array of clinical practice guidelines as well as an increase in reporting forms. Immunization must compete for time with the other services called for by those guidelines. Dr. Fontanesi’s studies have found that the time required to administer an immunization is about 3.5 minutes and has remained constant. Although the time required for a single immunization is not great, the total number of required immunizations creates a more substantial demand on national health resources. For example, the national birth cohort included 3,959,417 live births in 1999. Providing a single immunization for each of these children will require 230,965 person hours. Completing the recommended 4:3:1:3:3 series7 will require 2,540,610 person hours for an entire national birth cohort of about 4 million children.

Dr. Fontanesi suggested that additional provider and staff time could be made available to meet immunization and other health care needs by reducing redundancies in administrative tasks. For example, his studies found that a group of 9 clinics used about 200 different forms to record or report information on children under the age of 3 years. Of these forms, 72 required information about immunizations, and many of them were required by federal programs. However, less than 85 percent of immunizations administered were recorded in patient records, leading to underestimates of immunization coverage. Having contracts with many managed care plans also added to the administrative burden for clinics and provider practices. Each plan had a separate process for credentialing providers, required a separate Health Plan Employer Data and Information Set (HEDIS) audit for immunization coverage (along with other HEDIS measures), and expected different quality improvement activities.

Better methods for managing patient flow and office procedures may also help ensure that children receive necessary immunizations. Observation has shown variation among clinics in the length of the average visit and in the time spent at each stage of the visit (e.g., registration, waiting, examination). Furthermore, at a single clinic, those times vary from patient to patient. However, the differences are not related to whether a child received an immunization during the visit. Dr. Fontanesi observed that it is necessary to reduce such variability to improve the overall quality of service delivery. Work flow is affected by factors such as differences between scheduled and unscheduled visits or between pa-


The 4:3:1:3:3 series refers to four or more doses of diphtheria and tetanus toxoids and whole-cell or acellular pertussis vaccine (DTP or DTaP); three or more doses of poliovirus vaccine; one or more doses of any measles-containing vaccine; three or more doses of Haemophilus influenzae type b (Hib) vaccine; and three or more doses of hepatitis B vaccine.

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