-VAR 3-HPV | (females) | ------------------------------------------------------------------------------- Total Active Patients reviewed: 724 Total Active Females reviewed: 381 Total Patients reviewed who had Refusals on record: 7 ------------------------------------------------------------------------------- *Denominators are Active Clinical Users: 2 clinical visits in the past 3 years. *Patients considered "Current" have 1-Td_B, 3-HEPB, 2-MMR, 1-VAR/Hx_Varicella. -------------------------------------------------------------------------------

33. Vaccine Accountability Report At most sites done by Pharmacy –order, store & account for vaccines. Report to your State’s VFC Program –overall number of vaccine doses used

34. Adult Report (Active = those with 2 visits in past 3 years) –Adults by age >65 >50 –Influenza in past year –Pneumovax in lifetime Also for Alaska - in past 6 years –Td in past 10 years GPRA measures > 65 years of age Influenza past year Pneumovax ever

35. Pediatric Influenza Report INFLUENZA IMMUNIZATION REPORT 1 - Report Year (Flu Season)...: 2008 (09/01/08 - 12/31/08) 2 - Community..................: ALL 3 - Health Care Facility.......: ALL 4 - Case Manager...............: ALL 5 - Beneficiary Type...: INDIAN/ALASKA NATIVE

36. Influenza Immunization Report 20-Jan-2009 ------------------------------------------------------------------------- Beneficiary Type: INDIAN/ALASKA NATIVE ------------------------------------------------------------------------- | Age in Months on 12/31/2008 | |--------------------------------------------------| Totals | 10-23 24-59 | Denominator | 189 502 | 691 ------------------------------------------------------------------------- 1-Influenza | 95 159 | 254 2008 Season | 50% 32% | 37% Fully | 49 110 | 159 Immunized | 26% 22% | 23% ------------------------------------------------------------------------------ - Total Patients included who had Influenza Refusals on record 3