Time Flow Analysis of the Impact of an Immunization Registry on Vaccine Documentation M. Irigoyen, S. Findley, D. See, O. Peña, S. Chen, E. Mendonça Columbia University, New York, NY

Background Manual documentation of vaccine administration involves recording data in multiple locations, including chart notes, flow sheets, encounter forms, and parent’s cards. The use of an immunization registry allows for automation of some of these procedures at the point of service.

EzVAC Immunization Registry In 2000, we launched a private registry at NY Presbyterian Hospital Populated by registration system Web-based and point of service 30+ practices, 160,000+ children Regular uploads to NY Citywide Immunization Registry Types of clinics and settings

EzVAC Registry EzVAC Registry New York Presbyterian Hospital Ambulatory Care Network School Based Clinics Community Providers NYC DOH Citywide Immunization Registry

Study Question What is the impact of the immunization registry on the time spent on vaccine documentation?

Study Objective To evaluate nursing time spent documenting vaccine administration before and after implementation of an immunization registry.

Study Method Time-flow observational study of nursing time spent on vaccine documentation tasks Data collection at Baseline and 2-years after implementation of the registry

Study Setting Pediatric hospital-affiliated practices network Low income, minority community in New York City By 2001, registry capture rate >95% of immunizations

Sequence of Manual Documentation Signs order in Medical Record Enters Data into IZ Flow Sheet Complete VFC Eligibility Form Updates Parents’Health Record Fills out Health Ed Form Medical Record

EzVAC Features Nurses log on with ID and password Child’s record accessed by number or name Child’s VFC eligibility predetermined Nurses select new vaccine to be administered date, manufacturer, lot, exp date default Nurse prints record for chart

Sequence of Registry Documentation Updates Parents’Health Record Complete VFC Eligibility Form Fills out Health Ed Form Medical Record Signs order in Medical Record Enters Data into IZ Flow Sheet 3 steps are automated

Number of observations Patient encounter unit of observation December 1999 Pre-registry 85 encounters observed average 2.3 vaccines per encounter October 2002 Post-registry 66 encounters observed average 2.4 vaccines per encounter

Comparison of Time Elapsed in Each Step of Immunization Documentation

Cumulative IZ Documentation Time 2’44” 2’04”

Results Average time spent documenting immunizations increased slightly from 2’04” to 2’44”. 1 minute of the registry entry was consumed by log-on delays.

Nurses Prefer the Registry Nurses highly satisfied with registry Nurses would NOT go back to paper system “Old habits are hard to break.” There is still an adjustment period to gain confidence in the system. Some nurses are completing manual forms in addition to registry entry.

Registry Documentation Payoffs Improved data quality Consolidates documentation Vaccine inventory tracking and management Instant records retrieval for QA Automated immunization reminder-recall Registry entry has greater payoffs than manual entry: Improved data quality (error checks built-in) Consolidates documentation in one place Vaccine inventory tracking and management Instant retrieval of vaccine records for patient care and quality improvement activities Automated immunization reminder-recall

Conclusions The immunization registry slightly increased nursing time for vaccine documentation Almost all additional time is due to system delays Nursing staff highly value registry