PTE Pediatric Immunization Metrics Reporting Update
Introduction: The Maine Health Management Coalition’s (MHMC) Pathways to Excellence (PTE)
initiative has updated its pediatric immunization metrics. Ratings on the MHMC website
(www.getbettermaine.org) using the previous metrics, expired on July 1, 2013. Practices which did not
update these metrics as of July 1, 2013 were reported as “Did Not Report” on the GetBetterMaine.org
website.
Practices submitting new or updated data on these measures by February 15, 2014 can have their new
ratings updated for April 1, 2014.
SUBMISSION INSTRUCTIONS:
1. Complete form and have responsible clinician sign.
2. Send to Maine Health Management Coalition either by fax or scan and email:
a. FAX: 207-899-3207
b. Email to pte@mehmc.org
3. Recognition will be effective for 2 years from the date of submission and the practice agrees to
be publically reported on the www.getbettermaine.org reporting website.
4. If desired, practices who currently have the PTE “Good” or “Better” rating may resubmit for a
higher rating prior to their expiration date.
PTE Immunizations Targets and Specifications
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Practice Name: _____________________________
Practice Address: ______________________________
Date:
________________________________
Person Completing: _________________________
Phone: _____________________________
Responsible Clinician:________________________
Signature: ___________________________
PTE Child Immunization Metrics, Benchmarks, and Scoring (Updated Sept. 2012)
Immunizations
2 YR Old-4 DTaP
2 YR Old- 3 IPV
2 YR Old- 1 MMR
2 YR Old- 3 HIB (type B)
2 YR Old -3 Hepatitis B
2 YR Old- 1 Varivax
2 YR Old- 4+ PCV
2 YR Old- 3 Rotavirus (RV)
(See #5 inclusion criteria).
Please check here if using the 22 YR Old- 2 Hepatitis A
2 YR Old- 2 Influenza
(Seasonal Rate, Sept-April of
preceding year)
CDC National
Average
Benchmark
(3.5 points each for
at or above)
75-90th Percentile
Scoring
(*Based on First
STEPS practice
performance)
(3.5 points each for
at or above)
≥84
≥93
≥91
≥90
≥91
≥90
≥83
> 93
> 94
> 93
> 93
> 93
> 93
> 93
≥59
≥49
> 85
> 60
≥42
> 75
Immunization
Rate
Practice Points
(3.5 Points for CDC
National Average and
performance at or
above 90th percentile(7 points possible for
each measure)
13 YR Old-1 dose of TdaP or
≥63
> 85
Td >10 yrs of age
13 Yr Old-1 dose MCV
≥63
> 85
13 Yr Old- 3 doses of HPV for
≥23
> 30
Girls (See #1 inclusion criteria)
13 Yr Old- 3 doses of HPV for
≥1
TBD
Boys (See #1 inclusion criteria)
Does your practice submit
9 Points
patient level data to ImmPact2?
Total Available Points = 100
MHMC PTE Rating: Good > 45 Points Better > 65 Points Best > 90 Points*
*Best is only achievable for those reporting their total population regardless of the final score
PTE Immunizations Targets and Specifications
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INCLUSION CRITERIA
1. Maine IHOC Pediatric Measures Master List Numerator/Denominators used (see Measure 1
and 3: these are the Immunization Measures for the CHIPRA Core Set of Child Health measures
#5 and #6) **HPV for girls is Maine IHOC Measure #4. Advisory Committee on Immunization
Practices (ACIP) recently revised its permissive recommendations to a full recommendation for
HPV for boys in October 2011. Reporting for boys will be optional in 2012 and mandatory
beginning April 2014.
2. Practices need to submit data on all patients that meet criteria in their practice. It is expected
pediatric practices will have at least 40 patients per FTE clinician. If this minimum is not met for your
practice, please include an explanation with your submission materials (Assigned to practice for 12
months; what is definition for Moved or Gone Elsewhere [MOGE] for a practice)
3. Include all patients regardless of payer (e.g. commercial, Medicare, Medicaid, self-pay, uninsured,
etc.).
4. Include only patients who are active patients in your practice – i.e. the patient has had 1 or more
visits of any type to the practice within the past 12 months, and there is no other known primary care
provider.
5. Rotavirus - >2 or >3 or more doses of Rotavirus vaccine, depending on product type received (>2
doses for Rotarix® [RVI] or >3 doses for RotaTeq® [RV5]. (National Immunization Survey, 2010).
6. For 2 year old = programmed as up to date on 2nd birthdate looking at all kids in the 24 to less than
36 months cohort as of the 15th of the previous month at the time the report is run. For 13 yr old =
programmed as up to date on 13th birthdate looking at all kids in the 13 to less than 14 yr old cohort as
of the 15th of the previous month at the time the report is run.
About the Expanded Immunization Measure Set
PTE has expanded its child health immunization measure set to reflect a core set of federal child
immunization measures (e.g. CHIPRA measures). For 2-year old immunizations, this includes adding
measures for annual flu shot, Hepatitis A (2 Hep A) series, and Rotavirus (2 or 3 RV depending on type
of vaccine). PTE will introduce new reporting requirements for adolescent immunizations to include
children at age 13 years with meningococcal, Tdap, and human papilloma virus (HPV for girls only—
series of 3 completed). Practices will also be encouraged to participate in optional reporting for HPV
for boys starting this year, with plans for PTE to begin assigning points to this measure in 2014. PTE is
adopting the federal immunization metrics for children, which are defined using age cut-offs to include
only vaccines given by the specified birth date (i.e., at age 2 or at age 13) in the rate (see #6 above for
birthdate category cut-offs).
This means that immunizations given after the child’s 2nd or 13th birthday do not count in the reported
rate. The full set of measures reflecting these additions are as follows (new measures are in italics):
PTE Immunizations Targets and Specifications
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
Immunizations at age 2 years: % of children in the practice who have at least all of the following
immunizations recorded:
o 4 DTaP
o 3 IPV
o 1 MMR
o 3 HiB
o 3 Hep B
o 1 VZV
o 4 PCV
o 2 Hep A
o 2 or 3 RV
o 2 influenza vaccines.

Immunizations at age 13 years: % of children in the practice who have at least all of the following
immunizations recorded:
o 1 meningococcal vaccine
o 1 Tdap or Td
o Completed series of 3 HPV for girls
Reporting Methods
The MHMC recognizes that data reporting can be extremely time-consuming for practices, and we are
committed to promoting efficient reporting by using existing clinical tools whenever possible. Only
practices who submit practice-wide (population) data will be eligible to achieve a “best” rating; practices
using chart review will be eligible for “good” or “better” only.

Registry-based reporting: The MHMC strongly encourages practices to use registry-based
reporting for immunization measures. We recognize that many Maine practices use the Maine
CDC’s ImmPact immunization registry. Currently, 21 practices receive regular immunization reports
based on the new metrics through the First STEPS Learning Initiative. There are planned reporting
updates so that practices in ImmPact can print their own data in the future supported by the
Improving Health Outcomes for Children (IHOC) project.

Please contact if interested:
Kyra Chamberlain, BS, RN
Project Manager CHIPRA/IHOC (Maine)
Muskie School of Public Service
207-228-8085
kchamberlain@usm.maine.edu

Chart review: Submission by chart review is allowed if practices have not been entering per dose
data into ImmPact for at least one year. Practices will need to review 40 charts each for children
ages 2 and 13. Practices must determine that the vaccines were given on or prior to the 2nd or 13th
birthday to include the doses in the rate, to be consistent with the federal immunization metrics age
cut-offs described above.
PTE Immunizations Targets and Specifications
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