1. 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

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

3. 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

4. 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
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5. 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
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6. 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
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7. 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
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8. 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.
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9. 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
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10. 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
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11. CIIS Production Statistics
As of March 2009:
Participating Sites 460/880 = 57%
Client Records 1,804,349
0-18 yrs ,310,808
>19 yrs ,526
IZ Services 21,668,909
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12. CIIS Saturation: Percent of 0-6 yr olds w/ 2+ Immunizations
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13. 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
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14. 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
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15. West Slope Recall Project Goals
Implement immunization recall for 9-10 month and month-old children in diverse practice settings
Assess the time, resources, challenges and benefits associated with starting and maintaining recall using CIIS
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16. 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
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17. 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)
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18. 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
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19. 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 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
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20. 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
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21. Site #1: Outcomes Plan Follow-up after transition of recall to clinic
Monthly 9-10 and 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
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22. 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 children per recall
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23. Site #2: Outcomes Plan Follow-up after transition of recall to clinic
Monthly month recall
Review CIIS records on all children with each recall
Follow-up after transition of recall to clinic
8 recalls in 9 months
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24. 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
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25. 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
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26. 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)
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27. 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
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28. 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 hours
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29. 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)
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30. 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
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31. 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
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32. Parent & Provider Attitudes Toward CIIS Recall
Telephone interviews conducted by CCGC December January 2008
15 parents/14 providers
Overall: Strong support for CIIS and recall (provider-based and geographic)
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33. 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.
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34. THANK YOU!!! Questions about Recall Study: Carolyn Swenson, MSPH, MSN Questions about CIIS Recall: Kathleen Haas, MPH, RN Questions about CIIS Program: Diana Herrero, MS
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