Creating PH Informatics Tools to Implement Efficient, No-Wait Mass H1N1 Vaccination Clinics

State: CO Type: Model Practice Year: 2010

This practice solved the following mass vaccination problems: - Ensured that vaccine supplies were always sufficient for every clinic’s attendance - Ensured that people did not come to the clinic who were not in priority groups for vaccination, with the ability to change these groups as vaccine supplies increased. - Eliminated long lines and waits for immunizations despite serving large numbers of people at each clinic by spreading people evenly over time, and limiting numbers who could be served to vaccine supplies on hand. - Allowed clinic organizers to gauge public demand for vaccine by monitoring how quickly vaccination appointment slots filled up through web and phone registration, and adjust staffing and hours accordingly. - Sped up client registration considerably with 85%+ of attendees bringing their already-completed pre-registration screening forms with them. - Ensured effective management of volunteers - Ensured planning information was available to staff and partners   Goal: To develop informatics tools that would help us overcome the problems that plague mass vaccination clinics in times of vaccine shortages: - Frail patients and parents of young children having to stand in line for hours - People that arrive 5-6 hours before a clinic opens to be sure they get vaccinated, or that all arrive when the clinic opens, creating human traffic jams and crowding that’s undesirable in a pandemic - People who don’t have time to wait for hours and decide it’s not worth being vaccinated - Mismatches of vaccine types, vaccine amounts, and clinic staffing compared to the number of people seeking vaccines. - Difficulties with recruiting, scheduling, training, and managing volunteers and paid staff to work each clinic - Challenges of keeping staff and partners informed about plans   Objective 1: Develop an online and phone pre-registration system for patients that would manage patient flow and speed up service delivery by - Obtaining all screening information required for the clinics in advance - Requiring all persons to select an available 15-minute time slot for their vaccinations - Using automated logic to reject those that did not fall into the current priority groups for vaccinations or weren’t eligible due to other medical contraindications, with an explanation about why they were rejected and what other options were available to them - Printing entrance “tickets” (their screening form) to admit them to the clinic   Objective 2: - Develop an online volunteer registration/scheduling/initial training website to manage volunteers for each clinic. Objective 3 - Develop secure web-based tools for ICS planning and situational awareness and detailed clinic operations planning where information could be shared with staff and key partners - Over 90% of our H1N1 clinic attendees registered online - 100% of our clinic volunteers registered online.Most read some additional training materials online before coming the the just-in-time training immediately before each clinic - Persons who were ineligible for vaccination (based on the priority groups in any given week) were not allowed to register, and given information about why and what their options were - The public expressed great overall satisfaction with the registration process and the ease of getting through the clinics due to the appointments being spread over time and knowing they would get their vaccine - The majority (60%) of clients were vaccinated in 10 minutes or less; 94% were vaccinated in 20 minutes or less. - 99.6% of attendees expressed their satisfaction with their H1N1 clinic experience, - Positive feedback from the public was incredible; no public health effort I’ve been involved in for the past 25 years has been so well received. - ICS, staff, and partners were able to find needed planning updates and situational awareness tools through secure wiki-type websites
To provide an effective response to an influenza pandemic, and fulfill the Health Department’s responsibility to implement an efficient and targeted mass vaccination effort that the public viewed positively and that workers and volunteers found manageable and satisfying.There were federal, state, and community expectations (and requirements) that our public health agency would be able to mount an effective mass vaccination effort as part of our overall response to the H1N1 pandemic. At the time, no other public health issues were viewed as more “relevant” to the community. We were fortunate to have working relationships with many key community partners due to our extensive pandemic planning efforts for a feared H5N1 outbreak. - Our IT tools, especially the advance registration for clients and volunteers, solved most of the problems that health agencies face with the daunting process of a mass immunization effort. - We has short throughput times (60% under 10 min, 94% under 20 min) and less crowding. - We ensured vaccines were going to the appropriate target groups. - We never ran out of vaccine before a clinic was over - People wanting to be immunized had no incentive to “come early” for fear of running out of vaccine. Community members had the convenience of reserving their vaccine by type and time without leaving home and the knowledge that, if the slots filled up for any given clinic, more slots would be opening up at another clinic in just a few days. - We saved considerable costs by having over 300 volunteers helping at our clinics who signed up using the online registration system. Once they experienced the clinics and found them to be so organized and positive, they chose to volunteer at additional clinics. The public was greatly impressed with their public health agency and with the county government, creating a lot of positive feelings from elected officials. A review of the scientific public health literature found no published reports on client use of online registration systems for mass vaccination clinics. One article published in 2003 ("Electronic patient registration and tracking at mass vaccination clinics: a clinical study," by Billittier AJ et al, in the J Public Health Management and Practice, 2003, Sep–Oct;9(5):401-10) used web registration by workers to register attendees after they showed up at a smallpox clinic exercise. This allowed them to quickly enter the data in their database, but did not spread the arrival of the patients over time, reduce crowding, or to ensure there was adequate vaccine for those show showed up. In the actual H1N1 pandemic, this jurisdiction did not appear to have used the tool reported in the journal article. After completing our mass vaccination clinics in early January, we did some Web searching to see if we could find other local or state health agencies who had offered online H1N1 registration. The state of Ohio offered the forms which the patients could complete online and bring to clinics offered throughout the state, but did not actually allow them to schedule a time and date or to ensure vaccine would be available. One local health department in Ohio subsequently contracted in December with a commercial company that makes appointments for patients to schedule times to arrive at a clinic, but did not appear to have the patient complete the screening information online in advance or use logical analysis of responses to screening questions. The commercial company is now seeking to use this success to increase their business with local health agencies, in addition to the physician offices they typically serve. There may have been other counties that used a system similar to ours that we were unable to find through internet search engines. We aren't aware of anyone trying to develop such systems in an open-source environment to make them available to all public health agencies. Other health departments may have used online volunteer recru
Agency Community RolesThe Larimer County Department of Health and Environment was the lead on the overall H1N1 response, incident command, and setting up the patient online registration system for the clinics. Our major partner, the Health District of Northern Larimer County, took on the responsibility of developing the online volunteer registration system. Both agencies used wiki-like tools to keep each other informed about the planning and progress in addition to one to three meetings together each week before launching the clinics. Each agency used their own respective IT staff to help modify IT systems used for other purposes to quickly meet the needs to respond to the pandemic. Several websites can still be visited to see how some of these systems worked, though they can no longer be used to actually register as patients or volunteers for clinics. See - Pandemic flu information website: - Patient registration website (linked to from when clinic registration was open):; - Volunteer registration/scheduling/training website: - Two additional secure websites were used: a wiki website for ICS planning, situational awareness, vaccine and antivral tracking, and a wiki-like website for detailed operational planning for the mass vaccination clinic. As above, the Health District of Northern Larimer County was absolutely essential in helping develop the tools to manage our volunteer worker recruitment and some of their training. They were partners in our ICS system, and had worked very closely with the Health Department since 2006 on community planning for pandemic response. Our county IT staff and webmaster were essential partners in developing the tools we used, as well as the open source re-coding of these tools. The Larimer Emergency Telephone authority assisted us in notifying all the registered clinic participants through automated calling when our very first H1N1 clinic was canceled by a blizzard, in addition to our email notifications. Costs and ExpendituresOur efforts were part of our response to the H1N1 flu outbreak in 2009. Our IT tools were developed to make use of lessons learned in the 2004 flu vaccine shortage, where we realized that it was necessary for clinic attendees to be spread out evenly over time (to avoid crowding and long waits of frail/at risk people). It was also important that no more people were waiting to get vaccines than the quantity we had available (to avoid anger/disappointment when vaccine supplies were exhausted). In 2004, we gave out tickets to people lined up for clinics, giving them a 15 min. time slot to come back for their shot with no waiting. People were reasonably happy with this solution, but it still seemed unnecessary for people to have to travel to the clinic just to find out when they should come back. In the five years since then, internet usage has grown (we now have 90% of our population with Web access) and many people are now familiar with using the web to buy tickets online to movies, concerts, etc. This seemed an ideal way to screen people interested in getting H1N1 to make sure they were eligible for vaccination (taking into account the types and amount of vaccines we had available in any given week) and to let them select a convenient date/time/location for their vaccination from one of several clinic options. We also made sure that phone registration was an option for those without internet access, and even printed up paper "tickets" to the H1N1 clinics for certain high-risk patients. We also wanted to create an online registration to recruit, schedule and manage volunteers to work in the clinics. We planned to pay for this with PHER funds, but they were so late getting to us that we cobbled together workable tools that accomplished these goals by modifying existing IT systems created for other purposes, at a cost of about $50,000 of in-kind work. Unfortunately, we were unable to quickly create an easily shareable system that other agencies could use, too. Now that we have PHER funds, we are going back and completing our original intention to create an open-source, integrated web-based patient and volunteer worker registration system. Our cost estimate for this is about $90.000 in contracted services. Existing Health Department and Health District (Health District of Northern Larimer County) budgets, supplemented by CDC H1N1 grants (PHER Phases I, II, and III) and in-kind and paid services by the county’s Information Technology Division and Health and Human Services Business Analysts. Most of the initial informatics tool development was done with funds from existing Health Department, Health District, and County IT budgets. The re-write of volunteer and client registration systems as open source programs so that they can be more widely used in the future is supported by PHER funds. ImplementationClient registration system: - Create the vaccination screening form (based on state-defined required data elements) for clinic registrants, and have programmer create online forms and underlying database) - Define logic that allows system to reject or approve patient for appointment (this logic must be able to quickly changed over time) - Create prototype system and test to make sure that data are collected as desired and logic decisions are operating properly - Move from development server to production server - Monitor client registration attempts when system goes live to check for problems - Assess, based on experience, need to overbook slots to compensate for no-shows - Assess, based on experience, need to load more slots later in the clinics to compensate for people who arrive early despite directions to come at appointed time Volunteer registration system: -Develop questions to be asked of volunteers, including documentation of professional license numbers as needed -Create job descriptions for volunteers and minimum requirements -Create job descriptions that potential volunteers can review to decide if a job type is of interest and they are qualified -Create online system to gather data, allow them to select clinic dates and shifts, and allow sign up - Develop reports that assist in worker/volunteer sign in and sign out for accountability of time worked, credentialing, name tags, vests, radios, etc. as needed Internal Secure Web information systems: - Primarily involved training in how to take paper document, (ICS org charts, Incident Action Plans, etc.) and moving them to the web where the information could easily be found and used by staff and key partners Most of the pre-event work was accomplished in a period of four–six weeks in September and Early October. Programming changes were made to client registration system on a frequent basis throughout month of November when seven large mass vaccination clinics were held as priority groups for vaccination changed, and types of vaccine available also changed.
To develop informatics tools that would help us overcome the problems that plague mass vaccination clinics in times of vaccine shortages.Develop an online and phone pre-registration system for patients that would manage patient flow and speed up service delivery. Use of registration system by the public Availability of screening forms when clients came to the clinic; percentage of no-show (registered but didn't attend); time from arrival at clinic to vaccination; satisfaction with registration system and overall clinic experience; worker and volunteer satisfaction surveys. Online registrations: vaccine slots open/total slots (similar for phone registrations). No shows: each hour of each clinic, actual vaccinations given were compared to the number of people registered. Patient through put time measured partly in real time by observers and partly online survey after clinic. Satisfaction surveys sent to about 6,000 persons who registered themselves/household members.Online and phone registrations: continuously monitored in real-time to see how quickly slots were filling up, whether to expand slots for certain vaccine types, etc., need to expand hours of clinic, etc. via administrative screens for registration system Some patient throughput times measured in real-time at each clinic by observers, most data from online survey (n>1800).After every clinic (for the first five or six) hot wash sessions were held to identify issues that needed to be resolved. Patients provided feedback from the website when they ran into problems with registration, which we were able to correct.Patient flow times, patient satisfaction surveys, were all extremely positive. Targets of less than 15 minutes for vaccinations on average were met, with 60% vaccinated in 10 minutes or less, 94% vaccinated in 20 minutes or less. Develop an online volunteer registration/scheduling/initial training website to manage volunteers for each clinic. Successful recruitment of number of needed volunteers. Number of volunteer no-shows. Number of repeat volunteers Worker and volunteer satisfaction surveys. Number of temps needed to fill in for unfilled slots.Positions needed vs. positions filled. No show volunteers identified at beginning of each clinic at worker registration desk. Counts of repeat volunteers. Satisfaction surveys.Daily assessment of volunteer recruitment goals up to four days before the clinic, when temps needed to be scheduled for unfilled positions. Staff reassigned as need to compensate for no-show. Worker survey after all mass vaccination clinics completed.Informal feedback to team leads brought to hotwash sessions.High levels of satisfaction. Most slots that didn't require licensed professionals filled for each clinic, temp and relief nurses were most likely to be hired in paid status. Overall savings from volunteers not yet calculated.Develop secure Web-based tools for ICS planning and situational awareness and detailed clinic operations planning where information could be shared with staff and key partners.Availability of data and plans as needed. Check to see if information was appropriately posted when neededAs needed by ICS team and operations managers. Letting people know if needed information was not available. Generally worked well and improved internal/partner communications
Yes, at least for our county. One of the real advantages of developing shareable open source software applications is that a public health agency pays only once to develop the tool, and many others agencies can benefit from its use (though there may still be costs in customization, maintenance, and staff training). With the right open-source license (our will likely be GNU General Public License or Mozilla Public License), improvements made by other health departments in the future are also required to be freely shared with others, continually improving the tool. We recognize that the applications we actually used for our clinics was not easily shareable outside our department, so the code re-write in an open source format (doesn’t require a Cold Fusion server, for example) was a priority to make the practice sustainable and of benefit to others. It will also allow us to improve some aspects of the applications, and support both low-tech and high-tech implementations at the actual mass clinic site. (We chose low-tech implementation at our actual clinics, meaning that we did not require and computers, printers or internet connections at the schools and exhibition hall where our clinics took place; however this meant that we had to add the patient vaccine type and lot number to their records after the clinic by manually data entry in the days following the clinic ; however we’d like to build in the option of using scanning tools that could add this information automatically at a clinic if the wireless infrastructure and scanners (which could be smartphones/iPhones) were available. This would speed uploads to state immunization registry. The continued existence of an open source application depends on the community of users that adopt it and work to maintain and improve it. We believe there’s a good chance that other organizations will see the real benefits we experienced in our mass vaccination clinics and choose to adopt it, and it can have advantages for other large vaccination clinics, not just emergencies. We will also make these tools part of an open-source Public Health Practice Management System we are developing (called “Public Health ETHOS”), which will include a public health-oriented electronic health record, a clinic scheduler, a cashiering system, and anenvironmental health inspection system. The scheduler will be in public release within the next two months, and the first release of the full ETHOS application will be December 2010. The re-write of our mass vaccination clinic patient and volunteer registrations systems in an open-source format will be completed by Aug. 2010. We believe that most of the costs of this system will have been paid for already, so that ongoing use and broader adoption will be relatively low cost, which will facilitate greater adoption and spread the costs of maintenance and improvements in the future.