Since the first step in improving quality is to develop measurement tools and set targets for achievement, we developed an electronic system to track the frequency of pneumococcal vaccination in our immunosuppressed rheumatology patients.6 We created lists of patients who did not meet the vaccination guidelines established by the Centers for Disease Control (CDC) and the ACR. We shared our data regularly with clinical staff, and provided rheumatologists with their monthly personal performance scores. However, it was not until we introduced a paper-based reminder attached to the billing sheet used at the point of care that we were able to substantially increase our rates of vaccination (see Figure 1).7 These efforts took considerable time and required a change in attitude on the part of staff members, including nurses, practice assistants, and rheumatologists, as well as patients. It was interesting to see just how different the vaccination rates were among rheumatologists and how much improvement was possible with a practical, paper-based reminder (see Figure 2). Just as our performance has achieved near 90% compliance, the CDC guidelines for pneumococcal vaccination for immunosuppressed patients were modified, increasing the complexity to conform to newer guidelines! Pneumococcal vaccine is just one of many quality indicators worth measuring and, as we observed, the workflow implications from this exercise of enhancing compliance are not trivial in a busy office practice. Yet this effort may pale in comparison to future vaccination efforts, such as providing zoster vaccine to our patients.
Perhaps we should take a surgical approach to these issues, as our colleague, Atul Gawande MD, MPH, professor of surgery at Harvard Medical School in Boston, has suggested, and employ a “checklist” to remind rheumatologists of the things that need to be done when managing complex patients.8 Checklists have been used successfully in other healthcare settings, such as in the prevention of catheter-related bloodstream infections in the intensive care unit and reducing mortality in the operating room. For patients starting DMARDs, either biologic or nonbiologic, there is a list of activities that one needs to review: age- and disease-specific vaccines, hepatitis testing, results of baseline blood counts, renal and hepatic function, tuberculosis screening, and discussion of risks/benefits of the DMARD, to name just a few.
To see whether we could influence physician behaviors, we created a paper checklist and posted it in our clinic examination rooms. The results were disappointing. What we learned is that, without an electronic checklist that is more integrated with clinical workflow, checklists may not be regularly utilized.
