Improving Immunization Rates among WIC Clients: How an immunization information system helped Martha Priedeman Skiles Lorraine Duncan Nhu To-Haynes Susan Woodbury Steve Robison Oregon Public Health Division

WIC – The Special Supplemental Nutrition Program for Women, Infants and Children WIC serves lower-income pregnant, postpartum, and breastfeeding women, and children under age 5 who have a health or nutrition risk. Prevention by design: Supports healthy pregnancies Prevents low birthweight infants Prevents chronic conditions (obesity, diabetes, heart disease) WIC works to support pregnancy, improve pregnancy outcomes, and establish healthy nutritional practices for young families. Oregon Public Health, NIC 2008

Oregon’s WIC Program 34 WIC Agencies serving 36 counties Operation - 30 local health departments, 2 Tribes, 1 Head Start, 1 Migrant Health Center Paperless - all agencies required to use TWIST, the WIC data system Population served in 2006 includes: 167,000 women, infants and children 40% of all infants born in state; 51% in rural counties 1 in 3 Oregon children under age 5 Working families – more than 72% are employed Oregon Public Health, NIC 2008

Why WIC-Imm partnering? Historically, children enrolled in WIC had lower rates than others in their age group: 70.3% WIC vs 76.4% non-WIC (1999 NIS US rates) Executive Memorandum of December 11, 2000 - immunization status of children receiving WIC services must be evaluated. All 0-23 month olds screened Minimum screening is counting DTaP doses Referral to immunization provider as needed WIC staff must be trained and supported WIC Policy Memo (803-AT), August 30, 2001 detailed the specifics for implementing the Dec 2000 executive memorandum, including minimum screening guidelines and October 2001 implementation date. Oregon Public Health, NIC 2008

Oregon Implementation Pre-2001 Oregon created a state WIC-IMM collaboration. 2001 - 2006 Provided training and materials to WIC agencies Added screening prompt to TWIST* Encouraged review of electronic immunization records – IRIS*, ALERT Registry, clinic EMR 2007 Added electronic forecast feature in TWIST* In the late 1990s, Oregon’s Imm and WIC programs signed a memorandum of understanding, creating a state collaboration. The state modeled collaboration and worked with their local partners to encourage collaboration and cross-referrals between programs. TWIST is the WIC data system. IRIS is the public-sector immunization data system. Both are housed under the umbrella of FamilyNet, a larger public-sector family health data system. ALERT is Oregon’s statewide immunization information system (IIS). Immunization records from IRIS are uploaded into Oregon ALERT, just as a large private-sector health system would share data electronically with the IIS. * TWIST and IRIS are 2 modules of FamilyNet, Oregon’s public-sector data system Oregon Public Health, NIC 2008

Oregon Evaluation 2004 - 2006 Annual survey of WIC Agencies to determine immunization screening practices Population-based immunization rates comparing WIC vs non-WIC participants. Produced from adjusted ALERT IIS data. 2007 Two surveys (Feb, Dec) to evaluate implementation of forecaster. Annual survey sent to the 34 WIC coordinators (100% response rate). Much of the survey collected information necessary to report annually to CDC. 2007 - Rapid evaluation survey in Feb, 1 month following roll-out of the new forecast option. Second survey sent in Dec to remeasure use of the forecaster. Oregon Public Health, NIC 2008

Practices: Screening in WIC Agencies Excepting 2007, the percent of Agencies reporting counting DTaP or reviewing entire imm records remained relatively constant. * 33 Agency responses in Dec ‘07 Oregon Public Health, NIC 2008

Practices: Records Reviewed in WIC Agencies Early on, WIC Agencies were required to ask for an immunization record for all certification appointments. Even as newer methods of assessment came on line, the Agencies continued to request and review handheld records. However, as staff became more familiar with available electronic records such as those from IRIS (the public-sector immunization data system) and ALERT (Oregon’s IIS), the percent of Agencies reporting review of these records increased steadily: E-records (IRIS, own clinic EMR): 29% in 2004 to 73% in 2007 ALERT IIS: 24% in 2004 to 55% in 2007 * 33 Agency responses in 2007 Oregon Public Health, NIC 2008

Practices: Assessment tools used in WIC Agencies Likewise, an increase in computerized assessment tool use mirrored the change in records reviewed. Computerized assessment: 21% in 2004 to 97% in 2007. * 33 Agency responses in 2007 Oregon Public Health, NIC 2008

Rates: Oregon Population-based immunization rates, 24-35 month olds Using ALERT IIS data and basic demographic methods to adjust for child mobility and incomplete provider reporting to the IIS, Oregon produced population-based immunization rate estimates. These rates are producible by geographic (county, census tract) and demographic (WIC, medicaid status) groupings. One clear advantage in using Oregon’s IIS data is that the confidence intervals are quite small 0.6% for WIC; 0.7% for non-WIC) for a state rate, allowing us to identify small yet significant changes in immunization rates. We can also look at the rate changes by county, however the confidence limits are wider (1.3 - 8.4). From 2004 to 2006, 7 counties had a measurable, significant increase in rates, while 1 significantly decreased. Over the 3 years of implementing required screening mandates and providing new tools and methods for meeting these requirements, we see that the imm rates for the WIC children have steadily increased from 67.7 in 2004 to 70.7 in 2006. This effort has helped WIC rates to reach parity with statewide population rates. * 2006 rates include minimum spacing btn 3rd – 4th DTaP 4:3:1:3:3:1 Series Oregon Public Health, NIC 2008

New in 2007: WICIMM Forecaster Oregon created bi-directional data link between the public-sector data system (FamilyNet) and Oregon Immunization ALERT. Immunization records are imported into FamilyNet which produces an immunization forecast. WIC staff are able to view participant immunizations due with a click of a button New forecast feature allows WIC staff to retrieve an electronic forecast from their main data system during an appointment for children already in the data system. Oregon Public Health, NIC 2008

WICIMM Referral Letter List of Shots Due Per the federal mandate, a provider letter is easily printed and passed on to parents. Translated Spanish message asking parents to take this letter to next provider visit Oregon Public Health, NIC 2008

WICIMM Forecaster Evaluation Feb 2007 - rapid evaluation survey distributed 1 month post-implementation 103 staff from 27 WIC agencies completed the survey Dec 2007 - survey distributed 11 months post-implementation 69 staff from 33 agencies completed the survey Oregon Public Health, NIC 2008

How frequently is the forecast button used? Oregon Public Health, NIC 2008

For those screening less than 25% of the time, Dec 2007 Half of the respondents reported a persistent skepticism of the data or unavailability of a forecast 55% of respondents who did not use the system regularly reported concerns with inaccurate data (forecast did not match the patient’s handheld record), or no record was available. The system can only produce a forecast once a child with demographics is entered in TWIST ~ 2 weeks prior to the visit to allow the time necessary for the data exchange between the registry and FamilyNet. Other responses include: forgot the forecaster was available, use ALERT or own EMR directly, harder to use, don’t work with clients.

When used, how often is a forecast produced? Oregon Public Health, NIC 2008

How often do you forecast for clients >23mos? Never 28% Routinely 33% Used but not yet a fully adopted as a core value or standard practice Parent Request 15% Time Permitting 25% Oregon Public Health, NIC 2008

Satisfaction with Forecaster 66% Satisfied/Very Satisfied 34% Not Satisfied

Conclusions WIC provides an important assessment/referral opportunity – WIC staff are key to this success WIC Agencies are adopting more sophisticated imm records and assessment methods Imm rates for WIC clients are steadily increasing Oregon Public Health, NIC 2008

Next Steps Continue to work with WIC staff to encourage use of the forecast button Identify and resolve issues regarding forecast availability and completeness of data Produce and compare immunization rates among WIC clients vs. total population Oregon Public Health, NIC 2008

Acknowledgments Oregon WICIMM Team Immunization Lorraine Duncan Gail McMurchie Jacki Nixon Martha Skiles Amanda Timmons WIC Jane Fouste Susan Greathouse Kim McGee Nhu To-Haynes Susan Woodbury Contacts: Martha Skiles Nhu To-Haynes martha.p.skiles@state.or.us nhu.to-haynes@state.or.us Oregon Public Health, NIC 2008

Questions? Oregon Public Health, NIC 2008