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

Background on
Immunization Registries
• 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

Background on Immunization Registries
• 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 IR
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 HEALTH
OFFICIALS

 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 of
11/30/05)
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
Current Status of HHCIR
273
107
73
0
100
200
300
2003 2004 2005 (as of
9/30/05)
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 Houston
Clinics
Private
Providers (large
and small)
School districts
(read-only)
Support Users
Registr
y
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
resources
A 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

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

Messaging and data exchange
Data Flow Diagram
HHCIRWeb1
City of Houston
HL7
Communication Platform
EMR PMS
HTTPS
Master Patient Index
Id1
Id2
Id3
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
Id1
Id2
Id3
IdN
Id4
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.

Informatics Assessment of an Immunization registry

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