BOSTON IMMUNIZATION INFORMATION SYSTEM: COST AND EFFICIENCY

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BOSTON IMMUNIZATION INFORMATION SYSTEM COST AND
EFFICIENCY
V.B. McKenna 1, A. Sager 2, J.E. Gunn 1, P.
Tormey R. Bajaj 1, M.A. Barry 1,2,3
1 Boston Public Health Commission, Communicable
Disease Control 2 Boston University School of
Public Health 3 Boston University School of
Medicine, Boston, MA

• CDC Award U1W/CCU114727-02

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INTRODUCTION

• In October 1993, the Boston Immunization
  Information System (BIIS) was introduced as a
  citywide electronic registry, tracking and recall
  system.
• BIIS is used in community health centers, in
  hospitals, and in private practices.

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BACKGROUND STRUCTURE OF BIIS

• Decentralized model.
• Sites upload data to the central registry at the
  city health department nightly via modem.
• Sites can access any immunization record in BIIS.
• Multi-task system (registry, tracking and
  recall).

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STUDY OBJECTIVES

• To quantify the costs of developing and
  maintaining BIIS.
• To measure the annual cost per BIIS immunization
  record.
• To identify savings accrued from using BIIS.
• To evaluate outcome measures (immunization and
  overimmunization rates).
• To explore the cost-effectiveness of BIIS.

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METHODS DEFINITIONS

• Building costs
• Fixed or variable costs incurred in constructing
  and maintaining the registry.
• Using costs
• Variable costs incurred by activities designed
  to enhance immunization services.

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METHODS DEFINITIONS

• Fixed costs
• Costs which do not vary with the quantity of use
  or level of
• output in the short-run (such as software,
  equipment,
• and occupancy).
• Variable costs
• Costs which vary with the level of output and
  which respond
• proportionally to changes in volume of activity
  (such as staff
• time for data entry).

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METHODS DEFINITIONS

• Direct using cost
• The actual cost of using the registry for
  immunization activities.
• Allocated indirect using cost
• Proportional allocation of all building costs
  among BIIS immunization activities.

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METHODS DEFINITIONS

• Active user
• Children up to age seven.
• Amortize
• Spreading a fixed cost (such as purchase of
  new software) over the number of years it is
  expected to be used. Costs have been amortized
  over five years at the City of Bostons borrowing
  rate in effect when the actual costs were
  incurred.

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METHODS DEFINITIONS

• Up- to-date (UTD) status defined as completion of
  a 431 series within 24-35 months.
• Overimmunization defined as receipt of any one of
  the following in a cohort of children aged 24-35
  months
• gt 4 doses of DTP
• gt 3 doses of OPV
• gt1 dose of MMR

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METHODS DEFINITIONS

• Immunization history report
• BIIS generates documentation of vaccination
  histories.
• Document includes the number of each vaccine
  given and
• a compliance statement (UTD vs. not UTD).
• Behind list
• A summary report identifying children who are not
  UTD.
• Can be generated for different age groups, by
  site, or at the
• health department.

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METHODS DEFINITIONS

• Immunization assessment
• A summary of childs immunization status for a
• scheduled health care appointment.
• Vaccine usage report (VUR)
• Monthly report used to track quantity of vaccines
  given
• at each health care site.
• Coverage level report
• Annual immunization level assessment report of
  city-wide and
• site specific coverage.

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METHODS STUDY DESIGN

• Data on building and using costs collected at 23
  BIIS sites and
• at the health department.
• Cost data is BIIS vs. controls (non-BIIS ,
  pre-BIIS).
• Immunization data is longitudinal and
  cross-sectional.
• BIIS rates 1993/1994 (pre) and 1997/1998 (post).
• Control site rates for matched periods, 1993/1994
  and 1997/1998.

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BUILDING COSTS INVESTMENTS
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BUILDING COSTS MAINTENANCE
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USING COSTS
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METHODS DOCUMENT BASED COST DATA

• Measured costs incurred in 1994 and 1998.

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METHODS INTERVIEW BASED COST DATA
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METHODS TIME AND MOTION BASED COST DATA
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METHODS 1999 PROJECTED COSTS(ASSUMPTIONS)

• Expand BIIS to additional 36 sites (city-wide).
• Assume optimal use of registry functions at all
  sites.
• Include cost of expanded database management.

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RESULTS COST OF BIIS IN 1998
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RESULTS DIRECT COST OF REGISTRY FUNCTIONS IN 1998
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RESULTS DO SITES USE BIIS TO ITS FULL
CAPACITY?
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RESULTS ESTIMATED 1998 COSTS AND SAVINGS
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RESULTS PROPORTION OF CHILDREN UP-TO-DATE FOR
IMMUNIZATION (BIIS vs. CONTROLS)

• Immunization rates increased at BIIS and control
  sites.
• No significant difference in change between the
  two
• groups (F1.47, p0.23)

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RESULTS OVERIMUNIZATION RATES

• No significant change in overimmunization rates.
• From 1993-1997 the average overimmunization rate
  by vaccine was
• DTP 1.2, MMR 0.78
• OPV 15
• 81 of all overimmunizations were due to one
  additional dose of polio vaccine (4 doses instead
  of 3).

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RESULTS 1999 PROJECTED COSTS
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RESULTS COMPARISON 1998 ACTUAL VS. 1999
PROJECTED COSTS
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RESULTS 1999 COSTS AND PROJECTED SAVINGS
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RESULTS WOULD AN EXPANDED REGISTRY SAVE MONEY ?
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CONCLUSIONS

• BIIS was cost-efficient in 1998.
• Even though BIIS was not optimally used, 1998
  savings were 44,000.
• Increased use will lead to increased savings.
• 1999 projected savings with citywide optimal use
  were 717,000.

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RECOMMENDATIONS

• Continue support for development, on-going
  operation and expansion of immunization
  registries as a cost-efficient way to maintain
  high immunization levels.
• Explore ways to reduce costs of registries
• -coordinate with other non-immunization systems
• -explore alternative methods of data entry

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RECOMMENDATIONS

• Work with clinical and practice managers to
  explore ways to increase usefulness and
  efficiency of immunization registries
• - data quality improvement
• - increase workflow integration
• - improved practice reminders

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STUDY OBJECTIVES AND RESULTSA SUMMARY

• To quantify the costs of developing and
  maintaining BIIS
• To measure the annual cost per BIIS immunization
  record.
• To identify savings accrued from using BIIS.
• To evaluate outcome measures (overimmunization
  and immunization rates).
• To explore the cost-effectiveness of BIIS.