1. Strategies to Improve the Quality of Vaccine Records in a Computerized Immunization Registry
Rosalyn Singleton MD, Alaska Native Tribal Health Consortium ,
Scott Hamstra MD, Whiteriver Medical Informatics Consultant, ,
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

2. 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..

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

4. 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!

5. 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

6. 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)

7. 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

8. 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

9. Improving Data Quality

10. 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

11. 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

12. 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®)

13. 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

14. Using the Data
Data
Policy

15. 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: and CDC, unpublished

16. 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.

17. How are we doing at vaccinating AI/AN children?

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

19. 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

20. 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

21. How To Use the Information: SCENARIOS

22. 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?

23. 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

24. IMMUNIZATION LISTS & LETTERS
1 - Date of Forecast/Clinic..: TODAY
2 - Age Range : 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

25. 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?

26. 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

27. IMMUNIZATION LISTS & LETTERS
1 - Date of Forecast/Clinic..: TODAY
2 - Age Range : 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