# Presentation: 421486

## A Business Case forElectronic Immunization Registries

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

## Study Goals

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

## 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**

## 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  **

## Tyranny of the Mean:Averaging Costs

## Parametric  Models

**Examine statistical relationships between:**
**Dependent variables**
**Independent variables**
**Preferred method in military and industry**
**Permits “benchmarking”**

## StandardParametric 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**

## 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**

## DOD MIL STD 881b                                      Work Breakdown Structure  

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

## Parametric Cost Estimating Process

## 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**

## WBS Populated with Data Form 

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

## Statistical Analysis

**Standard regression analysis**
**Can use null hypothesis**
**R, R****2,**** F and T statistics appropriate**
**Generates cost-estimating relationship            (CER)**
**Children 0-6**
**SLOC**
**End-users**
**Core functions**

## Comparison SLOC by Function (MEAN 9%)

## 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**

## 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**

## Background costs

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

## 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***

## Registry Cost/Benefits

**Manual HEDIS Audit >$100K 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***

## 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***

## 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***

## 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***

## Return on Investment

- <date/time>

***Return on Investment***

## Return on Investment (ROI)

## 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)**
**Q=F(C,K,S,L,I,t,) (1)t**

## Coverage Rates

## Registry Cost/Benefits

**Practice**** ****Pattern**

## Percent of Shots Missed By Visit Age

## Registry Cost/Benefits

**Missed Opportunities**

## Missed Opportunity Rates 

## Encounter Notification

## Contributing Factors

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

## 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**

## 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)**** **

## Obtained Production Values  Q Ratio

## Major Benefit Activities

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

## 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**

## 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)**

## NEXT STEPS: READINESS FOR CHANGE TEMPLATE

**Need to identify proposed site’s:**
**Willingness**
**Capacity**
**Ability to maintain**
**Need to identify appropriate strategies for “rollout” by clinic’s Readiness For Change characteristics**

## 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**

## 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”**

## NEXT STEPS: PROVIDER PROMPTS

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

## Results

**Immunization registries can be cost effective **
** ****3-year break-even point **
** ****5-year ROI of as high as 8:1**** **
**Immunization registries CAN improve and maintain  high coverage rate **_***ONLY***_** if they are made a part of an administrative TQM/CQI effort**