Improving Accountability of VFC Vaccine Using an Immunization Registry: The New York City Experience Department of Health and Mental Hygiene Bureau of Immunization 41th National Immunization Conference Kansas City, MO March 7, 2007 Michael Andreas Hansen, MPH, Vikki Papadouka, PhD, MPH, Amy Metroka, MSW, Jim Lutz, MPA, and Jane R. Zucker, MD, MSc

New York City Background Population: 8.2 million Annual birth cohort of ~125,000 High mobility of the population within the city Child immunizing sites ~1,700 Child immunizing practitioners ~ 5,000 70.5% coverage rate for 4:3:1:3:3:1 (NIS 2005)

Citywide Immunization Registry (CIR) Mandatory reporting of immunizations administered to children Birth to < 8 years old since January 1, 1997 Birth to < 19 years old since August 18, 2005 2.7 million records and over 24 million immunization events Birth certificates loaded weekly

NYC Vaccines for Children Program (VFC) 75% of children receive vaccines from VFC Includes S-CHIP Non-universal project 2.8 million vaccine doses distributed in 2006 to private practices, hospitals and clinics

Accounting for VFC Vaccines: Provider Generated Doses Administered Report (DAR) Required to order VFC vaccine Paper form which requires faxing Self reported by provider of aggregate doses Problems: Time consuming for provider to complete Time consuming for VFC staff to manually enter into VFC database Data non-verifiable: aggregate reports do not permit program audit Duplicative process: providers report similar information to DOHMH via CIR

CIR-Generated DAR Report that compares number of doses reported to the CIR to the number of doses distributed by the VFC program during the same period

Implementation of CIR-Generated DAR Integration of CIR and VFC databases CIR facility codes matched to VFC ‘pin’ numbers CIR generates DARs for all providers Providers notified in January 2006 of policy change effective September 1, 2006 Provider generated DAR no longer accepted Required to report to CIR > 90% of doses shipped to receive full order Providers received quarterly CIR-generated DARs beginning in June 2006

CIR Generated Doses Administered Report Can be easily produced by bureau staff as pdf files and emailed or faxed to provider

DAR by Hospital Network A Tool for Network Administrators

Implementation of Policy Change of Ordering Vaccines from VFC Reduced order algorithm established Above 80%: 100% approved 60% to 80%: 90% approved 30% to 60%: 75% approved Below 30%: 50% approved

Electronic Record Submission (Includes Paper Submissions) Implementation of CIR generated DAR Integration of VFC & CIR databases

Increased CIR Reporting

Immunizations Added in CIR 2006 – All Ages

Capturing VFC Eligibility

Distribution of Provider DAR’s

Aggregate NYC DAR Feb 07: Jan 06 – Dec 06 1,613 VFC Facilities # doses distributed: 2,317,342 # doses reported: 2,060,227 % doses reported: 89% Jun 06: 74%

Summary of Providers with Order Reductions 494 providers had reductions of their vaccine order 10% reduction: 258 providers 25% reduction: 152 providers 50% reduction: 84 providers 180 providers had their vaccine order reduced more than once

Development of a Provider Profile Initiated by linking VFC and CIR databases VFC doses distributed Doses reported to CIR Expanded by including: CIR-generated UTD coverage rates AFIX-generated UTD coverage rates Hep B Birth Dose VFC site visits Allows coordination between programmatic units across the Bureau

Provider Profile Main Menu

Provider Profile Database

Summary and Conclusions Improved vaccine accountability method Reduced paperwork for provider and VFC staff Improved reporting to CIR Increased by 70% Initiated Provider Profile database Allows identification of poorly performing providers More timely targeting of these providers Better program resource management

Future Concerns: VMBIP and VODS Unclear if VODs will require self-reported inventory from providers for accountability Lower standard than registry-generated DARs VFC staff must continue to be able to adjust provider orders based on registry-generated DARs Otherwise our gains will be lost Registry needs to be leveraged for vaccine ordering, rather than requiring providers to use a new application (VODs) CIR already familiar to providers Ordering vaccines through registry will create further incentives for providers to report to and use the registry Ordering independent of registry undermines vaccine accountability and reporting to registry