Informatics Assessment of an Immunization registry

Houston Harris County Immunization

Registry (HHCIR)

Raoul KAMADJEU, MD, MPH

Public Health Informatics Fellow

NIP/GID/GMB

January 13, 2006

Informatics Assessment of a Surveillance System

Layout

Objectives

Background on Immunization Registries

Houston Harris County Immunization Registry

Background on the HHCIR

Description of the system

Assessment of the system

Conclusions and recommendations

Objectives

Report on the informatics assessment of the Houston Harris County

Immunization Registry.

More specifically, at the end of this presentation, the audience should

be able to:

• Understand and explain the usefulness of an IR

• Apprehend the environmental and technical challenges

associated with the development and operation of an IR based on

HHCIR example


• Definition, functions and players in an immunization registry

• Why immunization registries?

• History of immunization registries in the US

• Benefits of immunization registries

• Current status of immunization registries in the US


• Katrina: Lost of personal medical information including vaccination

history

• 8,300 queries made to the Louisiana Immunization Network for Kids

Statewide (LINKS) by September 2005 regarding vaccination histories

for evacuees.

• 28 500 queries to LINKS through the HHCIR (As of December 2005)

Immunization information recovered, unnecessary revaccination avoided, estimated

saving US$ 1033 000

Katrina, Immunizations and Immunization

Information Systems

What is an immunization registry (IR)?

A confidential, population-based computerized system for

maintaining information regarding children’s vaccinations

Population-based IR contain information about all the children

in a given geographic area.

Immunization Information System (IIS): a registry with

added capabilities (vaccine management, adverse event

reporting, lifespan vaccination history, linkage with electronic

data sources)

Background on immunization registries

Healthy People 2010 objective 14-26

Increase to 95% the proportion of children aged <6 years who

participate* in fully operational, population-based immunization

registries.

Participation = Having two or more vaccination recorded in the IR


The 12 Minimal Functional Standards for an IR


1. Electronically Store data on all NVAC approved data elements

7. Exchange immunization record using HL7 standards

2. Establish a registry record within six weeks of birth for each new born child in the catchment area

8. Automatically determine the routine childhood immunization needed, in compliance with the ACIP

3. Enable access to and retrieval of immunization information in the registry at the time of encounter

9. Automatically identify individuals due/late for immunization(s) to enable the production of reminder/recall notifications

4. Retrieve and process immunization information within one month of vaccine administration

10. Automatically produce immunization coverage reports by providers, age groups and geographic areas

5. Protect the confidentiality of health care information

11. Produce official immunization records

6. Ensure the security of health care information

12. Promote accuracy and completeness of registry data

Why immunization registries?


Challenges to maintain high immunization coverage in children in the

US need to be addressed

These challenges provided the need for the development and use of

IR

Some figures:

- Four millions infants born every year (11,000/day)

- 18 to 22 vaccinations necessary for full protection against VPD



Increased complexity of vaccine schedule

“The complex and ever-changing nature

of childhood immunization schedule

makes it difficult for many clinicians to

keep up, even with the help of chart,

books and training.” Jeffrey P. Koplan,

Director CDC, 1999, NIC

• 23 changes in immunization schedule from 1985 – 2003 (new vaccines, age group,

new formulations)

• New single and combination vaccines are quickly becoming available, increasing

schedule’s complexity !!!



Societal changes

• Increase family mobility with frequent change in employers, insurers and care providers

• 25% children visit two or more providers for immunization before their third birthday.

• Immunization records scattered among different health care providers, offices and clinics.

Lack of accurate information about vaccination coverage

• Information gap for parents and providers: both believe that immunization coverage levels for children are higher than they actually are.

Decrease awareness of VPD and increase concerns about vaccine risks

• A potential for a comprehensive study of vaccine adverse effects

History of IR development in the US


1970

1974

1st IR (Delaware)

1980

1991

Registry development in large scale organizations

All Kid Count Program (RWJF)

1990

1997

IR included in the Childhood Immunization

Initiative

Registry goal included in the Healthy People

2010 goals

50 states have or are developing IR

2004

1999

Major landmarks in IR development in the US

Players in an IRBackground on immunization registries

Source: Freeman – Defriese. The Challenge and Potential of Childhood immunization Registries. Annu. Rev. Public Health 2003. 24:227-46

Benefits of Immunization Registries


IR

PROVIDERS

PARENTS

PLANS

PURCHASERS

COMMUNITIES

PUBLIC HEALTHOFFICIALS



FOR PARENTS

•Consolidate in one record all immunization the child has received

• Provide accurate information on child’s immunization history

• Help ensure that a child’s immunizations are up to date

• Provide reminders when an immunization is due

• Provide recalls when an immunization has been missed

• Help insure timely immunization when families move or switch providers

• Prevent unnecessary (duplicative) immunizations.



FOR PROVIDERS, PLANS AND PURCHASERS

• Consolidate immunization from all providers into one record.

• Provide a reliable immunization history for any child

• Provide definitive information on immunization due or overdue

• Provide current recommendations and information on new vaccines

• Produce reminders and recalls for immunizations due or overdue

• Complete required school, camp and day care immunization records

• May reduce practice’s paperwork

• Help manage vaccine inventories

• Generate coverage reports for managed care and other organizations



FOR COMMUNITIES

• Help control vaccine-preventable diseases

• Help identify high-risk populations and under-immunized populations

• Help prevent disease outbreaks

• Link (where supported by legislation) with other health databases such as

newborn and lead screening, or other state registries

• Provide information on community and state coverage rates

• Streamline vaccine management



FOR PUBLIC HEALTH OFFICIALS

• Provide information to identify pockets of need, target interventions and

resources, evaluate programs

• Promote reminders and recall of children of children who need

immunizations

• Ensure that providers follow the most up-to-date recommendations for

immunization practice

• Facilitate introduction of new vaccines or changes in the vaccine schedule

• Integrate immunization services with other public health functions

• Help to monitor adverse events

Current status of immunization registries in the US (2004)


Results of the CDC’s 2004 Immunization Information System Annual Report*

48% of US children aged <6 years participated in an IIS

76% of public and 39% of private provider sites submitted

immunization data to an IIS

Of the CDC grantees,

18% have achieved the national health objective (≥95%)

13% were approaching the national health objective (81% - 94%)

Immunization Information System Progress – United States, 2004

MMWR, Vol. 54 / No.45 Nov 2005; 1156-1157

*


Percentage of children aged <6 years participating in a grantee immunization information system – US, five cities, and the District of Columbia, 2004

Participation: Child having two or more vaccinations recorded in an IIS

Grantees include 50 states, five cities and the district of Columbia.


Reminder: NIP Classification of immunization registries

for technical assistance

Three groups: based on the 2004 IIS Annual Report and data input from CDC IIS

staff

Group 1: Active project IIS intervention

• Represented 38% of all US children aged <6 years

• Reported no or very low child participation rates

• Primary target group for enhance technical assistance

Group 2: Under active IIS project implementation.

• They have a plan to address their challenges and are making satisfactory progress.

• Represented 25% of US children age <6 years

Group 3: Mature IIS projects or making excellent progress

• Represented 37% of children aged < 6 years


Current status of immunization registries in Texas

2004 IIS Annual Report

• Active Registry Project Intervention

• 91% Functional Standards achieved

• 46% child participation

• 68% public provider sites participation

• 56% private provider sites participation

HOUSTON HARRIS COUNTY

IMMUNIZATION REGISTRY

(HHCIR)

Houston

The largest city in Texas

and the fourth in the US.

Know internationally as the

home of the Texas Medical

Center (TMC, 42

institutions including the

HDHHS and the Texas

Children’s Hospital)

Houston Harris County IR

A population-based local registry initially built to support immunization

activities in the Houston Harris catchment area

Hosted by the Texas Children’s Hospital

HHCIR Milestones and History

1992: The Baylor College of Medicine (BCM) is awarded $100 000 by the

Robert Wood Johnson Foundation to develop a local immunization registry

1995: Texas Department of Health (TDH) awards $421 000 to Texas

Children Hospital (TCH) and BCM to work collaboratively with HDHHS and

HCPHS to further the local immunization registry

1995 – 1999: Development of the HHCIR with software developed by BCM

and support and maintenance provided by TCH. HDHSS served as beta test

site during the period.

May 2000: Historical data entry of 310 760 patients records. HDHHS

became the first user of the registry

Sept 2000: HCPHS submits data for inclusion into the registry.

HHCIR Milestones and History

April 2002: SCT retained to develop a five-year strategic plan for the

registry

June 2002: Kelsey-Seybold became the first private provider to participate

in the registry

July 2002: over 660 000 patient record and 4 millions immunizations in the

registry

September 2002: SCT delivers Strategic Plan

5 071 053

5 936 868

5 705 449

5000000

5500000

6000000

2003 2004 2005(1st Qtr)

Immunization recorded in Registry

Current Status of HHCIR

678 361

739 647

827 430

600 000

650 000

700 000

750 000

800 000

850 000

2003 2004 2005 (as of11/30/05)

Number of children (0 – 17 yrs)

As of November 2005, over 75%

of the pediatric population of

Greater Houston had vaccination

recorded in the IR

Number of clinics using the Registry


273

107

73

0

100

200

300

2003 2004 2005 (as of9/30/05)

As of September 2005,

approximately 60% of the

providers in the Greater

Houston area that give

pediatric immunizations used

the registry

Structure of HHCIR

City of Houston

Private Grants 501(c)(3)

TCH IDS

Houston- Harris County

Immunization Registry

City of HoustonClinics

Private Providers (large

and small)

School districts(read-only)

Support UsersRegistry

TDH

Hospitals

Current Support

• City of Houston • Houston Endowment, Inc

• Texas Children Hospital • World Health and Golf Association

• Baylor College of Medicine • Sterling Bank

• SBC • Cameron Foundation

• William Stamps Farish Fund • Blue Cross Blue Shield of Texas

• Hamman Foundation • Wyeth

• Rockwell Foundation

Description of the system

A web-based access

An area for the general public,

providing information on the

registry, on immunization and links

to additional immunization

resourcesA secured area for authorized users

Minimum requirements for web access

include:

• Any internet connection

• Internet Explorer 5.0 or higher

• Netscape 6.0 or higher

• Minimum monitor resolution at 800

x 600

Selected snapshots

Log-in screen

Search screens

Search result screens

Preview of a client record

Sample immunization record

Access to the system

THICK (RICH) CLIENT

All kelsey ClinicsFlat File Import

47 Private ProvidersMisys®

26 Private ProvidersMedisoft®

Texas Children’s Hospital ClinicsLogician®

All City of Houston ClinicsQuick Recovery®

Mobile vans

THIN CLIENT

Private providers

A web-based application: Internet services must be available

Advantages of Thin Client

• No specific software need to be installed

• Improved transaction processing

• Improved performance

Advantages of the Thick Client

• Interfaces with existing billing and PMS

•Transmits patient and vaccination data from provider’s billing and PMS.

• Eliminates the need to enter vaccination information twice

• Provides a mean to eliminate duplicate data entry

IR

Current data elements

Inspired by the CDC Recommended List/NVAC-approved core

data elements:

• Patients • Vaccinations • Vaccines • Vaccine manufacturers• Vaccine lots • Providers• Users • Sites

Servers

TCH Firewall

* Oracle 9i

Database * Applications Forecasting

Web RSA

encrypted

encrypted

User

http://images.google.com/imgres?imgurl=http://www.innu.org/~super/dnac/rsa-logo.gif&imgrefurl=http://www.innu.org/~super/dnac/&h=300&w=419&sz=7&tbnid=aqadyvGaRHYJ:&tbnh=87&tbnw=122&hl=fr&start=37&prev=/images%3Fq%3DRSA%26start%3D20%26svnum%3D10%26hl%3Dfr%26lr%3D%26sa%3DN

Messaging and data exchange

Data Flow Diagram

HHCIRWeb1

City of Houston

HL7Communication Platform

EMR PMS

HTTPSMaster Patient Index

Id1

Id2Id3

IdN

Id4

Various hospital ID numbers

Messaging and data exchange

HL7 Communication Platform

Data quality issues

Immunization registry are prone to many causes of duplicate

and incorrect data

• Duplicate data in batch records from providers billing systems

• Duplicate create from batch load

• Data input errors

• Addresses change

• Guardian name change

• Adoption creating name and address change

DuplicationsDe-duplication process

Master Patient Index

Id1Id2

Id3

IdNId4

Various hospital ID numbers

Data quality issues

DE-DUPLICATION ALGORITHM

• Developed by the BCM

• Estimated to keep data duplication rates around 1%

Security: Administrative procedures

Under the TCH administrative procedure:

Security certification done through the internal TCH process

Secure data transfer using HTTPS and a 128 bit encryption

Contingency plan

- Application and data critical analysis

- Backup plan and recovery plan

Information access management, with access authorization, establishment

ad modification

Security: Physical safeguards

To guard data Confidentiality, Integrity, and Availability (CIA)

Limited access to the server room

Access monitor 24/7

Sign-in and escort

Guideline on workstation use

Procedure for verifying access authorization

APC and generators

Review of the 12 Minimum Functional Standards

in the HHCIR

Minimum functional requirement Actions undertaken or

achieved

1. Data on NVAC-approved core data elements

2. Registry record within 6 weeks of birth for each newborn child born in the catchment area

3. Access and retrieval of immunization information at the time of encounter

4. Receive and process immunization information within one month of vaccine administration

5. Protect confidentiality of information

6. Ensure security of information

Assessment of progress towards compliance to

the 12 Minimum Functional Standards in the

HHCIR Minimum functional requirement Actions

undertaken or achieved

7. Exchange immunization record using HL7

8. Automatically determine the routine childhood immunization (s) needed in compliance with current ACIP recommendations

9. Automatically identify individuals due/late for immunization(s) to enable the production of reminders

10. Automatically produce immunization coverage reports

11. Produce official immunization records

12. Promote accuracy and completeness of registry data

Link other Registries: Texas Immunization

Registry (ImmTrac)

I mmTrac Data Sources

HHCIR

Link other Registries

Link to Louisiana Immunization Network for Kids

Statewide (LINKS)Immunization information for Louisiana children available through HHCIR (28 500 queries

as of December 2005)

Access to LINKS

Upcoming challenges to HHCIR

Operational

Increase the number of consented records in the registry

Increase the number of providers enrolled in the registry

Secure a MOU with DSHS for data exchange between HHCIR

and ImmTrac

Continue the development of interface between HHCIR and

patient management systems

Upcoming challenges to HHCIR

Potential technical improvement

Continue effort to link with other public health systems

• NEDSS

• Pharmacy Inventory Systems

Develop some vaccine inventory functionalities

Develop functionalities to track vaccine adverse events or linkage

with vaccine adverse event applications

Develop some GIS capabilities

Acknowledgements

• Steve McLaughlin, Mac Otten (Mentors)

• Janise Richards (Director PHIFP)

• Gary Urqhuart (Branch Chief - IRSB)

• Diana Bartlett (IRSB)

• Williams Gail (IRSB)

• Cohill Dontanette (IRSB)

• Williams Warren (IRSB)

• Moore Maureen (Administrative Supervisor - HDHHS) • Anna Dragsbaek (IR Coordinator - TCH)

• Khan Andala (Senior Fellow)

• Deepak Sagaram

• Public Health Informatics Fellows • ORISE

Acknowledgements

Raoul K. Anna D. Maureen M.

Resources

Informatics Assessment of an Immunization registry

Documents

Transcript of Informatics Assessment of an Immunization registry