August 1996
BALTIMORE — The solution to the problem of keeping accurate, current immunization records may be found in the local grocery store.
Bar codes, those zebra-striped strips found on everything from aspirin to yogurt, may one day be found on vaccine bottles. Although the idea is in its infancy, the plan has promise. Certain technical obstacles must be overcome first, however.
At a seminar sponsored by the Maryland Chapter of the American Academy of Pediatrics, representatives from manufacturing, health maintenance organizations (HMOs), private and public sectors, the military and the computer programming profession discussed the feasibility of using bar code technology to track immunizations, said J. Crossan O'Donovan, MD. O'Donovan is president of the Maryland chapter.
Tracking is an essential element in achieving the immunization coverage goals set by the U.S. Public Health Service. The goal is to have 90% of 2-year-old children fully immunized by 2000. Tracking systems not only assess the child's immunization status but also prompt reminder postcards or phone calls to parents.
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The difficulty with tracking systems, however, is provider participation. Pen-and-paper forms are time-consuming, and although computerized systems are attractive, many physician's offices, especially in rural areas, do not have computers, O'Donovan said.
The premise behind bar coding vaccines would be that all vital information — unique patient identifiers, demographics, immunization history and vaccine lot numbers — would be recorded with a pen stroke. Although the technology is commonplace in the retail industry, it is not yet available in physician's offices, and this has been a problem.
"The [computer] program has not been written," O'Donovan said. "No one is using bar codes and scanning pens to record patient information. Several medical billing programs are available, but some do not store all of the information we need; for example, lot numbers."
In addition to developing the vaccine tracking software, other technical obstacles must be overcome. What information will be included on the bar codes, for example, must be decided, O'Donovan said. Bar codes offer a limited amount of space; condensing the space between the lines gives more room for information, but it makes the code more difficult to read.
Another consideration is choosing one of the many bar code languages as the standard.
"We have to adopt a standardized medical shorthand for manufacturer identification," O'Donovan explained. "There are only a few manufacturers, so this could be a one-digit number. We also have to adopt a one- or two-digit number to identify each vaccine. If this could be standardized now, it would make life much simpler."
Location of the bar code is another problem. Vaccine vials are small with little extra space. Plus, bar codes are best read when they are on a flat surface.
"We thought about putting the bar codes on the back of the label so they could be read through the bottle," O'Donovan said. "But some vaccines are opaque; what do you do then? Maybe we can put them on the package insert. There's room, and it can be done with little or no increase in cost."
The idea of using bar codes to record and track immunizations is still in the "very preliminary" stages, O'Donovan said, but it is attracting interest from a variety of sectors.
"There is a wide level of interest, and everybody is interested for different reasons," he said.
Perhaps the strongest support comes from HMOs. Immunization coverage rates are one tool HMOs use to assess the care practitioners provide.
"The pressure is on HMOs to document quality medical care," O'Donovan said. "They are in favor of doing anything to help them document this."
Manufacturers are not opposed to the idea, O'Donovan said, "but they are concerned with the technical problems that have yet to be resolved." A steering committee will meet later this summer to begin working on these issues.
Oregon isn't waiting. During June, the state health division tested a program that uses a different approach with bar codes to record immunizations, said William Yasnoff, MD, PhD, director, Oregon Immunization Alert (OIA), Oregon Health Division. The OIA is primarily funded by a grant from the Centers for Disease Control and Prevention and by matching funds from Oregon Medicaid. It is sponsored by Oregon Health Systems in Collaboration and the Oregon Preschool Immunization Consortium.
The system is being tested in nine private offices. Private providers are the initial targets because public providers already participate in a computerized registry, Yasnoff said. Furthermore, most children in Oregon receive health care either exclusively from private providers or from both the public and private sector. The OIA is designed to follow children if they change providers.
"The most difficult and most vexing problem is how to get input from private providers," Yasnoff said. "Private providers are unwilling to spend much time recording information. At first they said they could not spend any more than a second, and they finally agreed on three seconds; four seconds would not do. That is a very difficult requirement."
Oregon's solution was to use bar codes. In an elaborate system that involves three color-coded forms, a series of peel-off labels with unique bar codes for patient identifiers and vaccines, and centralized data entry, providers are indeed spending no more than a few seconds to record each immunization.
Providers peel off a label from one form and stick it on a card. Once a week, the cards are mailed to the Oregon Health Division in Portland, where they are scanned and entered into a database. It is estimated that it will take less than an hour a day to scan the forms for the entire state, Yasnoff said.
The system eventually will provide an immunization "forecast" for each child, he said. When an enrolled child returns to the office, the provider's receptionist will call an interactive voice mail system while the child waits. The office will then receive by fax a list of the vaccines that are to be administered.
OIA bar code input has been well-received during this testing phase.
Other types of registries are being tested in other states, but the advantage of the OIA is that it requires so little of the providers' time. For example, Yasnoff said, Savannah, Ga., has what is considered an advanced registry with 65% of its private practitioners having signed up to participate. Participants received the software and are making extraordinary efforts to enter data but are concerned about the additional time required. Registry staff are convinced that bar code forms like those in Oregon will be needed to extend the system statewide.
"It takes too long," Yasnoff said. "If you have ever been to a pediatrician's office, unless you know what you are doing, it's hard to distinguish the office activity from total chaos. ... This is not a problem that can be solved by a computer; it has to be solved by a piece of paper."
Another advantage of the OIA is its price tag.
"The interesting thing about this system is it is cheap," Yasnoff said. "It does not require any equipment for the provider — there is no computer, no scanner, no nothing."
Once the system is up and running statewide, Yasnoff estimated it will cost about 75 cents per month per child for the first two years of life.
"That is about a 4% add-on to the cost of immunizations themselves," he said. "But it will be a savings because there will be a reduction in over-immunization rates and there will be a tremendous savings in administrative expenses of record-keeping."
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