42nd National Immunization Conference Atlanta, GA April 20, 2010 Integrating Electronic Information to Improve Documentation of Immunization Rates for a Low-Income, Minority Population Melissa Stockwell Karthik Natarajan, Amy Metroka, Angel Aponte, Yiye Zhang, David Vawdrey Division of General Pediatrics, Department of Pediatrics Department of Population Family Health Department of Biomedical Informatics Department of Biostatistics CityWide Immunization Registry (CIR), New York City Department of Health and Mental Hygiene  42nd National Immunization Conference Atlanta, GA April 20, 2010 

Background Urban low-income, minority children are at high risk for underimmunization Fragmented records from multiple providers May also be at risk of overimmunization City or regional IIS ameliorate effect of scatter Stokley S et al 2001; Yusuf H et al 2002; Santoli JM et al 2000, Yawn BP, 1998

IIS Data in End User EHR Having registry data readily available in electronic health record (EHR) is important Missed opportunities/over immunizations due to incomplete records Time saving

EzVAC NewYork-Presbyterian Hospital (NYP) Immunization Registry, EzVAC Point-of-service registry Over 140,000 children, adolescents and adults, 1.3 million vaccinations Linked to hospital billing system Includes all children receiving care at hospital and affiliated ambulatory clinics

New York Citywide Immunization Registry (CIR) Population-based registry 4.3M individuals with 47M immunizations Load birth certificates. Mandated reporting of vaccines administered to patients ≤18 given by providers in NYC CIR captures >85% immunizations administered, 93% of Vaccines For Children (VFC) immunizations Papadouka et al. New York City Department of Health and Mental Hygiene "Impact of Childhood Hepatitis A Vaccination: New York City". 41st National Immunization Conference (Kansas City); March 2007 Metroka AE et al 2009

Objective 1) To describe how a local and a city wide IIS can exchange data real time 2) To assess the impact on immunization record completeness and coverage rates of integrating data from a public IIS into a hospital information system

CIR-Web Service CIR recently provided secure web-services allowing immunization data to be queried from CIR Web-services allow systems to communicate outside of an organization’s firewall over the Internet Batch as well as single real time queries Opportunity to put IIS information directly into end user EHR Previously had to manually look up patient in CIR

CIR-Web Service Development Investment in bi-directional integration Uses HL7 version 2.3.1 VXQ (query) and VXU (update) messages delivered over SOAP/XMLP ~ 9 Months of requirements, design, implementation, testing, and deployment

EHR Queries Must find 1 unique match Data combined to perform 30+ exact match database queries then 1 approximate search Ex: Last name, MRN, facility; First Name, Last Name, DOB, Gender Median response time is 2 seconds

Querying Webservice End users uses EzVAC to query CIR web service with patient name, DOB, local MRN Downloads immunization information and tags it with CIR as source FIREWALL CIR (John Smith, 1/1/01 MRN: 99999) John Smith’s Immunizations Missing Iz EzVac DB

Matching CIR returns immunization data in ~ 88% cases

De-Duplication Data run through de-duplication script Considered duplicate if two vaccines given within 10 days: based on own assessment of synchronization data and IIS literature

De-Duplication Class level not vaccine level de-duplication If discrepancy: preference given to EzVAC as preferred source (own data) and more specific vaccine information ie ActHib rather than Hib NOS

EzVAC CIR

Study Setting NYP Ambulatory Care Network practice sites in Washington Heights/Inwood area of NYC Disadvantaged community Primarily Latino, publicly insured Mobile population

Study Population and Design Random sample children (n=2529), visit in last 12 mths  7-23 months old (n=950) 24-36 months (n=960) Adolescents 13-18 years old (n=619) Total of 32, 173 children 7-36 months and 13-18 years old with visit in last 12 months Immunization record synchronized with CIR (batch query), each vaccine labeled automatically by source (EzVAC vs CIR)

Outcome 7-36 months: Age Appropriate up to date immunization status, according to the 4:3:1:3:3:1 series (DTaP, IPV, MMR, Hib, HepB, varicella) Hib adjusted due to shortage Adolescent immunizations: TdaP, MCV4 and first HPV

Analysis Assessed contribution of each source (EzVAC, CIR) Test of two proportions: Immunization coverage rates EzVAC alone and EzVAC with CIR

Contribution of Source to Record

Change in Immunization Rates * P < 0.05; ** P <0.01; *** P < .001; **** P < 0001

Summary Webservice fast, easy, allows real time synchronization Clinicians found it very useful Significantly increased record completeness, improved documentation of coverage rates Brought documented coverage rates for young children above Healthy People 2010 goals Greatest impact for adolescent patients

Limitations Integration Study Need personnel to set up synchronization by end user into EHR (took 80 estimated person hours programming time) Deduplication Trust data Study Generalizability of effect size, may have greater effect in pop at greatest risk for record scatter Did not include all age groups

Public Health Implications Real time, two-way communication regarding immunizations between public and private information systems should be widely considered

Acknowledgements Melissa Stockwell, Medical Director EzVAC Team Melissa Stockwell, Medical Director David Vawdrey, Informatics Director Oscar Pena, Operational Coordinator Balendu Dasgupta, Programmer Karthik Natarajan, Programmer/Data Manager Citywide Immunization Registry (CIR) Amy Metroka, Director Angel Aponte, Programmer Vikki Papadouka, Director of Research and Evaluation Jane R. Zucker, Assistant Commissioner, Bureau of Immunization, New York City Department of Health)