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AFIX Quarterly Conference Call Minutes

October 31, 2012

Awardee Attendance

Present: Alaska, Arizona, Arkansas, Chicago, Colorado, Connecticut, District of Columbia, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New York, New York City, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Philadelphia, Puerto Rico, San Antonio, South Carolina, South Dakota, Texas, Vermont, Virgin Islands, Virginia, Washington, West Virginia, Wisconsin, Wyoming

 

Summary

AFIX

  • Welcome and Introduction
  • General AFIX Program Updates
  • Sharing AFIX Info and Best Practices among Grantees
  • Follow up Tasks for CDC

CoCASA

  • CoCASA v8.0
  • CoCASA Version History

2013 AFIX Quarterly Call Schedule

  • Dates: January 16, April 17, July 17, October 16

 

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Minutes

AFIX

Welcome and Introduction

The AFIX Quarterly calls will be held once every 3 months according to pre-scheduled dates and times. These dates and times, along with meeting minutes, are available on the following AFIX website.

During the conference calls, time will be used to inform attendees about AFIX Program updates, new developments, and other program information. Part of the conference call time will also be spent on sharing Grantees’ AFIX programs and best practices.

  • POB Branch Chief Brock Lamont
    • Brock Lamont began his new role as the Program Operations Branch Chief on October 8th.
    • Brock Lamont welcomed the participants and expressed his support for the AFIX program, which is a program he’d personally worked on and experienced the benefits of. Brock emphasized POB’s support for AFIX and for ensuring its effective and continued success.

General AFIX Program Updates

  • Program implementation for 2013
    • CDC will not be introducing any AFIX Program changes in 2012 for implementation during 2013. There will be no updated standards or additional required reporting elements for 2013’s program implementation. CDC’s AFIX Lead and team members, however, will continue to provide technical assistance to Grantees’ AFIX programs during 2013.
  • Program direction for 2014
    • CDC’s direction moving into 2014 will be to provide program updates taking into account several important resources; 1) The IPOM Objective for AFIX (Objective B-3) which will remain the same for 2013-2017 and may differ in the list of activities from one year to another, 2) Healthy People 2020 Objectives (Objective IID-17, page 180, Target: 50%), 3) NCIRD priorities (i.e. Improving HPV rates in adolescent populations), and 4) Feedback from grantees and POB field assigned staff.
    • It is recommended that Grantees consider these priority resources when developing their AFIX operational and strategic plans for the new project period (2013-2017).
    • AFIX Program updates for implementation in 2014 and onwards include:  
      • Streamlining the AFIX program using registries as primary source of data for assessments.
      • Increasing the focus on feedback and the follow up process - there will be additional guidelines covering feedback and follow up with the goal of strengthening these elements to ensure the success of AFIX as a Continuous Quality Improvement Program.
      • Increasing the focus on improving adolescent coverage rates (HPV, other). Adolescent coverage rates continue to be low and AFIX as a QI program can be very effective in improving practices at provider offices and contributing to improved coverage rates and reduced missed opportunities.  
      • Standard Policies and Procedures Guide - this document will replace the use of the Standards Guide and the Core Elements documents. It will build upon prior AFIX standards with a more direct focus on: 1) assessing different age groups, 2) using different assessment tools, 3) AFIX/IIS best practices, 4) standards and helpful tools for site visit, and 5) standards for completing feedback and follow up. The Guide will be developed in collaboration with other CDC SMEs through an internal CDC AFIX Workgroup that meets monthly.  
      • Site visits - The Standard Policies and Procedures Guide will provide information and tools that will be helpful when conducting site visits: 1) standards for selecting providers, 2) scheduling a site visit, 3) standards for both the quantitative and qualitative portions of site visits, 4) a standards list of assessment reports to share with providers, 5) an AFIX site visit questionnaire, and 6) a QI plan template
      • Annual Report. The AFIX reporting requirement beginning March 2014 will include the annual submittal of an AFIX Annual report. The following are details about annual reporting requirements:
        • March 1, 2013 - Required submittal of VFC Management Survey for both the VFC and AFIX programs.
        • March 1, 2014 - Required submittal of the AFIX Annual Report including AFIX annual data covering January 2013 through December 2013. This report will look identical to the AFIX section in the VFC Management Survey submitted on March 1, 2013.
        • March 1, 2015 - Required submittal of the AFIX Annual Report including AFIX annual data covering January 2014 through December 2014. The form of this report will look different than the prior year. You will need to program this report into IIS if you’re only using IIS. If you’re using CoCASA, the data will be calculated and saved for you to submit your annual report, similar to current practice with the VFC Management Survey. More information about this will be forthcoming.
        • The AFIX Annual report will be submitted in PAPA.
      • Training / website update
        • AFIX Coordinators have the option of receiving automatic notices about AFIX website updates. Should you wish to subscribe to CDC's AFIX web site email subscription service, please signup using the "get email updates" box in the right column of the AFIX website.
        • Two recent additions made to the AFIX web site (links can be found on the AFIX home page):
          • For Grantees: AFIX Logic Model
          • For Providers: Suggestions to Improve Your Immunization Services
        • Training venues for AFIX will be identified for 2014 as most of the training will be necessary after the program updates are in place.
    • We will continue to discuss program updates during quarterly calls and any changes or deviations from this plan will be brought up during the calls for further discussion.

Sharing AFIX Information and Best Practices among Grantees

Michigan’s AFIX Program (Stephanie Sanchez, Michigan AFIX Coordinator)

Stephanie Sanchez described Michigan’s process that moved their AFIX visits from state-based staff conducting the manual chart reviews (using CoCASA) as the method of assessment to Local Health Department (LHD) immunization nurses conducting registry based assessments using the IIS (MCIR = Michigan Care Improvement Registry).

Beginning in 2001 the AFIX specialists conducted a Quality Data Comparison (QDC) project, comparing the immunization data collected from patient charts at the provider office with the data available for the same patients in the MCIR. The QDC project confirmed that BOTH the patient chart and the MCIR record should be accessed and used to appropriately assess a patient’s immunization status. The QDC project was performed until 2004. With permission from the provider offices, in compliance with HIPAA and the Michigan Public Health Code, more than 36,000 patient charts (19-36 month olds) were reviewed, more than 46,000 vaccines were entered into the MCIR and more than 58,000 vaccines were identified in the MCIR that were NOT in the patient chart at the provider office. More than 2,000 missed opportunities for simultaneous administration were identified during the QDC project along with more than 1,000 children that had completed the series late (after 24 months of age). The current ACIP recommendations are applied with all AFIX visits; more than 4,000 invalid doses were identified and addressed with the provider office during the 1-hour on-site feedback meeting. The QDC project was labor and time intensive but proved to be effective in building confidence and identifying areas to present to public and private providers to decrease barriers and improve vaccination of their patients. The conclusion of the project confirmed that Michigan was going to use the MCIR as the standard for assessment coverage levels for provider offices, county jurisdiction levels and statewide coverage levels.

In early 2000 the CDC/NCRID encouraged and recommended grantees to conduct the VFC site visits at the same time as the AFIX visits. Michigan was hesitant to make the visits combined, as the LHD nurses were not familiar with the dynamics of presenting AFIX information at provider level feedback meetings. However with the conclusion of the QDC project and the confidence that the MCIR is reliable in conducting assessments, Michigan moved from state-based AFIX staff conducting AFIX site visits to the LHD immunization nurses conducting the VFC and AFIX together at site visits. With the combination of VFC/AFIX site visits, the AFIX visits at Michigan provider offices dramatically increased from an average of 100-150 providers a year to 800+ providers a year. However, the allotted time for AFIX feedback meeting, the details and the dynamics of the feedback and exchange of information decreased from 60+ minutes to approximately 15 minutes.

The current AFIX visits in Michigan are conducted at the same time as the VFC site visit by the LHD immunization nurses. The LHDs are contracted to conduct VFC / AFIX site visits annually with a minimum of 50% of enrolled VFC providers in their jurisdiction. The Michigan Site Visit questionnaire used at the site visits contains BOTH the VFC questions and AFIX questions. The information and data from the AFIX visit is entered into CoCASA along with the VFC information. The AFIX information entered into CoCASA is used for several things:

  1. Generating reports used to complete the annual VFC Management Survey
  2. Assist with writing and reporting on grants
  3. Generating reports used to present to Michigan stakeholders at state-wide conferences and Bi-Annual IAP meetings.

Michigan has had success with using the IIS to generate coverage levels and assessment data for conducting AFIX visits; and CoCASA is used for the entry of the information and to generate reports needed for CDC and statewide activities.

New York City’s AFIX Program (Karen Fernandez, Provider Quality Assurance Unit Chief)
 

Background:

In NYC, the IIS is called the Citywide Immunization Registry (CIR).  There is mandatory reporting of immunizations since January 1, 1997 for birth through <8 years of age and since August 18, 2005 for birth through <19 years of age.  NYC has a large population of approximately 2,000,000 children 0-18 years of age and about 125,000 births each year.  There are about 1,800 provider sites reporting to the CIR and about 1,550 providers enrolled in VFC.  72% of children 0-18 years of age are eligible for publicly funded vaccines (65% are VFC eligible and 7% are SCHIP eligible).  Since September 1, 2006, VFC accountability has been done through the CIR, which led to increase reporting.  Currently, there are about 4.7 million records and over 60 million immunization events in the CIR.

In NYC, The PQA Unit conducts AFIX and VFC compliance site visits among the VFC enrolled providers.  The PQA Unit was the result of merging two units that conducted AFIX and VFC compliance site visits in 2008 to reduce duplication of services, to improve communication with providers, to allow more through and complete evaluations by staff members, and to be able to increase the number of site visits.   NYC began conducting AFIX through the CIR in December 2006.  The process to start conducting AFIX through the CIR included: meeting with the CIR staff to discuss immunization series to be assessed, determine CIR algorithms to match the AFIX statistical program algorithms, discuss possible challenges and limitations, and receive CIR training; conducting a pilot assessment among providers; conducting follow-ups 3 months later to see if the AFIX process have had an impact among the piloted providers; working with the CIR to develop a user-friendly online UTD program.  Based on findings and mutual discussions, the CIR added a MOGE field, disease history field, and expanded the de-duplication process to facilitate the AFIX through the CIR process.  As of July 1, 2010, the PQA unit transitioned to conducting all AFIX via the CIR. 

The process of AFIX in NYC currently involves:

  • Assessment:  running immunization coverage through the CIR’s web-UTD program; identifying and merging duplicate names; re-running immunization coverage after merging, generating list of children not UTD; reviewing and printing CIR-online records of children missing vaccines; identifying specific practice issues
  • Feedback: discussing face-to-face immunization coverage, practice specific barriers, and recommendations to improve coverage
  • Incentive: developing a positive relationship with the providers; recommending to recall and immunize patients missing vaccines; re-running immunization coverage 3 to 4 months after the assessment and provide them with feedback; providing certificates of achievement for reaching the goal of ≥90% coverage and recognizing providers who have high immunization coverage at the quarterly coalition meeting
  • Exchange: we have upgraded our own systems to assist providers with recalling their children through a CIR recall system; we are always willing to serve as the liaison between providers and the CIR and other units within the BOI

NYC has found that the benefits of using an IIS to conduct AFIX are: less time consuming, less disruptive to provider’s practice, facilitates targeting certain groups and assessing them in a timely manner, improves immunization coverage and immunization reporting.   

Thanks to conducting AFIX through the CIR, the following was achieved in 2011:

  • Number of AFIX conducted among 2-year-olds increased by 29% from 2010, when we were still conducting AFIX through chart review during the first 6 months of the year
  • Number of AFIX conducted among 13-year-olds increased by 31% from 2010
  • Coverage for the 4:3:1:4:3:1 series increased by 20% (20 percentage points) for current AFIX when compared to a previous IIS AFIX (any previous year)
  • Coverage for the 4:3:1:4:3:1 series increased by 19% (11 percentage points) after the time of follow-up measuring the same cohort on an average of 7 months later
  • Coverage for the 1:1 series increased by 6% (4 percentage points) after the time of follow-up measuring the same cohort on an average of 6 months later

Comprehensive Clinic Assessment Software Application (CoCASA)

CoCASA V8.0:
  • Brief overview of the proposed changes to the AFIX Evaluation Tab
    • CoCASA V8.0 will not include major changes to the AFIX portion of the program.
    • Grantees will continue to have access to the same (AFIX) tabs; Provider Setup, Assessment Setup, Data Entry, Reports, and the AFIX Evaluation tab which has been renamed “2013 AFIX and pre 2013 VFC/AFIX”.
    • There have been a few programmatic enhancements made in V8.0 for AFIX and these changes are listed below.
    • CoCASA V9.0 is scheduled to include major changes to the AFIX portion of the program. A new AFIX Evaluation tab will be developed enabling Grantees to save site visit information, assessment rates, missed opportunity rates, feedback, and follow up.
    • More information will be forthcoming about this.

Version History

AFIX changes from Version 7.0 to 8.0:

  1. Import Error when Shot Type is not included in the template - Allow the user to exclude shot type and date from the import template and just import patient information from a registry without receiving any kind of error message.  CMT 835
  2. Add CVX code and CPT code reports to the CoCASA Library -  Add two new reports that would run against the new tables used for CVX and CPT importing and would display which code(s) map to which antigens.  Display the reports directly in .pdf format if possible, or in the ActiveReports viewer like all other reports if not.  Reports should be selected from the first section of the Library menu in CoCASA. CMT 838
  3. Missing Immunization Report DTaP 4/6 Month Section Bug - Given this scenario:  DOB 3/17/2009, DTAP1 6/23/2009, DTAP2 10/13/2009, DTAP3 3/19/2010, DTAP4 6/25/2010, DTAP5 11/16/2010, running the MI Report for 5DTaP.  6/25/2010 is invalid because it is not greater than 4 months from 3/19/2010.  11/16/2010 is between 4 months and 6 months when measured from 6/25/2010, but is over 6 months when measured from 3/19/2010.  In general, CoCASA measures from the last dose, whether valid or invalid, so it should be measuring from 11/16/20010, not 3/19/2010, and therefore it should show up in the DTaP 4 to 6 month section of the report. CMT 841
  4. Reasons Not Given Falling on Compliance Date Are Not Being Counted -  In HepA, HepB, MMR, and Varicella, make the Reason Not Given selection be less than or equal to the compliance date, rather than just less than.  CMT 842
  5. Add a Process Complete message to the text file export - Add a "Export Complete" message to the end of the text file export process. CMT 843
  6. Bug in the CoCASA Export - Add an "Export Complete" message to the end of the text file export process, a file that is exported and encrypted gives an error when trying to import. Bug 844
  7. Change PCV algorithm such that any dose after 24 months is C & UTD -  Change so if the 1st, 2nd, or 3rd dose of PCV occurs after 24 months of age, the patient is complete and up-to-date. CMT 850
  8. Missing Immunizations Report - Add Recommended Intervals to Overdue Section - Use the Recommended and Minimum Ages and Intervals between Doses chart in the back of the Pink Book to determine the Recommended Intervals to add to the test deciding whether or not a patient is Overdue.  In the case of ranges, use the higher of the two numbers as the deciding factor. CMT 866

2012 Quarterly Call Schedule

  • January 16, April 17, July 17, October 16.
    • The next conference call is scheduled for January 16th, 2013. If any of the above dates or times must be changed, an e-mail will be sent to you 2 weeks prior to the scheduled call. 
    • If participants would like to suggest issues for the agenda, please forward those suggestions to Hanan at wgn5@cdc.gov. These suggestions need to be forwarded to CDC 2 weeks prior to the scheduled conference call date.
  • Meeting minutes and meeting schedule
    • All meeting minutes for this call and prior ones (VFC/AFIX combined) can be found at the same website.

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