Immunization Registries and Electronic Health Records: Potential to Better Capture Immunization Status through Merging of Systems

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1 Immunization Registries and Electronic Health Records: Potential to Better Capture Immunization Status through Merging of Systems Laurie L. Duran, MSN, CRNP Pacific Region Vaccine Safety Hub Immunization Healthcare Branch Presentation for California Immunization Coalition Summit Sacramento, CA 17 Apr 2017

2 Disclosures and Disclaimer The views expressed in this presentation are those of the authors and do not reflect official policy or position of the Departments of the Army, Navy, Air Force, Department of Defense, or U.S. Government. No commercial products are identified in this presentation. However, any discussion of specific products does not constitute endorsement or implied endorsement on the part of the authors, the Department of Defense, or any component agency.

3 Objectives Participants will be able to: Describe challenges in accurately capturing immunization data for populations of school-aged children; Identify differences between immunization registries and electronic health records in capturing immunization data; Apply an understanding of data from this San Diego-based cohort to other populations needing to capture complete immunization data.

4 Background Immunization information systems (registries) aspire to capture complete vaccination data on defined populations, such as school-aged children within a county Similarly, electronic health records (EHRs) are expected to capture all vaccinations received by a population in a defined healthcare system As per CDC/ACIP Best Practices: Appropriate and timely documentation helps ensure not only that persons in need of recommended vaccine doses receive them, but also that adequately vaccinated patients do not receive excess doses

5 Background It would be valuable to understand how well vaccinations are represented in these systems for a population that is covered by both an immunization registry and EHR Children residing in San Diego County represent a unique population for such an evaluation since their care should be represented in both a strong immunization registry (SDIR) and a robust worldwide EHR

6 Methods Up-to-date vaccination status defined by CDC-recommended vaccines applicable to this birth cohort 4 doses DTaP, 3 doses IPV, 1 dose MMR, 3 doses Hib, 3 doses HepB, 1 dose VAR, 4 doses PCV, 2 doses HepA Up-to-date vaccination status was alternatively defined by California-required school-entry vaccines applicable to this birth cohort 4 doses DTaP, 3 doses IPV, 2 doses MMR, 3 doses HepB, 1 dose VAR Among children represented in both EHR and SDIR, up-to-date vaccination status was evaluated via a virtual merging of the systems Only clearly unique doses were included in merged system. For example, a child with 2 doses of DTaP in EHR and 2 doses of DTaP in SDIR was not considered to have 4 unique doses, and therefore was not up-to-date in merged system.

7 Results Cohort included 4173 children 3847 (92.2%) had vaccine records in the military EHR 1817 (43.5%) had vaccine records in SDIR 1676 (40.2%) had vaccine records in both systems military-kids-missing-vaccines-in-big-numbers.html

8 Results Representation in military EHR and SDIR among 4173 military beneficiary children Records in military EHR Records in SDIR Number of children (% of cohort) 3847 (92.2) 1817 (43.5) Number of children (% in system) with records of recommended vaccines: 4-DTaP vaccines 2363 (61.4) 1599 (88.0) 3-IPV vaccines 2434 (63.3) 1658 (91.3) 1- MMR vaccine 3419 (88.9) 1662 (91.5) 3-Hib vaccines 2227 (57.9) 1347 (74.1) 3- HepB vaccines 1-VAR vaccine 4-PCV vaccines 2- HepA vaccines Any Influenza vaccine 2250 (58.5) 1642 (90.4) 3408 (88.6) 1654 (91.0) 1766 (45.9) 770 (42.4) 2666 (69.3) 1212 (66.7) 3126 (81.3) 753 (41.4)

9 The military EHR included substantially more vaccination records (83,216 vaccine doses) compared to SDIR (40,399 vaccine doses) for this cohort of children When children had records in SDIR, this system was more likely to show up-to-date status for individual vaccines required for school, compared to the military EHR The military EHR was more likely than SDIR to include vaccines not required for California school entry (PCV, HepA, Influenza vaccines)

10 Results Evaluation of up-to-date vaccination status among military beneficiary children CDC-recommended preschool vaccine schedule defined as: 4 doses DTaP, 3 doses IPV, 1 dose MMR, 3 doses Hib, 3 doses HepB, 1 dose VAR, 4 doses PCV, 2 doses HepA California state preschool vaccine schedule defined as: 4 doses DTaP, 3 doses IPV, 2 doses MMR, 3 doses HepB, 1 dose VAR

11 Results Less then 40% of children appeared up-to-date on the full CDCrecommended vaccine schedule in either system, but the military EHR appeared to capture this status better than SDIR In contrast, SDIR appeared to capture up-to-date status for the California-required vaccine schedule much better than the military EHR Among children represented in both the military EHR and SDIR, virtual merging of systems revealed that more than 57% were upto-date on the full CDC-recommended vaccine schedule and more than 90% were up-to-date on the California-required vaccine schedule

12 Discussion More than 92% of military children in San Diego County had records in the military EHR, but less than 44% of these children were represented in SDIR Under-representation in state and county tracking systems may be reflective of frequent moves by military families

13 Discussion Virtual merging of systems revealed that neither the military EHR nor SDIR completely captured immunization data for a cohort of children that appeared, overall, up-to-date on vaccinations Note that data merging rules were conservative in this analysis, such that up-to-date percentages may be even greater than reported here Incomplete capture of immunizations in the military EHR and/or other systems may have contributed to low estimates of immunization coverage in previous studies of military children (Dunn, et al. Pediatrics 2015)

14 Discussion The importance of data linking between immunization information systems is increasingly recognized as critical to public health (Fuller, et al. Matern Child Health J. 2017) Bidirectional movement of data must be assured between state/ county systems and clinical care systems (Murthy et al. MMWR. 2017) Barriers to information exchange, including regulatory diversity, must be overcome to assure complete capture of immunization data (Martin, et al. J Public Health Manag Pract. 2015) Complete capture of immunization data is vital to best practices in clinical care of children

15 Conclusion For this population of school-aged children, neither electronic health records nor a county immunization registry completely captured immunization data. However, when systems were virtually merged, a remarkably higher proportion of children were confirmed as having up-to-date immunizations. This project underscores the important potential of merging systems to capture complete immunization information.

16 References Dunn AC, Black CL, Arnold J, Brodine S, Waalen J, Binkin N. Childhood vaccination coverage rates among military dependents in the United States. Pediatrics. 2015;135(5):e Fuller JE, Walter EB Jr, Dole N, et al. State-Level Immunization Information Systems: Potential for Childhood Immunization Data Linkages. Matern Child Health J. 2017;21(1): Murthy N, Rodgers L, Pabst L, Fiebelkorn AP, Ng T. Progress in Childhood Vaccination Data in Immunization Information Systems - United States, MMWR. 2017;66(43): Martin DW, Lowery NE, Brand B, Gold R, Horlick G. Immunization information systems: a decade of progress in law and policy. J Public Health Manag Pract. 2015;21(3):

17 Project Team Margaret Ryan, MD, MPH Laurie Duran, MSN, CRNP Matthew Humphreys, MD, MPH Eric McDonald, MD, MPH DHA Immunization Healthcare Branch Pacific Region Office and San Diego County Department of Health

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