Carolyn Swenson, MSPH, MSN Project Manager CCGC Implementing Immunization Recall using CIIS: Lessons Learned from the West Slope Recall Project Diana Herrero, MS CIIS Program Manager CDPHE Carolyn Swenson, MSPH, MSN Project Manager CCGC

Generous support for this project was provided by The Colorado Trust 11/17/2018

CIIS – CCGC - COHO Colorado Immunization Information System (CIIS) Statewide immunization registry managed by the CO Department of Public Health & Environment Colorado Clinical Guidelines Collaborative (CCGC) Statewide coalition of organizations working to improve healthcare in CO Colorado Health Outcomes (COHO at UCD-Fitzsimmons campus) Conduct and evaluate interventions to improve population health and the overall quality of health care 11/17/2018

Overview of Immunization Recall A “best practice” Identifies children not current for immunizations Promotes bringing child in for immunizations and other care May lead to other improvements: Improved accuracy of immunization records Better tracking of active clinic population Avoidance of over immunization Improved timeliness of immunizations Improved coordination of clinic services 11/17/2018

References Patient reminder and patient recall systems to improve immunization rates. Jacobson VJ, Szilagyi P. Cochrane Database Syst Rev. 2005 Immunization recall: effectiveness and barriers to success in an urban teaching clinic. Kempe A, Lowery NE, Pearson J Pediatrics. 2001 Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. Briss PA Am J Prev Med 2000 11/17/2018

What is CIIS? Colorado Immunization Information System Web-based, centralized information system designed to collect & combine immunization records for Colorado residents Private & Confidential Efficient Timely Secure Voluntary 11/17/2018

CIIS Background 1996: CDC 5-yr grant to UCHSC to promote rural immunizations 2001: Became web-based 2002: Statewide immunization registry operated by UCHSC 2007: Designated life-long IIS 2008: Program operations transitioned to CDPHE 11/17/2018

CIIS Core Functions Program Support Consolidated IZ Record Medical Record Clinical Decision Support/Screening School/Child Care/Camp Documentation Personal/Parental Health Record Inventory Management Reminder/Recall Immunization Rate Assessment using CoCASA Emergency Preparedness The core functions of CIIS are to provide a consolidated immunization record for each individual. CIIS can be used as the medical record for immunization if an office enters the required information for Vaccine given, date, who gave the immunization, Lot number and manufacturer. CIIS has the capability to be used for clinical decision support and screening of children’s records for needed vaccines. Offices have the ability to print a CDPHE approved school/childcare form from CIIS. A record of all immunizations recorded in CIIS can be printed for a person or parent to use. For offices that enter their inventory information into CIIS reports can be run to reflect doses given. There are also capabilities in CIIS to run recall lists and create files to generate labels for mailing. Offices can also generate electronic files that can be imported into the CDC CoCASA software to perform assessment activities. 11/17/2018

CIIS Data Sources CIIS Clinics Vital Stats HCPF Medicaid HMO & Health Providers Hospitals Clinics Vital Stats HCPF Medicaid CIIS CIIS is populated through a download of demographics from Vital Statistics each week since 1/1/03, including the birth dose of Hep B, since 1/1/07. This slide shows all the types of persons and entities that are allowed to give data to and receive data from CIIS. The green cylinders show current data sources: Vital Statistics, Providers, Hospitals, Clinics and HMOs. We are rolling out access to Schools. Earlier this year HCPF and CDPHE signed an MOU that allowed CIIS to provide data to HCPF for its HEDIS measures and allows HCPF to provide information to CIIS. We have ongoing projects to explore data exchange with Regional Health Information Exchanges, including QHN on the West Slope and CORHIO. We have an active work group that is examining what information would assist parents in determining what immunizations their child needs to have based on the immunization history of the child. HMO & Health Insurers Person Health Info Systems Schools 11/17/2018

CIIS Saturation: Providers 39% 80% 66% 100% 0% 10% 20% 30% 40% 50% 60% 70% 90% Public Health Community Health Rural Health Pediatrics Family Practice 11/17/2018

CIIS Production Statistics As of March 2009: Participating Sites 460/880 = 57% Client Records 1,804,349 0-18 yrs 1,310,808 >19 yrs 493,526 IZ Services 21,668,909 11/17/2018

CIIS Saturation: Percent of 0-6 yr olds w/ 2+ Immunizations 11/17/2018

Current CIIS Recall Activities Provider-based Available to all CIIS sites since 2005 After at least 6 mos. use & DQ review Currently 126 sites performing recall Centralized A participating site performs recall for another participating site Public health performs for private Medicaid – ID Medicaid clients at a site and train staff to perform recall Centralized- all sites having recall done for them must sign a delagatory letter of agreement giving the site performing recall access to their CIIS database Public health sites performing centralized recall do it for public and private sites in their own county and some do it on behalf of pub/pvt sites in other counties as well The Medicaid project was a 2 year grant from the CO Child Health Access, worked with 10 pediatric practices 11/17/2018

Current CIIS Recall Activities Geographic Pull records by county zip coding 2006 MCH grant for 6 county area Public health nursing service performed recall for all public and private sites, 9-10mo & 19-20mo Sentinel Site grant 14 counties 35 clinics = 14 public, 15 private, 6 CHC 19-20mo bi-monthly with one month F/U CIIS staff perform recall centrally Geo- CDPHE Maternal and Child Health section project was 9 month grant with monthly recalls 11/17/2018

West Slope Recall Project Goals Implement immunization recall for 9-10 month and 19-20 month-old children in diverse practice settings Assess the time, resources, challenges and benefits associated with starting and maintaining recall using CIIS 11/17/2018

Project Summary 2006 – 2008 Five counties in western Colorado: Rio Blanco - Mesa - Delta – Montrose – Ouray 11 clinics and County Public Health offices Introduced recall using CIIS at each site Turned recall over to the clinic Tracked implementation and sustainability Did not track immunization outcomes 11/17/2018

Participating Sites All had adopted CIIS Reasonably comfortable with CIIS immunization entry All did manual CIIS entry (one eventually adopted electronic data transfer) None were doing recall with CIIS (some were doing manual reminders) 11/17/2018

Non-Participating Sites Six sites were approached but declined to participate 4 large pediatric or family practices 2 small family practices Reasons for non-participation Staff turnover Other priorities, e.g. currently adopting an EHR Used another reminder/recall method No reasons given 11/17/2018

Project Implementation Steps Review clinic immunization process Perform immunization data quality review Update immunization data in CIIS (if needed) Select age cohorts to recall (9-10 and 19-20 month) Develop & translate HIPAA compliant recall notice Implement recall Monitor recall follow-up (bad addresses, MOGEs) Train clinic staff and turn over recall Help sites establish a sustainability plan 11/17/2018

Site #1: Profile Family practice in a small town Paper charts (disorganized) Considerable immunization resistance in the area Very incomplete CIIS immunization data Behind on CIIS entry by ~3 months Spent 1.5 months on data cleanup Identified 3-12 children per recall Recall implementation led to more standardized immunization documentation process 11/17/2018

Site #1: Outcomes Plan Follow-up after transition of recall to clinic Monthly 9-10 and 19-20 month recall Do recall after CIIS data entry is caught up Follow-up after transition of recall to clinic No recalls done by the clinic in 12 months 11/17/2018

Site Profile #2 Large private pediatric practice in a medium sized town Patients come from five counties Up to a 6 week wait for appointments Adopted an EMR just before the project - difficult transition Non-standardized documentation in different places in records Incomplete CIIS data Identified 30- 65 children per recall 11/17/2018

Site #2: Outcomes Plan Follow-up after transition of recall to clinic Monthly 19-20 month recall Review CIIS records on all children with each recall Follow-up after transition of recall to clinic 8 recalls in 9 months 11/17/2018

Site #3: Profile Large County Public Health office in a medium-sized town Fairly unstable patient population – including migrant farm workers Excellent immunization data quality Addresses were not consistently updated Recall implementation motivated clinic to comprehensively review all records Identified 4-13 children per recall 11/17/2018

Site #3: Outcomes Plan Follow-up after transition of recall to clinic 9-10 month recall probably every other month Follow-up after transition of recall to clinic One recall in 9 months 11/17/2018

Site #4: Profile Rapid recall implementation site Medium-sized family practice in a small town CIIS functioned as the sole immunization record Standardized documentation process Did data quality review using CIIS recall Excellent data quality (i.e., only 1-2 children with immunizations recommended) 11/17/2018

Site #4: Outcomes Plan Follow-up after transition of recall to clinic Quarterly recall of children age 0-18 years Follow-up after transition of recall to clinic Two recalls in 6 months 11/17/2018

Time to Implement Recall Data quality review Immunization data cleaning Develop/Translate recall notice Recall follow-up (for example, “bad” addresses, “MOGEs”) Time required (includes all implementation activities) Range: 12 – 126 hours 5 clinics needed 40-60 hours 11/17/2018

Results: CIIS Completeness Among a subset of clinics in the project (N=6) 1143 children were identified through recall 603 (53%) had immunizations recommended After clinics reviewed and updated CIIS data 420/1143 (37%) of the children identified actually needed a recall notice (i.e. needed immunizations) 11/17/2018

Maintenance of Recall Barriers to maintenance None: 2 sites Low: 3 sites Moderate: 2 sites High: 4 sites Barriers to maintenance Time Lack of good consistent office systems for using CIIS and its recall function Possibly also the low yield of recall 11/17/2018

Lessons Learned Recall using CIIS Easy to perform, but may be challenging to incorporate into office workload Requires dedicated staff time Improves immunization data quality and completeness Helps clinics define their “active” population Leads to improved clinic immunization process Staff turnover is a continuing challenge May be less useful in sites with small number of pediatric patients 11/17/2018

Parent & Provider Attitudes Toward CIIS Recall Telephone interviews conducted by CCGC December 2007 - January 2008 15 parents/14 providers Overall: Strong support for CIIS and recall (provider-based and geographic) 11/17/2018

Take Home Messages Provider-based recall on the Western slope was successful in some clinics, but was not consistently applied to maximally effect population immunization rates Geographic-based recall was associated with increased rates, though no control group was part of this study, making it unclear what portion of the increased rates can be attributed to recall. 11/17/2018

THANK YOU!!! Questions about Recall Study: Carolyn Swenson, MSPH, MSN cswenson@coloradoguidelines.org Questions about CIIS Recall: Kathleen Haas, MPH, RN kathleen.haas@state.co.us Questions about CIIS Program: Diana Herrero, MS diana.herrero@state.co.us 11/17/2018