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Service Delivery Innovation Profile

Comprehensive Vaccine Program More Than Triples Immunization Rates for Children

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The El Rio Health Center developed a comprehensive program to increase pediatric immunization rates consisting of the following key elements: ongoing immunization training for pediatricians and nurses, a computerized data system to track immunizations, reminders for both patients and providers, and nurse-run immunization clinics offered at the center and in the community. The program has more than tripled immunization rates since its inception, achieving levels that exceed Federal standards for childhood immunizations.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of immunization rates, along with informal feedback from providers and parents.
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Developing Organizations

El Rio Health Center, Tucson AZ
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Date First Implemented

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Patient Population

Vulnerable Populations > Children; Insurance Status > Medicaid; Vulnerable Populations > Medically uninsured; Urban populationsend pp

Problem Addressed

Although pediatric immunization rates have improved substantially in recent years, Centers for Disease Control and Prevention (CDC) goals have not yet been consistently met. In addition, immunization rates for minorities and those living in poverty lag behind rates for white children.1-3 Parents face a number of barriers and challenges in keeping their children's immunizations up to date.
  • Not yet meeting immunization goals: Although great progress has been made over the past 20 years, overall immunization rates remain below established goals, and disparities still exist among minorities and those living in poverty. For example, 86 percent of white children have received the diphtheria, tetanus, poliomyelitis, and pertussis vaccines (DTP/DT/DTAP), compared with 79 percent of black children and 80 percent of those children living below the poverty level.2 The CDC set a goal of achieving and maintaining childhood immunization rates of at least 90 percent by 2010.3
  • Many barriers and challenges for parents: Keeping immunizations up to date can be challenging for parents, as transportation problems, scheduling conflicts, and/or financial constraints often serve as barriers. In addition, many parents have only one option (a well-child visit at their pediatrician's office) for getting their child immunized.

What They Did

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Description of the Innovative Activity

The El Rio Health Center developed a comprehensive program to increase pediatric immunization rates. The program consists of ongoing immunization training for pediatricians and nurses, a computerized data system to track immunizations, reminders for both parents and providers on needed immunizations, and periodic nurse-run immunization clinics held at the center and in the community. Key program elements are described below:
  • Ongoing immunization training: Pediatricians and nurses receive training regarding the current standards for pediatric immunizations, including recommendations related to providing multiple vaccinations simultaneously and parameters for when vaccinations may be given. Initially, annual 1-hour refresher sessions provided updates on these issues; formal trainings for all staff regarding immunization practices are now held less frequently, typically every 3 to 4 years. Regular updates that address changes in immunization practices made by the CDC are provided electronically and through support staff meetings. Discussions regarding quality assurance issues with the immunization program are held 1 to 2 times per year with the pediatric provider staff.
  • Electronic data tracking: A computerized data system tracks each patient, including the types of vaccines received and the specific dosages given. This registry assists with the generation of patient and provider reminders (see next two bullets) and allows for routine quality assurance monitoring. Record keeping for patient immunizations is now kept in the immunization module within the commercial electronic medical record used at El Rio Health Center. Information provided in June 2013 indicates that the health center has standardized its workflow for pediatric providers to include a review of a patient's immunization module with each clinic visit. This increases the chance that a patient behind on immunizations will be given the necessary vaccines.
  • Parent reminders: A medical assistant tracks patients between 15 and 24 months of age to identify those not up-to-date with their immunizations. The parents of these children receive reminder calls and postcards. For those who still do not bring in their children, flags in the patient chart prompt additional reminders during routine visits. The clinic also uses a software tool (called I2I) to find patients who are behind on their well-child care, as recommended by the American Academy of Pediatrics. This tool prompts staff to send reminder letters to families with children who are due for a well-child visit.
  • Physician reminders and prompting of patients: As mentioned above, the pediatricians and nurses review the patient's immunization module in the EMR at every visit, including well-child visits and other clinic appointments. Pediatricians use each visit as an opportunity to educate parents about the benefits of the recommended vaccines and offer them to healthy patients. If a patient is ill (and thus not able to be vaccinated), the pediatrician advises parents to bring the patient, health permitting, to an immunization clinic (see below) at a given date and time.
  • Nurse-run immunization clinics: The center offers both onsite and community-based immunization clinics run by nurses, as described below:
    • Onsite clinics: Once or twice a week, trained nurses staff immunization clinics in the medical office for approximately 2 to 4 hours depending on the size of the clinic. They ask parents questions from a standardized intake form regarding the child’s health and past vaccine complications. Pediatricians see all patients with histories of past complications or other complexities, while nurses administer vaccines in routine cases. In all cases, nurses follow standing orders (or immunization instructions) that appear in patients’ charts.
    • Community clinics: Up to four times a year, the program offers immunization clinics in community settings. For example, 3,500 doses of vaccine were administered during a “back-to-school” clinic at a grocery store. A medical assistant worked with the grocery store to arrange the logistics and advertise the event. The center offers other clinics in response to seasonal outbreaks (e.g., flu shot clinics) or local outbreaks of specific diseases such as measles. Additionally, local Boys and Girls Clubs facilities are used to host back-to-school immunization events.

Context of the Innovation

El Rio Health Center, a Federally Qualified Health Center, is the largest provider of health care for uninsured individuals and Medicaid enrollees in Pima County, AZ. The center serves approximately 80,000 people and has the largest pediatric practice in Tucson, serving roughly 35,000 children at 6 pediatric clinic sites and 5 family medicine sites. Recognizing the organization's low immunization rates, one Rio Health Center leader (now the center's associate medical director) approached administrators with a proposal to examine the barriers to achieving higher immunization rates. Soon thereafter, the CDC and the American Academy of Pediatricians (AAP) began creating materials to encourage work in this area. On the recommendation of the chief medical officer of the Pima County Health Department, a community coalition formed to train physicians and community members about the benefits of immunization using the CDC and AAP materials. The coalition also created multimedia educational materials for the general public. These early efforts stimulated support within El Rio Health Center and the community for the development of this program.

Did It Work?

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Pre- and post-implementation comparisons show that the program has more than tripled immunization rates since its inception, achieving levels that exceed Federal standards for childhood immunizations. Anecdotal reports from providers and parents suggest that the program has improved the quality of care.
  • Tripling of immunization rates: During the first 3 to 5 years of the program, immunization rates for 2-year-old children increased from approximately 30 to 94 percent. By 2006, rates reached 97 percent. The program has maintained high rates each year that adequate supplies of vaccines are available. As of 2014, all El Rio Pediatric Clinics have achieved immunization rates of 84 percent for the combo-3 vaccines for two-year-old patients who remain in the clinic's care, and 44 percent for the expanded combo-10 vaccines. The rate of combo-3 vaccinations at two of the largest pediatric clinics within the health system is over 90 percent (updated June 2014).
  • Exceeding standards: The program won the Daniel T. Cloud Outstanding Practice Award from The Arizona Partnership for Immunization for exceeding Federal standards and achieving immunization rates of 90 percent or more for children turning 2 years old.
  • Anecdotal reports of better quality: Anecdotal reports from providers suggest that the training sessions have allowed for a more collaborative approach to monitoring whether immunizations are up-to-date and administered correctly. Parents view the immunization clinics as an added benefit, and providers have not noticed changes in compliance with well-child visits.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of immunization rates, along with informal feedback from providers and parents.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Physician and nurse training: The center's associate medical director participated in a "train-the-trainer" workshop on how to educate physicians and nurses on steps to increase immunization rates. This individual used materials from the workshop to provide the initial training to El Rio's providers.
  • Designation of dedicated staff: El Rio created a full-time staff position to assist with the development and administration of the immunization program. The individual in this position, currently a medical assistant with significant training in immunizations, takes responsibility for parent reminders, nurse training, vaccine inventory control and ordering, and quality assurance. She also staffs approximately one-half of the immunization clinics.
  • Revisions to standard paperwork and procedures: Program developers comprehensively reviewed and revised paperwork and procedures in an effort to boost immunization rates. For example, they created a blue immunization card placed in the same location in each patients' chart to facilitate ongoing monitoring efforts.
  • Development of standing orders: Based on materials provided by the Pima County Health Department, the AAP, and the CDC, the associate medical director developed standing orders (instructions found in patients' charts) that trained nurses may follow to administer vaccines. These standing order forms are revised at least annually.

Resources Used and Skills Needed

  • Staffing: Program staff consists of one full-time medical assistant. The center employs approximately 20 pediatricians and nurses across 6 locations who incorporate program activities into their regular duties.
  • Costs: The program’s operating budget ranges from $75,000 to $100,000 per year. Direct costs include salary and benefits for the full-time employee and supplies. Indirect costs include time donated by other salaried providers and oversight by the program developer.
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Funding Sources

El Rio Foundation; Arizona Department of Health Services; Tucson Medical Center Foundation; University of Arizona, Department of Pediatrics; Vaccines for Children Program
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Adoption Considerations

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Getting Started with This Innovation

  • Find a champion: Identify a provider dedicated to increasing immunization rates. Although this champion need not be an infectious disease specialist, he or she should have a strong interest and willingness to develop expertise in this area and to serve as a point person within the organization on this topic.
  • Dispel myths and concerns: Administrators, physicians, and nurses at El Rio were initially hesitant to offer nurse-run clinics and to provide immunizations outside of well-child visits. They feared an increase in medical errors and expressed concerns that parents whose children received immunizations at the clinics would not schedule well-child visits. These fears, however, did not materialize, and parents have expressed appreciation for having other options for getting their children immunized, which helps them overcome transportation and scheduling barriers.
  • Collaborate during program development: Take advantage of materials that have been developed by the CDC, AAP, and others, as there is no need to "reinvent the wheel."

Sustaining This Innovation

  • Conduct ongoing monitoring: A sense of complacency often arises once immunization rates reach the levels outlined in Federal standards. Ongoing monitoring can help maintain high immunization rates.
  • Advocate to maintain support: Share data on the program's impact to demonstrate how the initiative helps the organization meet its goals. This type of ongoing advocacy helps convince leaders to maintain their support for program infrastructure.
  • Carefully manage integration with electronic health record (EHR): In 2009 and 2010 El Rio implemented an EHR, with the goal of integrating it into this program and thus enhancing data tracking capabilities to allow the health center to identify and reconcile errors in previous immunization data. Unfortunately, this process created problems with immunization record-keeping, as errors in paper chart abstraction into the EHR, and bugs in the computer software reduced the quality of immunization data and documented immunization rates. The clinic implemented a program to manually correct the EHR immunization data, although it will take several years to complete for the health center's entire pediatric population. The immunization module is now fully integrated with the EHR and the clinic staff adapted well to the use of the immunization module. However, each time the EHR undergoes an upgrade, the clinics face challenges related to training providers and support staff in the appropriate and successful use of the changed immunization template (updated June 2014).

More Information

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Contact the Innovator

Andrew Arthur, MD
Associate Medical Director
El Rio Health Center
839 W. Congress St.
Tucson, AZ 85745
Phone: (520) 792-9890

Innovator Disclosures

Dr. Arthur has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.


1 Offit PA. Children's Hospital of Philadelphia Vaccine Education Center [Web site]. 2010. Available at:
2 Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2010 (Table 81). 2010. Available at: (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
3 Centers for Disease Control and Prevention. Eliminate disparities in adult and child immunization rates. 2007.
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Original publication: June 22, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 27, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.