# Presentation: 161814

## BOSTON IMMUNIZATION INFORMATION SYSTEM: COST AND EFFICIENCY

**BOSTON IMMUNIZATION INFORMATION SYSTEM: COST AND EFFICIENCY**

- CDC Award #: U1W/CCU114727-02

- 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

## 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.

## 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).

## 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.

## 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.

## 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).

## 	METHODS: DEFINITIONS

- 	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.

## 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 Boston’s borrowing rate in effect when the actual costs were incurred.

## METHODS: DEFINITIONS

- Up- to-date (UTD) status defined as completion of  a 4:3:1 series within 24-35 months.
- Overimmunization defined as receipt of any one of the following in a cohort of children aged 24-35 months
-  > 4 doses of DTP
-  > 3 doses of OPV
-  >1 dose of MMR

## 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.

## METHODS: DEFINITIONS

- _Immunization assessment_
- A summary of child’s 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.

## 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.

## BUILDING COSTS: INVESTMENTS

## BUILDING COSTS: MAINTENANCE

## USING COSTS

**Notes:**
...

## METHODS: DOCUMENT BASED COST DATA

- Measured costs incurred in 1994 and 1998.

## METHODS: INTERVIEW BASED COST DATA

## METHODS: TIME AND MOTION BASED COST DATA

## METHODS: 1999 PROJECTED COSTS(ASSUMPTIONS)

- 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.

## RESULTS: COST OF BIIS IN 1998

- RESULTS: COST OF BIIS IN 1998

## RESULTS: DIRECT COST OF REGISTRY FUNCTIONS IN 1998

## RESULTS: DO SITES USE BIIS TO ITS     FULL CAPACITY?

- RESULTS: DO SITES USE BIIS TO ITS     FULL CAPACITY?

## RESULTS: ESTIMATED 1998 COSTS AND SAVINGS

## RESULTS: PROPORTION OF CHILDREN UP-TO-DATE FOR IMMUNIZATION (BIIS vs. CONTROLS)

- 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 (F=1.47, p=0.23)

## 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).

## RESULTS: 1999 PROJECTED COSTS

## RESULTS: COMPARISON 1998 ACTUAL  VS. 1999 PROJECTED COSTS

## RESULTS: 1999 COSTS AND PROJECTED SAVINGS

## RESULTS: WOULD AN EXPANDED REGISTRY SAVE MONEY ?

## 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.

## 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

## 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

## STUDY OBJECTIVES AND RESULTS:A 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.