Susan Kreimer


When Susan Kressly started her own practice in 2004, she invested in an electronic medical records system designed for pediatricians. 

It works like this: As the nurse administers a vaccine, the system “subtracts” a dose from the inventory, records the immunization in the patient’s chart, and automatically adds the correct reimbursement code to the electronic superbill. “With a few clicks of a button, the patient’s immunization history and chart can be printed and handed to the parents,” says Kressly, who practices in Warrington, Pa. 

High-volume acquisition, storage, and administration of vaccines - along with tedious record keeping and retrieval - have become a hot topic for pediatricians. The good news is that a well-organized practice, with policies and systems in place, can weather the flurry of requests for immunizations even in the busiest of seasons. 


Of key concern is whether or not to charge families for these immunization record requests. Most practices still supply the records at no cost while absorbing the expense of office productivity used to furnish this information, sometimes more than once to the same person. 

Kressly Pediatrics P.C. gives an immunization history free of charge at the time of the office visit. At any other time, there is a $5 or $10 fee, but Kressly rarely collects it unless someone acts unusually demanding. However, as more and more schools, camps, sports leagues, and other venues require proof of immunization, she plans to institute a processing fee for all requests made outside the context of an office visit. 

“Our profit margin in pediatrics is shrinking every day, which is why there are very few independent practices remaining. Physicians are beginning to think the only way to stay alive is to join a larger group or sell out to a hospital-based organization,” says Kressly, who launched her own practice after 15 years in a big group. In 2006, she hired another female pediatrician who became her business partner in January. 

Louis A. DiNicola, pediatrician and associate medical director at Gifford Medical Center in Randolph, Vt. says that it costs at least $5 to $7 worth of a nurse’s time to handle an immunization record request. “This dollar figure is something that we looked at a few years ago,” says DiNicola, who is also vice president of the American Academy of Pediatrics Vermont Chapter. 

“It represents the time to field the phone call, pull the chart, review the chart, call, fax, or mail the information, and refile the chart.” The turnaround time is the same day or immediately, especially if the record is needed for school, camp, or other urgent reasons, DiNicola says, while admitting, “This does put a significant amount of pressure on a busy day.” 

Despite the time-consuming nature of filling immunization record requests, some outpatient clinics are able to produce immunization records quickly and without a fee. “It is a free service, and yes, people can ask for it as many times as they want,” says Susan Meedon, practice manager of the Primary Care Clinic at Lucile Packard Children’s Hospital at Stanford in Palo Alto, Calif. 

“We have a little promise that all requests are filled within five to 10 business days,” she adds. But usually, the immunization card is furnished on the spot, especially if needed in a hurry. “For some people, it really is a crisis, meaning they’re leaving the country tomorrow and they need their shot record to fly to certain countries.” 

The key to avoiding cost and time inefficiencies due to handling record requests is to streamline the process as much as possible. At Meedon’s clinic, one office employee is designated to handle these requests along with other duties. All calls regarding forms for immunization records, sports physicals, daycare, and supplemental nutrition for Women, Infants, and Children are transferred directly to her. 

For walk-in requests, parents are asked to fill out a form with their name, the patient’s name, date of birth, and medical record number (if they know it), Meedon says. Then they sign it and put a checkmark beside what they need - a replacement immunization card or one of the other records, some of which require a physician’s review and signature and often cannot be provided immediately. 

The immunization record is inserted in a protective plastic cover. “It’s an actual yellow cardboard type of card that California issues,” Meedon says. Clinic employees urge parents to keep it in a safe place. Suggested places include a diaper bag, mother’s purse, or a filing cabinet at home. “All Social Security cards for children could be kept along with the immunization records,” she says. 

Privacy provisions under HIPAA should not be taken lightly in dispensing immunization records. Kristan Collins, a pediatrics partner at Broadway Medical Clinic in Portland, Ore., says parents who phone in a request must present proper identification upon pickup. They also can mail, fax, or bring a written release for the records to be sent or faxed to their home. In both situations, documentation of a parent’s signature is kept on file, and a notation of record release is made in the chart. 

“We tell them that it can be available in 24 hours, but it’s usually available in a couple hours,” says Collins, who is president of the North Pacific Pediatric Society, which covers Oregon, Washington, Montana, Idaho, Alaska, Alberta, and British Columbia. The service is initially provided at no cost. After the third time in a calendar year, families are reminded that additional requests will incur a $25 fee. That usually keeps them from losing the records again. “I’ve probably only had to charge one or two parents in my 18-year career,” Collins says. 

Oregon uses a special form for immunizations. It can be filled out by parents, medical personnel, or school staff. “This form is relatively straightforward to complete; however, some parents find it confusing and may need assistance,” Collins says. “When we complete the form for a parent, it usually takes three to four minutes. Providing a Xerox copy of the immunization record is a quicker process if the parent is able to fill out the state of Oregon form.” 

The technology that allows for quick access to records comes at a significant investment not only financially, but also in revamping practice operations. Physicians acquiring an EMR system incur startup costs as well as fees for on-going maintenance and technical support. But the eventual payoff in lowered overhead and easier access to records can be substantial. 

One technology company catering to pediatricians is Connexin Software Inc., which has locations in New York and Pennsylvania. Its Office Practicum includes an immunization management module that physicians use to track vaccine inventory, enter immunizations, document vaccine administration, forecast shots, and receive alerts when shots are due or past-due, says Connexin account manager Louise Aronowitz. 

The company charges between $4,000 and $10,000 per provider (depending on full- or part-time status) to use its full EMR, plus a one-time $500 fee to set up the optional module that reports vaccination records to the state’s immunization registry. Doctors also pay between $500 and $2,000 for an online patient portal and a monthly usage fee ranging from $150 to $250. 

Some states are also providing helpful technologies. A program called Oregon Immunization Alert assists with the immunization request process. The statewide registry compiles all immunizations into one record, saving medical staff and parents the time and effort it would take to contact multiple offices and sift through paperwork to update a child’s record and administer missing vaccinations. Also, by quickly verifying a child’s immunization status, it prevents unnecessary vaccinations, reducing pain and costs, Collins says. 

Vermont also established an online electronic immunization record. In development for about eight years, it has been extended to most practices in the last few years. “We are using one person a day, three days a week, to enter all the old information from the charts. This part is expensive,” says DiNicola of his medical center in Randolph, Vt. “In general, what we have done to date has worked but is inefficient. The new electronic record should improve this overall.” 

Some pediatricians shy away from relying on a state’s vaccine registry to generate records. “I found it very cumbersome outside of my electronic health record and have discontinued use of that system because it requires reluctant time-intense service,” says Mark Simonian, a pediatrician in Clovis, Calif., and chair of the Council on Clinical Information Technology for the American Academy of Pediatrics. While he looks forward to someday linking to the state’s registry, “the accuracy of the information is not there today or in the foreseeable future.” 

What Simonian has found helpful is sharing secure information through a Web site called the Patient Portal. Parents log in using their telephone and insurance policy numbers. They can access any of their child’s past vaccinations that they have shared with the practice. The Web portal may become unavailable to patients after they leave Simonian’s practice, but parents can create a portable history at www.ihealthrecord.com. 

William Zurhellen, a pediatrician in Putnam Valley, N.Y., and a member of the same AAP council as Simonian, also has an interactive Web site through which parents can request records. But due to privacy concerns, it does not offer direct access to clinical information. “Since we can produce [immunization records] on the spot, there has not been a tremendous need to put them on the site,” says Zurhellen, who embraced EMR technology in the late 1980s. 

The practice follows a policy to print at least one copy during an annual appointment. Then “we can print any number of copies, at any time, with little effort or cost to us,” he says. Parents “can call, write in, or show up at the front desk.” 

While Zurhellen views computerized solutions as the only answer to retrieving immunization records efficiently, he laments that current “state-of-the-art” electronic systems “are not designed properly to assess clinical outcome and perform true quality improvement, nor does a national health information network yet exist,” he says. “These two issues are the major roadblocks to the deployment of electronic health record technology in primary-care practice.” 

An optimal solution would give patients access to their personal data through state registries. Scientific Technologies Corporation, based in Tucson, is trying something new in Arizona: Patient immunization records that are furnished to the state are available to health insurers for their enrolled members to pull up through secure online portals, says Michael Popovich, president and chief executive officer. 

“Empowering the individual with information, which can mitigate the risk of vaccine preventable diseases,” he says, “is a win-win for all - from both a health and economic standpoint.” And it could save your practice time and money. 

is a New York-based freelance medical and business writer. She can be reached via 

This article originally appeared in the May 2008 issue of Your Best Practice: A Practice Management Supplement for Pediatricians. 


Articles

Here’s how to stay on top of requests for up-to-date immunization records, from low-tech solutions to Web-based answers and electronic medical records.

In Practice: Handling Immunization Record Requests


A relatively new phenomenon among physicians over the past few years, blogging has gained momentum. Doctors are starting to read one another’s blogs out of curiosity, and the lay public is perusing these tidbits to glean more information about the real person behind that formal white coat. 

All individuals who choose to express themselves on the Internet by creating their own blogs assume a certain amount of risk. But doing so as a physician poses specific dilemmas that you should carefully consider. 

A key decision is whether to blog anonymously or to use your real name. Your choice often dictates where you should draw the boundaries between frankness and reserve. 

“Blogging under your own name gives a certain sense of legitimacy, but you really can’t gripe about people you know,” says a family-medicine physician who maintains an anonymous blog (

). “Blogging under a pseudonym is freeing.” Nevertheless, she admits that at times she has considered “coming out” to her readers. Consideration for her employer is part of what keeps her from doing so. 

And although she doesn’t bring up politics often, this blogger makes no bones about being a Democrat, and she lists most front-running candidates in her writings. But she adds that general medical commentary that steers clear of advice is often a far safer topic: “I did one about the flu shot last year, cutting down all the usual arguments patients give me for not having one.” 


Kevin Pho, a primary-care physician in Nashua, N.H., blogs under his real name. He says he launched his blog (

) in May 2004 to give the public a doctor’s perspective on medical news, which he considers unfiltered and without context. For example, the Vioxx recall left many people confused. Pho suggested specific questions that patients could ask their own physicians. He says his blog has been cited multiple times in the mainstream media, including the 

CBS Evening News and The Wall Street Journal

“Blogging under my real name is a little bit restrictive,” Pho admits, although he says that it also gives him added credibility. “It’s a way to pull the curtain back and expose some of the problems and frustrations that physicians face on a daily basis,” he says, citing declining Medicare reimbursement, the primary-care shortage, and rising healthcare costs. 

Like Pho, many physician bloggers make the conscious decision to avoid discussing patients or dispensing advice. If they do, they alter any potentially identifiable information. Remember that HIPAA applies to your posts. You only have one reputation, so guard it carefully. 

It’s also wise to remain judicious about mentioning controversial subjects like politics and religion. That’s unless, of course, you are willing to disclose your views to everyone, including your patients, says Dmitriy Kruglyak, CEO of 

, a community Web site for healthcare bloggers. The company helped conduct a survey over the past two years evaluating the popularity of this genre of blogging. 

“Physician blogging keeps growing unabated,” Kruglyak says. But it isn’t as simple as it may initially seem. “Creating a successful blog requires constant attention, true love of writing, and willingness to put your ideas out there. As to what topics to discuss and avoid, I recommend a common-sense test: Would you be willing to have your writings attributed to you on the front page of the 

And remember that blogging isn’t just a soapbox for your opinions. It’s also a medium that allows others to respond to your messages with their own thoughts. 

“You have to be prepared for people to write back, sometimes not pleased with what you’ve said,” notes Robert Wachter, chief of hospital medicine at the University of California, San Francisco, who also has his own blog. “If you aren’t provoking that kind of response, you must not be saying much of importance. But I’ve been around the block a few times, and it isn’t for the faint of heart.” 

This article originally appeared in the March 2008 issue of Physicians Practice.

Have no idea what the buzz on blogging is all about? Tour the world of physician bloggers and consider the pros and cons of voicing your opinion in cyberspace.

The Tech Doctor: All About Blogs


Often pegged as IT averse, an increasing number of physicians are going paperless to stay up-to-date on the latest clinical advances within their specialties. 

So says Mark Bard, president of the New York-based Manhattan Research Group, a healthcare market research and services firm that conducts an annual survey of physicians on their adoption of emerging information technologies. 

“The most visible shifts from offline to online are the following: professional journals, conferences, and accessing clinical news,” Bard says. 

“In fact, more physicians get their clinical news online today more than they do from offline sources.” 

The Manhattan Research Group’s most recent survey reports that the number of physicians who say that technology is vital to their practice surged from 114,000 in 2002 to 488,000 in 2007. 

Pharmaceutical companies have taken notice of this trend, and they are increasingly exploiting their online presence to complement and reinforce the personal representative visits they have traditionally used to educate physicians about their new product offerings. 

“Many of these [pharmaceutical] programs are purely promotional in nature, but increasingly we are seeing programs being developed that truly desire to establish a respectful online relationship with the physician,” says Jon Sawyer, vice president of integrated marketing services at Closerlook, a Chicago-based marketing and communications firm whose clients include pharmaceutical companies. 

Closerlook’s programs help pharmaceutical companies focus on physicians’ specific areas of interest and then prioritize those interests when physicians visit their Web sites. “The content is aimed at providing physicians with the essential clinical and product information they need to enhance patient care,” says Sawyer. 

Online, physicians can access company-provided case studies, product safety information, videos, and more. Pharmaceutical firms point out that physicians can log onto their sites whenever they have time for research, so their time spent online doesn’t interfere with patient appointments. Physicians can also e-mail companies to inquire about a drug, request samples, or ask that a representative visit their practice. 

Pharmaceutical companies say that such convenient, value-added services benefit clinicians by helping them build virtual two-way online relationships with companies with which they may not otherwise have time to interact. The pharma companies opting for this method of physician contact say they have significantly reduced the number of sales reps they send to practice offices; typically, these companies say they make personal visits to the top 20 percent of their prescribers who indicate they have time to visit with sales representatives. 

Should I provide feedback to pharma companies about their electronic channels of communication available to providers? 


 Do let them know what you think and what you would like to see from them. The development of electronic relationship marketing evolves through a give-and-take approach. If you do your part, smart companies will do theirs and develop content that is most relevant to your needs. 

Do you have a question for the Tech Doctor? 


This article originally appeared in the May 2008 issue of Physicians Practice.

The days of “detailer” visits may be ending. As physicians shift rapidly to the Internet for clinical and professional information, pharma companies are following suit.

The Tech Doctor: From In-Person to Online

A key decision is whether to blog anonymously or use your real name. Your choice often dictates where you should draw boundaries between frankness and reserve. 

“Blogging under your own name gives a certain sense of legitimacy, but you really can’t gripe about people you know,” says a family-medicine physician who prefers to remain anonymous. (See 

.) “Blogging under a pseudonym is freeing.” Nevertheless, she admits that at times she has considered “coming out” to her readers. She says consideration for her employer is part of what keeps her from doing so. 

Kevin Pho, a primary-care physician in Nashua, N.H., blogs under his real name. He says he launched his 

 in May 2004 to give the public a doctor’s perspective on medical news, which he considers unfiltered and without context. For example, the Vioxx recall left many people confused. Pho suggested specific questions that patients could ask their own physicians. He says his blog has been cited multiple times in the mainstream media, including the 


This article originally appeared in the March 2008 issue of Physicians Practice.

Ever thought about starting your own online journal, or “blog”? It may be good for business, and it’s easier than you think.