Committee Opinion
Number 661, April 2016


Committee on Gynecologic Practice
Committee on Obstetric Practice
Immunization Expert Work Group

This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice, Committee on Obstetric Practice, and Immunization Expert Work Group in collaboration with committee members Linda O’Neal Eckert, MD; Richard Beigi, MD, MSc; J. Martin Tucker, MD; and Howard Minkoff, MD.

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.


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Integrating Immunizations Into Practice

ABSTRACT: Immunization against vaccine-preventable diseases is an essential component of women’s primary and preventive health care. Despite the importance of vaccination and clear guidance from public health agencies, rates of vaccination lag behind national goals. Obstetrician–gynecologists can play a major role in reducing morbidity and mortality from a range of vaccine-preventable diseases, including pertussis, influenza, human papillomavirus, and hepatitis. Given demonstrated vaccine efficacy and safety, and the large potential for prevention of many infectious diseases that affect adults, pregnant women, and newborns, obstetrician–gynecologists should include immunizations as an integral part of their practice. To do so, they must embrace their role as important sources of information and advice on immunization for adults, adolescents, and pregnant women, and advance their patients’ well-being with continued efforts to augment immunization services in their offices. Increasing awareness combined with the many suggestions in this document will work to enhance immunization uptake.


Recommendations

The American College of Obstetricians and Gynecologists (the College) has developed numerous resources, including a dedicated immunization web site, Immunization for Women (www.immunizationforwomen.org), to help equip obstetrician–gynecologists to become routine vaccinators. Increasing awareness combined with the many suggestions in this document will work to enhance immunization uptake. Given demonstrated vaccine efficacy and safety, and the large potential for prevention of many infectious diseases that affect adults, pregnant women, and newborns, obstetrician–gynecologists should include immunizations as an integral part of their practice. The American College of Obstetricians and Gynecologists offers the following recommendations:

  • Talk with each patient directly and strongly recommend indicated immunizations. Many studies have shown that a recommendation from an obstetrician–gynecologist or other health care provider for an immunization is one of the strongest influences on patient acceptance.
  • If a patient declines an immunization, document the discussion and her decision. Inquire about her reasons for declining and reintroduce the discussion and offer the immunization at the next office visit.
  • Designate an immunization coordinator in the office and identify a backup coordinator who is trained in case the designated coordinator is absent. Among other duties, the immunization coordinator orders the vaccines, receives vaccine deliveries, and ensures the vaccines are stored properly.
  • Use prompts—paper or electronic—to remind physicians and staff which patients need to be immunized. Many electronic medical record systems have these prompts available.
  • If allowed by state law, institute standing orders for indicated immunizations. Standing orders allow immunization administration to appropriate patients without an individual physician order. However, obstetrician–gynecologists and other health care providers should familiarize themselves with local statutory requirements before standing order protocols are established.
  • After educating the patient, the obstetrician–gynecologist should document that the patient has been counseled regarding recommended immunizations, has been offered these immunizations, and that the patient accepted, declined, or obtained her immunization at an outside facility. Obstetrician–gynecologists should complete documentation in the patient’s chart and the state’s immunization registry.
  • Federal law (the National Childhood Vaccine Injury Act of 1986) mandates that all health care providers who administer vaccines must give patients or their parents or legal representatives the appropriate vaccine information statement (VIS), which can be used to educate patients, before administration of each dose of a vaccine.

Immunization against vaccine-preventable diseases is an essential component of women’s primary and preventive health care. Despite the importance of vaccination and clear guidance from public health agencies, rates of vaccination lag behind national goals. Obstetrician–gynecologists can play a major role in reducing morbidity and mortality from a range of vaccine-preventable diseases, including pertussis, influenza, human papillomavirus, and hepatitis. To do so, they must embrace their role as important sources of information and advice on immunization for adults, adolescents, and pregnant women, and advance their patients’ well-being with continued efforts to augment immunization services in their offices (1). Obstetrician–gynecologists have a tradition of providing preventive care to women. An annual visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks (2). The annual health assessment should include screening, evaluation, counseling, and immunization assessment and recommendations based on age and risk factors. By making state-of-the-art immunization practices a part of the culture of obstetrics and gynecology, obstetrician–gynecologists can continue to be recognized as the guardians of female and neonatal health. This document will outline the manner in which immunization advocacy and provision can be integrated into office practice. The College addresses specific immunization recommendations in separate Committee Opinions (35).

Tips for Office Immunization Program Success

Many investigations have addressed successful implementation strategies that are relevant to immunizations indicated for obstetric patients and gynecologic patients. The following techniques have been successful in promoting immunization in office settings:

Advocate

Talk with each patient directly and strongly recommend indicated immunizations. Fellows from the College should counsel their pregnant patients about vaccination in an evidence-based manner that allows patients to make an informed decision about its use (6). Share tailored reasons why immunization is beneficial for her and her family, and highlight the benefits of immunization and the risks of not immunizing. Address patient questions and concerns while reminding patients that immunizations are the best protection against many common and serious diseases. Many studies have shown that a recommendation from an obstetrician–gynecologist or other health care provider for an immunization is one of the strongest influences on patient acceptance (7, 8).

Identify

Use prompts—paper or electronic—to remind physicians and staff which patients need to be immunized. Many electronic medical record systems have these prompts available. Electronic medical records that use reminder systems can improve opportunities to immunize when patients are in the office for regularly scheduled appointments (9). Immunization Information Systems are also useful tools to assess and document a patient’s immunization history. All states have an existing immunization registry or a registry in development. Each state has unique functionality, age requirements, and limitations. Patient consent requirements vary from state to state (10). For information on how to access your state’s registry, see For More Information.

Educate and Vaccinate

Designate an immunization coordinator in the office and identify a backup coordinator who is trained in case the designated coordinator is absent. Among other duties, the immunization coordinator orders the vaccines, receives vaccine deliveries, and ensures the vaccines are stored properly. All state health departments have an immunization department with an immunization program manager who is able to help practices. The immunization coordinator and the backup coordinator should know whom to contact at the local, regional, or national level for answers to clinical or logistical immunization questions. See For More Information to access a complete list of state immunization program managers.

Educate office staff about the recommendations, safety, and efficacy of immunizations. Office personnel may express their own uncertainty or lack of knowledge to patients. This may have a detrimental effect on a patient’s willingness to receive an immunization. In contrast, a study showed that educational efforts for all office staff can markedly increase patient immunization rates (11, 12). Immunize office health care providers and staff as recommended. This serves to meet quality criteria for practices and ethical obligations for clinicians to decrease vaccine-preventable diseases for health care providers and staff, provide leadership through example, develop an immunization culture in the office, and importantly, avoid being the source of infection in your office (6).

Federal law (National Childhood Vaccine Injury Act of 1986) mandates that all health care providers who administer vaccines must give patients or their parents or legal representatives the appropriate VIS, which can be used to educate patients, before administration of each dose of a vaccine. Vaccine information statements are official documents and are not the same as vaccine fact sheets (see For More Information for additional resources on VISs and patient education materials).

Integrate

If allowed by state law, institute standing orders for indicated immunizations. Standing orders allow immunization administration to appropriate patients without an individual physician order (see For More Information). However, obstetrician–gynecologists and other health care providers should familiarize themselves with local statutory requirements before standing order protocols are established. Standing orders can be an effective way to integrate immunizations into practice flow (13). Encourage all office staff to use standing orders and offer necessary immunizations. After educating their patients, obstetrician–gynecologists should document that recommended immunizations have been offered and that the patient accepted, declined, or obtained her immunization at an outside facility. Physicians should be aware that patients are protected by the National Vaccine Injury Compensation Program and if a patient believes that she has been harmed by a vaccine covered by this program, she can file a claim to the U.S. Court of Federal Claims (14).

Practice Management Considerations

Many obstetrician–gynecologists perceive a lack of reimbursement as a major barrier to including immunization services in their practices (15). However, with proper documentation and coding, these services can be reported to third-party payers, and appropriate reimbursement can be received.

The practice should adhere to basic coding principles when billing for immunization services. In general, one should always report the appropriate vaccine product code along with the appropriate Current Procedural Terminology (CPT) vaccine administration code. These codes should be linked to the appropriate ICD-10-CM code to support the medical necessity for the service(s). The inherent components of a vaccine administration code include making an appointment for the patient, pulling the chart or accessing the electronic record, and billing the service. Clinical services such as greeting the patient, taking vital signs, reviewing the immunization history and allergies, and charting the immunization administration also are considered inherent components of this service.

The CPT guidelines state that vaccination services should be reported separately from a standard preventive medicine service or “wellness” visit. In addition, immunization services are not part of the global obstetric package and should be reported separately as well. If a significant, separately identifiable, problem-oriented evaluation and management service is performed, the appropriate CPT Evaluation and Management code should be reported in addition to the immunization codes.

It is important for a practice to track reimbursement for immunization services. Explanation of benefits should be examined at periodic intervals to ensure that reimbursement covers the costs of the vaccine product. With diligent oversight, immunization services will be sustainable for most practices.

The American College of Obstetricians and Gynecologists provides several resources to help physicians and their staff with coding and reimbursement issues related to immunization services. Additional resources about the implementation of an immunization program in your office, including vaccine purchasing, storage, and handling, and safety can be found on the College’s Immunization for Women web site (www.immunizationforwomen.org) and in the College’s Immunization Guide “Immunizations and Routine Obstetric–Gynecologic Care: A Guide for Providers and Patients” (see For More Information).

For More Information

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s web site, or the content of the resource. The resources may change without notice.

ACOG has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/ImmunizationsinPractice.

References

  1. Power ML, Leddy MA, Anderson BL, Gall SA, Gonik B, Schulkin J. Obstetrician-gynecologists’ practices and perceived knowledge regarding immunization. Am J Prev Med 2009;37:231–4. [PubMed] [Full Text]
  2. Well-woman visit. Committee Opinion No. 534. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:421–4. [PubMed] [Full Text]
  3. Update on immunization and pregnancy: tetanus, diphtheria, and pertussis vaccination. Committee Opinion No. 566. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:1411–4. [PubMed] [Obstetrics & Gynecology]
  4. Influenza vaccination during pregnancy. Committee Opinion No. 608. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;124:648–51. [PubMed] [Obstetrics & Gynecology]
  5. Human papillomavirus vaccination. Committee Opinion No. 641. American College of Obstetricians and Gyne-cologists. Obstet Gynecol 2015;126:e38–43. [PubMed] [Obstetrics & Gynecology]
  6. Ethical issues with vaccination for the obstetrician-gynecologist. Committee Opinion No.564. American College of Obstetricians and Gynecologists. Obstet Gyne-col 2013;121:1144–50. [PubMed] [Obstetrics & Gynecology]
  7. Influenza vaccination coverage among pregnant women: 2011–12 influenza season, United States. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep 2012;61:758–63. [PubMed] [Full Text]
  8. Ding H, Black CL, Ball S, Donahue S, Fink RV, Williams WW, et al. Influenza Vaccination Coverage Among Pregnant Women--United States, 2014–15 Influenza Season. MMWR Morb Mortal Wkly Rep 2015;64:1000–5. [PubMed] [Full Text]
  9. Guide to Community Preventive Services. Increasing appropriate vaccination: provider reminders. Available at: http://www.thecommunityguide.org/vaccines/providerreminder.html. Retrieved December 14, 2015.
  10. Centers for Disease Control and Prevention. About immunization information systems. Available at: http://www.cdc.gov/vaccines/programs/iis/about.html. Retrieved December 14, 2015.
  11. Hoppe KK, Eckert LO. Achieving high coverage of H1N1 influenza vaccine in an ethnically diverse obstetric population: success of a multifaceted approach. Infect Dis Obstet Gynecol 2011;2011:746214. [PubMed] [Full Text]
  12. Broughton DE, Beigi RH, Switzer GE, Raker CA, Anderson BL. Obstetric health care workers’ attitudes and beliefs regarding influenza vaccination in pregnancy. Obstet Gynecol 2009;114:981–7. [PubMed] [Obstetrics & Gynecology]
  13. McKibben LJ, Stange PV, Sneller VP, Strikas RA, Rodewald LE. Use of standing orders programs to increase adult vaccination rates. Advisory Committee on Immunization Practices. MMWR Recomm Rep 2000;49:15–6. [PubMed] [Full Text]
  14. Health Resources and Services Administration. What you need to know about the National Vaccine Injury Compensation Program (VICP). Rockville (MD): HRSA; 2015. Available at: http://www.hrsa.gov/vaccinecompensation/84521booklet.pdf. Retrieved December 14, 2015.
  15. Leddy MA, Anderson BL, Power ML, Gall S, Gonik B, Schulkin J. Changes in and current status of obstetrician-gynecologists’ knowledge, attitudes, and practice regarding immunization. Obstet Gynecol Surv 2009;64:823–9. [PubMed]

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Integrating immunizations into practice. Committee Opinion No. 661. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e104–7.

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