ACP: Make flu vaccination a team effort

A guest column by the American College of Physicians, exclusive to

Fall is the time of year when the CDC, CMS, insurance companies, and professional societies bombard physicians with reminders to vaccinate their patients against influenza. I will do these groups one better and not only remind you, but also share a couple of ideas for improving your immunization rates. These are strategies that I use in my practice and are very effective in both getting more of my patients to receive flu shots and decreasing the amount of time that I spend doing it.

Every vaccine campaign has a slogan. Mine is “Get Out of the Way!” The key is to make the process less dependent on the physician and more dependent on the patient care team.

In the “old days,” my flu vaccination efforts consisted of a patient coming to the office for a scheduled visit. I’d ask if the patient wanted a flu vaccine and discuss the benefits of a flu vaccine and the potential adverse reactions. Next, I stepped out of the exam room to draw up the vaccine and returned to administer it.

Sometimes I would forget to ask and the patient left the office without a flu shot. Or, I would remember to ask at the beginning of the visit and forget to give it at the end. Later, I got smarter and asked the medical assistant (MA) to ask the patient when rooming them and if the patient was interested, I would be notified so that when I entered the room, I had the flu shot already in hand. Despite this modification and my staff’s pre-filling syringes, the process slowed me down and only a fraction of my patient population ended up being vaccinated.

Several years ago, I got out of the way. I read somewhere about using standing orders that authorized qualified staff members to administer flu shots to patients. My MAs, who spent most of their time bringing patients to rooms, answering phones, and filing, were more than happy to take this on, since it allowed them to practice a skill that they learned when training to be an MA.

Our physicians created a standing order that allowed the MAs to offer a flu shot to a patient who came to the office for any reason, be it a visit, a lab test, to drop off a form, or when accompanying another patient to a visit. The standing order specified how to screen patients to identify those who should not get vaccinated (or should be vaccinated by the MD, PA, or NP) as well as other steps in the process, such as providing a Vaccine Information Statement (VIS) to the patient and documentation requirements. Here are sample standing orders.

Because of the standing order for flu shots, now when I enter the exam room, the patient has already been immunized, unless he or she wants to discuss it with me first, in which case the MA gives the vaccine after I am done with the visit and already in a room with the next patient.

Use of a standing order improves my practice’s flu vaccination rate significantly while decreasing my workload and increasing job satisfaction among the MAs. It also expands patient access to flu vaccines, since the process does not depend on patients having a scheduled appointment with me. Because of the success of our standing order for flu vaccine, we now have standing orders for pneumococcal vaccine and Tdap.

Another example of getting out of the way may be more controversial. That is to use community resources to increase immunization rates. Pharmacies providing flu vaccinations is a sore subject for many physicians, partly because of the difficulty that some practices have acquiring the vaccine, partly because of philosophical disagreements over whether this is an appropriate role for pharmacies.  I am a primary care physician and want to provide as much of my patient’s care as I possibly can, but that desire shouldn’t get in the way of patients getting what they need.

The Health Map Vaccine Finder is a searchable website that identifies locations, such as pharmacies, where patients can go for flu vaccine. State and county health departments and immunization coalitions maintain web sites that list public flu vaccination clinics. You can post these lists in your waiting and exam rooms as well as on your practice website. You should also remind your patients to let you know if they are vaccinated elsewhere so that you can document it for quality measurement and pay for performance purposes.

By making vaccination a team effort, you can increase your vaccination rates without decreasing your productivity, while using your staff more effectively. The ACP Immunization Portal and CDC website are good sources of additional ideas for how to incorporate immunization into your workflow. And ACP offers an ACP Immunization Advisor mobile app.

Yul Ejnes practices internal medicine in Cranston, Rhode Island, and is the Immediate Past Chair, Board of Regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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