Between September 2011 and January 2012, we administered an Internet and mail survey to a national network of pediatricians. The human subjects review board at the University of Colorado Denver approved this study as exempt research not requiring written informed consent.

The survey response rate was 71% (288 of 408; e-mail 77% [221 of 287], mail, 55% [67 of 121]). Respondents were similar to nonrespondents with respect to age, gender, practice setting, practice location, region of the country, size of practice, and whether or not they were in a state that requires mandatory reporting of vaccinations to the state or regional IIS (Table 1).

This national study was conducted to assess in detail pediatricians’ current systems for recording vaccine administration and tracking vaccine inventory and attitudes related to adoption of bar codes to aid in these efforts. We found that methods for recording vaccine administration and tracking inventory were often duplicative and time-consuming, and that, for most pediatricians who participate in an IIS, double data entry rather than electronic uploads was the method of submitting data. While pediatricians reported positive attitudes regarding the adoption of a bar code system for vaccines, they also reported numerous features that would be essential for adoption, and clear requirements for affordability.

Our findings present a snapshot as practices transition from paper based records to EHRs. Two-thirds of physicians in our study reported that they had an EHR, which is similar to a recent report from the National Center for Health Statistics.¹⁶ However, similar to previous studies, we found that simply having an EHR does not necessarily increase efficiency.¹⁷ For example, we found that the practice of double data entry is common even among those who have an EHR and participate in an IIS, with a minority of providers automatically uploading data to an IIS, even in larger practices. Some posit that some EHR vendors purposely avoid interoperability to protect their market share, holding clients hostage to EHRs that reduce efficiency and prevent innovation.¹⁸ Policy makers should consider continuing to incentivize interoperability such as through further meaningful-use revisions,¹⁹ and pediatric practices should demand it when considering EHR purchases and upgrades.

A somewhat surprising finding of our study was the complete lack of a standard approach to tracking vaccine inventory. Most physicians reported using multiple methods for tracking inventory, often ordering on the basis of seasonal demand or simply when stock looks low. Almost no physicians were using automated or integrated systems, and three-quarters of providers reported that the inventory process was time consuming. Given this lack of a standard approach to tracking inventory, it is not surprising that one-fourth of respondents reported that their practice frequently runs out of vaccine. Better and more efficient methods of tracking vaccine inventory have the potential to decrease staff time and also prevent running out of vaccine or waste due to expiring vaccines.

The use of 2-D bar codes on vaccines may offer one part of a solution to the problems of double data entry, inaccurate or incomplete data capture, and time consuming tracking of inventory. One could envision a system in which a child is administered a vaccine, and the administering provider scans the vaccine vial with a 2-D bar code scanner, which then populates the patient’s medical record that the dose was administered, including all relevant details about the vaccine, such as expiration date, lot number, and manufacturer. This information could be then seamlessly transmitted by the EHR to the practice’s billing and inventory management systems and automatically uploaded to the IIS, which could also potentially be used to track inventory.²⁰

Adoption of this hypothetical system could facilitate health care providers’ use of an IIS by automating data entry into the IIS,²¹ and aid in the transition to Meaningful Use for eligible providers. Meaningful Use incentivizes adoption of IIS, with the objective that EHRs submit electronic data to IISs except where prohibited, with an outcome measure of successful ongoing submission of electronic immunization data from certified EHR technology.²² While reporting to IIS is mandatory in some states, most have voluntary participation. Increasing participation in IIS in those nonmandatory reporting states is also important because IIS have been shown to be effective for increasing vaccination coverage.²⁰ For both mandatory and nonmandatory reporting states, data entry into IIS with 2-D bar code scanning also has the potential to improve IIS data quality. While essentially all IIS have the ability to capture information such as vaccine lot number and vaccine manufacturers, these data elements are complete in only 60% and 63% of IIS records, respectively.¹⁰ Data from a fully integrated system would also be available for downstream use by vaccine safety surveillance mechanisms, such as the Vaccine Adverse Event Reporting System (VAERS), the Vaccine Safety Datalink (VSD), or other future vaccine safety surveillance systems.

The promise of 2-D bar codes as part of a solution to some of the vaccine tracking and inventory management problems—as well as the interoperability with IIS—should not be overstated however. At a basic level, a bar code scanner is simply an input device. Several of the functions that many of our respondents considered crucial to adoption of a bar code system, such as the ability to record vaccines doses in an EHR, maintain inventory, and automatically upload to an IIS, are not part of the price tag of a bar code scanner. In some cases, where a software solution to incorporating a bar code scanner into an EHR already exists, many of the desired features associated with the use of bar code scanners will be available. In other settings, however, such as not having an EHR, or having an EHR that cannot efficiently take the scan data and use it to populate key data items, the benefits to the adoption of bar code scanners are harder to imagine. Interoperability with the IIS and bar code utilization are challenging issues, both of which will need to be addressed to meet the full potential of an integrated and useful vaccine network.

Pediatricians are not naïve to the potential system problems of 2-D bar code scanners: the most common barriers to the adoption of this technology that were identified in our survey were computer related, including technology support and the need for software and hardware. A recent feasibility study reinforces the notion that interoperability will be important to promote adoption of 2-D bar code technology. RTI International, a nonprofit research group, contracted with CDC to study the impacts 2-D bar codes may have on vaccine production, documentation, and public health reporting and tracking for immunization stakeholders.²³ One of the conclusions was that while EHRs are not required for the use of bar codes, EHRs with the ability to receive scanned data are necessary to take the fullest advantage of the use of 2-D bar codes. Regarding cost as a potential barrier, two-thirds of our respondents would adopt a system if the cost were $1000 to $5000, and almost all would if the total cost were under $1000. A recent cost–benefit analysis estimated that while adoption of 2-D bar code systems would result in a favorable benefit-to-cost ratio overall, the cost of adoption for a pediatric practice would be between $1016 and $7831, depending on practice size.²⁴ However, that estimate did not include the software or hardware that may be required to realize many of the functions desired by pediatricians in our survey, nor did it include ongoing maintenance or quality checks. The estimate also did not take into account the cost of an EHR. For practices that already have an EHR that has the ability to accept a 2-D bar code scan, though, the cost of adoption would be little more than the cost of the scanner itself, which, for a single scanner can cost anywhere from a few hundred to several hundred dollars, depending on desired features. As bar code technology is rolled out for vaccines, manufacturers, EHR providers, and state IIS should work together to make the transition as seamless as possible, and cost must be a consideration. To address the problem of technology underutilization, the CDC has published a resource guide to aid in the adoption of bar code technology.^25,26

This study has several strengths and limitations. It was from a national sample of pediatricians, and there was a high response rate. However, respondents’ attitudes and practices may have differed from nonrespondents, and network physicians may differ from physicians overall, although prior work suggests otherwise.¹² It is also should be noted that these were the responses of pediatricians who may not be the most knowledgeable people in a given practice regarding vaccine administration and inventory management. We did, however, offer respondents the choice of “don’t know” and have reported those results. Also, despite this clear limitation, pediatricians are often the primary decision makers in a given practice, and their attitudes and perceptions are therefore important, even if not always entirely accurate. Finally, questions regarding bar codes were hypothetical and may not reflect eventual practice.

On the basis of this survey among practicing pediatricians, current systems of recording vaccine doses and tracking vaccine inventory are duplicative, time-consuming and often not linked to the IIS. While the technology exists to streamline these processes and improve efficiency, such technology appears to be underutilized. The use of 2-D bar codes offers one part of a potential solution to many of the present problems with record keeping for vaccine administration and inventory, but to be successful must have good technical support, the capability to fully integrate with EHRs and IIS, and be affordable for practices.