Strategies to Improve the
Quality of Vaccine Records in a
Computerized Immunization
Registry
Rosalyn Singleton MD, Alaska Native Tribal Health Consortium
907-729-3418, [email protected]
Scott Hamstra MD, Whiteriver Medical Informatics Consultant,
520-338-1122, [email protected]
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
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
Advantages:
– Date
1. Accurate data
– Lot number/ manufacturer
2. Accurate forecasting
– Dose/amount
3. Appropriate administration
– Injection site
4. Timely data entry
– Facility
5. Ends duplicate data entry
– Person administering vaccine
6. Decreases charting
– VIS date
7. Print out Official Record
8. 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
• Minnesota
• South Dakota
• Utah
• Washington
• Wisconsin
Using the Data
Data
Policy
Invasive Hib Disease, Children Aged <5
Years, Alaska,1980-2002
700
Native
Non-Native
500
HibTiter
400
PedvaxHIB
300
200
Sequential
Pedvax/Hibtiter
Comvax
100
0
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
Cases/100,000
600
Year
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
100%
90%
Percent
80%
78%
82%
81%
77%
5-6
m/o
7-15
m/o
16-18
m/o
19-23
m/o
86%
82%
24-27
m/o
Overall
60%
40%
20%
0%
3-4
m/o
Age group
3-4 m/o
19-23 m/o
5-6 m/o
24-27 m/o
7-15 m/o
Overall
16-18 m/o
2-year old Immunization rate, AK Natives
compared with U.S. and other Alaskans:
National Immunization Survey
78
76.4
% immunized
76
73.3
74
72
4-3-1-3-3
69.1
70
68
66
64
Alaska Natives
Alaska Nonnatives
U.S. total
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..:
2 - Age Range................:
3 - Patient Group............:
4 - Communities..............:
5 - Case Managers............:
6 - Immunizations Received...:
7 - Immunizations Due........:
8 - Health Care Facilities...:
9 - Lot Numbers..............:
10 - Additional Information...:
11 - Order of Listing.........:
TODAY
12 -72 Months (Can change to Years)
Active (?add Inactive or Not in Register)
ALL
ALL
None
MMR
ALL
ALL
Forecast
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..:
2 - Age Range................:
3 - Patient Group............:
4 - Communities..............:
5 - Case Managers............:
6 - Immunizations Received...:
7 - Immunizations Due........:
8 - Health Care Facilities...:
9 - Lot Numbers..............:
10 - Additional Information...:
11 - Order of Listing.........:
TODAY
12 -72 Months (Can change to Years)
Active
ALL
ALL
None
None
ALL
D5489
Forecast
by Patient Age
Select a left column number to change an item.
List of Patients
Print Due Letters