Strategies to Improve the Quality of Vaccine Records in a Computerized Immunization Registry Rosalyn Singleton MD, Alaska Native Tribal Health Consortium 907-729-3418, ris2@cdc.gov Scott Hamstra MD, Whiteriver Medical Informatics Consultant, 520-338-1122, Scott.Hamstra@mail.IHS.gov Irma DeSmet RN, Alaska Native Tribal Health Consortium Michael Remillard DDS, computer programmer - Cimarron Amy Groom MPH, Indian Health Service Immunization Coordinator Sandra Frawley PhD, programmer, Medical Decisions Associates

Presentation Overview Background Disease rates among American Indians/Alaska Natives (AI/AN) What works to improve immunization coverage? Indian Health Service (IHS) Immunization registry Improving data quality and completeness Using the data I will begin with a brief background regarding Alaska and the epidemiology of Hib in Alaska in the pre-vaccine era. I will then review Hib disease on young children after widespread use of conjugate vaccines—how the epidemiology drove vaccine policy which impacted epidemiology and how the cycle of epidemiology and vaccine policy led to four different conjugate vaccine regimens over the past 11 years. In closing, I will also review what has occurred with non-type b Hi disease in young children and Hib and non-b Hi disease in older children and adults..

BACKGROUND Why are vaccines important for American Indians and Alaska Natives?

Vaccine-Preventable Disease in AI/AN: Before and After BEFORE VACCINES: Hib – rates 6-10 fold higher Pneumococcus – rates 3-5 fold higher Hepatitis A – widespread epidemics Hepatitis B – up to 10% carriers in Alaska AFTER VACCINES: Only 2 cases of Hib in 3 years in Alaska! 10-fold decrease in PCV7-type pneumococcal cases No Hep A epidemics since vaccine! No Hep B carriers in children!

What Works to Improve Rates? Patient-focused Tracking and Reminder-recall systems Incentives Media/education Provider Interventions Provider reminders and incentives Standing orders System Interventions Walk-in / Satellite clinics - ACCESS Streamline process Direct data entry – DATA QUALITY Registries

The IHS Immunization Registry Part of the IHS Resource and Patient Management System (RPMS) Immunization information is integrated into an electronic health record Used since 1980s to: Forecast immunizations due for individuals Run lists of patients due for immunizations Print due letters Print immunization audits 3-27 month olds 2 year olds (19 – 35 months)

IHS Immunization Registry 10 customized forecasting options All follow standard minimum ages and intervals Can forecast on minimum vs. recommended ages Different recommended ages for Hep B 3, DTaP 4, etc. With or without 4 day grace period Won’t count an invalid dose Contraindications – E.g. Prior chicken pox, Anaphylaxis, Immune deficiency. Patient refusal – lists, but still forecasts

Tracking and Recall Options Can query the data base to run lists and print due letters for various groups of patients: Due for immunizations More than a month overdue Received a specific lot number (in case of recall) Due for a specific vaccine (e.g. MMR for measles outbreak) Patients who had a visit with an ICD9 code (e.g. COPD) that puts them in a high risk group for Influenza

Improving Data Quality

PROBLEM: Poor data quality Delays in data entry Coding errors DTaP vs DTP; Hib vs Flu; Hib vs HBV; Hep A vs Hep B Incomplete records (vaccines at other facilities) RESULT: Providers don’t trust record Missed opportunities – don’t know what’s due Time – need to call and look up records Can’t send letters or print accurate lists Computerized Immunization audits not accurate

Point of Service Data Entry Nurse gives vaccines Nurse enters vaccine info directly into the hospital computer: Vaccine name Date Lot number/ manufacturer Dose/amount Injection site Facility Person administering vaccine VIS date Advantages: Accurate data Accurate forecasting Appropriate administration Timely data entry Ends duplicate data entry Decreases charting Print out Official Record Increased data access

Standard HL7/CVX/MVX codes Able to utilize forecaster from Medical Decisions Associates Sets up potential to exchange data with State immunization registries Includes combination vaccines: Enter as brand name (e.g. Comvax®) Prints out as separate antigens Hep B (Comvax®) PedvaxHIB (Comvax®)

Data Exchange Project Development of bi-directional data exchange between RPMS and state immunization registries CDC Implementation Guide for HL7 standards Batch and real-time exchanges Currently being piloted in 6 states • Arizona • Utah • Minnesota • Washington • South Dakota • Wisconsin

Using the Data Data Policy

Invasive Hib Disease, Children Aged <5 Years, Alaska,1980-2002 HibTiter PedvaxHIB Sequential Pedvax/Hibtiter Comvax During the period from May 1996 through Sept. 1997, 16 cases of invasive Hib disease were identified Singleton, et al. J Pediatr 2000; 137:313-20 and CDC, unpublished

Provider Incentive: ANMC Provider Immunization Report Providers receive a monthly immunization report on their patients 0-27 months: Lists % up-to-date for DTaP, Polio, Hib, HepB, MMR Compares to all providers Lists children who are past due with their last visit date.

How are we doing at vaccinating AI/AN children?

Age-Appropriate Immunization Rates, AI/AN, IHS report 1st Quarter FY2004

2-year old Immunization rate, AK Natives compared with U. S 2-year old Immunization rate, AK Natives compared with U.S. and other Alaskans: National Immunization Survey MMWR 2003 Vol 52/ No 30 page 711-713

Summary The IHS immunization registry is an innovative tool that has contributed to high immunization rates for AI/AN children. Strategies to improve data quality include … facilitating point-of-service data entry data exchange with state immunization registries

How To Use the Information: SCENARIOS

Situation #1 Measles Outbreak reported in your County! Who is at risk? How can you find out? What options do you have? What do you do now?

Measles Outbreak - Steps Print a list of children who are due for MMR vaccine (may select specific age ranges, communities, etc). Design a specific parent letter. Print the letters for parents of all children due for MMR

IMMUNIZATION LISTS & LETTERS 1 - Date of Forecast/Clinic..: TODAY 2 - Age Range................: 12 -72 Months (Can change to Years) 3 - Patient Group............: Active (?add Inactive or Not in Register) 4 - Communities..............: ALL 5 - Case Managers............: ALL 6 - Immunizations Received...: None 7 - Immunizations Due........: MMR 8 - Health Care Facilities...: ALL 9 - Lot Numbers..............: ALL 10 - Additional Information...: Forecast 11 - Order of Listing.........: by Patient Age Select a left column number to change an item. List of Patients Print Due Letters

Situation #2 Varicella vaccine Lot #D5489 – considered sub-immunogenic by Manufacturer & Recommends re-vaccinating all children vaccinated with this lot! How can you find out those at risk? What options do you have? What do you do now?

Due Lists & Letter Options May select by … Registry status Active, Inactive, Not in Registry Range of Patient Ages (in months or years) Community (or group of communities) Vaccine Type (given or due) Lot Number

IMMUNIZATION LISTS & LETTERS 1 - Date of Forecast/Clinic..: TODAY 2 - Age Range................: 12 -72 Months (Can change to Years) 3 - Patient Group............: Active 4 - Communities..............: ALL 5 - Case Managers............: ALL 6 - Immunizations Received...: None 7 - Immunizations Due........: None 8 - Health Care Facilities...: ALL 9 - Lot Numbers..............: D5489 10 - Additional Information...: Forecast 11 - Order of Listing.........: by Patient Age Select a left column number to change an item. List of Patients Print Due Letters