A Business Case for Electronic Immunization Registries

1
A Business Case forElectronic Immunization
Registries

• University of California, San Diego, CA
• John Fontanesi, Ph.D.
• CDC Award U1W/CCU914714-01Award

2
Study Goals

• Articulate strategic long-term capitalization
  requirements
• Methodology
• Develop realistic business case scenarios
• Develop cost/benefit model
• Provide cost effectiveness benchmarks

3
Cost Model Requirements

• Predict registry costs
• Planning, Development, Maintenance
• Relate costs to performance requirements
• CDC 12 core functions, inventory, CASA reports
• CPU usage, transaction times, administration
• Identify cost drivers
• SLOC, population, end-user support

4
Easier Said Than Done

• Averaging costs of funds spent DOES NOT
• Adjust for performance
• CDC core functions
• Size of registry
• Technical performance
• Identify cost drivers
• Suggest areas for improvement
• Account for different stages of development

5
Tyranny of the MeanAveraging Costs
6
Parametric Models

• Examine statistical relationships between
• Dependent variables
• Independent variables
• Preferred method in military and industry
• Permits benchmarking

7
StandardParametric Cost Models

• Proprietary
• REVIC
• PRICES
• SASET
• SEER-SEM
• SLIM

• Public
• COCOMO (87 and II)
• DOD MIL STD 2167/498
• DOD MIL STD 499A
• DOD MIL STD 1703

8
Immunization Registries A Special Case

• Traditional database applications DO NOT
• Track independent name changes
• Track items affected
• At different times
• By unrelated organizations
• Have accurate records of these affects
• Widely available
• Constrained by confidentiality

9
DOD MIL STD 881b
Work Breakdown Structure

• System functions
• System performance
• Types of personnel
• Equipment
• Administrative and planning tasks
• Other

10
Parametric Cost Estimating Process
11
Work Breakdown Structure

• Process tree composed of hardware, software,
  services, and data types
• Define technical objectives
• Assign management and technical responsibilities
• Monitor costs, engineering efforts, schedules,
  and technical objectives

12
WBS Populated with Data Form

• Basic accounting records
• Cost reports
• Historical databases
• Functional specialist
• Technical databases
• Other information systems
• Contracts
• Cost proposals

13
Statistical Analysis

• Standard regression analysis
• Can use null hypothesis
• R, R2, F and T statistics appropriate
• Generates cost-estimating relationship
  (CER)
• Children 0-6
• SLOC
• End-users
• Core functions

14
Comparison SLOC by Function (MEAN 9)
15
Cost Drivers(Cost Estimating Ratios)

• Number of end-users
• Number of functions
• Population size

• 5300 per station (3 year life)
• Linear relationship r.94
• 8 per SLOC
• Linear relationship r.83
• 2.06 per record
• Curvilinear r.73

16
Do Registries Fit Standard Business I.T.
Models?

• Rationales for Information Technology Investment
  
• Labor savings
• Improved quality
• Greater product variety
• Better customer service
• Faster response time

17
Background costs

• Chart pulls cost between 8 and 14
• Audit costs approximately 60 per chart
• Non-M.D. staff costs approximately 15 per hour

18
Registry Cost/Benefits

• 2800 Immunization records printed every 4 hours
• Negates chart Pulls
• Savings of 22,400 per 4 hours
• 2,500-5,000 programming costs

• Labor savings
• Improved quality
• Greater product variety
• Better customer service
• Faster response time

19
Registry Cost/Benefits

• Manual HEDIS Audit gt100K per annum
• Ad Hoc HEDIS reports - 2.5K to 5K programming
  costs

• Labor savings
• Improved quality
• Greater product variety
• Better customer service
• Faster response time

20
Registry Cost/Benefits

• 250,000 in performance penalties annually
• 2,500-5,000 programming costs to produce 20
  month old outreach

• Labor savings
• Improved quality
• Greater product variety
• Better customer service
• Faster response time

21
Registry Cost/Benefits

• Increased patient flow from 12 to 15 per hour
• 30-50 labor cost reduction
• 1,211,422 shots administered 1/98-10/98
• Labor savings of 700,000

• Labor savings
• Improved quality
• Greater product variety
• Better customer service
• Faster response time

22
Registry Cost/Benefits

• Improved data QA
• Switch to Standing Orders
• Inventory Reports
• Billing Cross-reference
• Seasonal Predictions

• Labor savings
• Improved quality
• Greater product variety
• Better customer service
• Faster response time

23
Return on Investment
24
Return on Investment (ROI)
25
Operational Cost Modeling

• Output (Q)
• Production function (F)
• Increase in immunized children
• Computer capital (C)
• Non-computer capital (K)
• I.T. staff (S)
• Other labor/expenses (L)
• QF(C,K,S,L,I,t,) (1)t

26
Coverage Rates
27
Registry Cost/Benefits

• Practice Pattern

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Percent of Shots Missed By Visit Age
29
Registry Cost/Benefits

• Missed Opportunities

30
Missed Opportunity Rates
31
Encounter Notification
32
Contributing Factors

• Use of Reminder/Recall Systems
• Assessment Feedback, Information and Corrective
  Action (AFIX )
• Readiness to Change
• Linkage to other Data Sources

33
Contributing Deficiencies

• Compliance
• Less than 80 of shots given are entered
• Data Accuracy
• Over 15 error rate when completed by clinical
  staff
• Convenience
• Data terminals most often placed in billing
  office
• Stand alone systems
• Data Availability
• 50 of 2 year olds have 2 or more providers

34
Cost/Benefit by Function

• Greatest ROI per man-hours per SLOC
• Retrieve patient information (54)
• Print record (124)
• Coverage level reports (180)
• HL7 (136)

• Requiring most man-hours per SLOC
• Determine immunization needs (550)
• Determine individuals due/late for immunizations
  (220)

35
Obtained Production Values Q Ratio
36
Major Benefit Activities

• Improved targeting
• Rapid response
• Change in I.T. culture
• QA activities
• Practice oversight
• Review of procedures
• Improved client relations

37
Lessons Learned

• To maximize ROI
• Record prints
• Accessibility of terminals
• Workflow dynamics
• Standard reports
• VFC
• Billing
• HEDIS
• CASA

• To maximize immunization rates
• Provider profiles
• AFIX
• QA

38
NEXT STEPS DEVELOPER GUIDELINES and TEMPLATES

• Performance Planning (PL 103-62)
• Business Results (PL 100-107)
• Resource Deployment (PL 101-576)
• Best in Business standards (executive Order
  12862)
• Technology Management Reform Act (PL 104-106)

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NEXT STEPS READINESS FOR CHANGE TEMPLATE

• Need to identify proposed sites
• Willingness
• Capacity
• Ability to maintain
• Need to identify appropriate strategies for
  rollout by clinics Readiness For Change
  characteristics

40
NEXT STEPS FEEDBACK

• Combining with other Data sources to provide
• Missed Opportunity Feedback
• Practice Patterns
• Population Patterns
• Non-Responders
• Case Management
• Geo-demographics
• Vaccine Safety Studies

41
NEXT STEPS REMINDER/RECALL

• What are the functions of Reminders?
• What are the functions of Recalls?
• Timing?
• Which methods fits a clinic type?
• Small vs large practice
• Community-based clinic
• Organized vs storefront

42
NEXT STEPS PROVIDER PROMPTS

• Printing Record at Encounter
• Flagging Record for Review
• Immunization Due
• Contraindications
• Familial Objection

43
Results

• Immunization registries can be cost effective
• 3-year break-even point
• 5-year ROI of as high as 81
• Immunization registries CAN improve and maintain
  high coverage rate ONLY if they are made a part
  of an administrative TQM/CQI effort