Immunization Information Systems

Script

Monday, November 13, 2023

**Slide 1 -- Title Screen**

Welcome to "Immunization Information Systems: What Every Program Manager
Should Know," an education module developed in partnership with CDC's
National Center for Immunization and Respiratory Diseases, States, the
Association of Immunization Managers, the American Immunization Registry
Association, and Every Child by Two.

**Slide 2 -- Need For This Module**

This module was developed to address the educational needs of both the
IIS and immunization communities. Education efforts to date have been
primarily focused on specific IIS topics, such as data quality and
provider participation; however, there exists no introductory IIS
education for the IIS community, immunization programs or their
partners.

Regular staff turnover at the local and state levels can interrupt
quality of services delivered by the IIS and Immunization Programs. As
the IIS community continues to grow and expand its linkages with various
partners, the need to provide basic training on how IIS functions has
never been more relevant.

**Slide 3 -- Learning Objectives**

Learning objectives for this session are:

1\. Describe what immunization information systems (IIS) are

2\. Describe the benefits of IIS

3\. Describe basic functions of IIS, and

4\. Describe how IIS can be used to support immunization and other
programs' activities

**Slide 4 -- Continuing Education Credit**

Please make a note of the following information. Continuing education
credit is available only through the CDC/ATSDR Training and Continuing
Education Online System at www.cdc.gov/TCEOnline/.

You must have a verification code specific to this program to apply for
CE credit. The code will be revealed during the course of the program.
CE credit for this activity will expire on [Change Me]{.mark}, 2007.

**Slide 5 -- Financial Interest Disclosure**

CDC, our planners and our presenters wish to disclose that they have no
financial interests or other relationships with the manufacturers of
commercial products, suppliers of commercial services or commercial
supporters.

**Slide 6 - Unlabeled/Unlicensed Use Disclosure**

Presentations will not include any discussion of the unlabeled use of a
product or a product under investigational use.

So now we will begin with a presentation.

**Slide 7 - Chaptering Slide**

This presentation will be segmented into the following topic areas. You
may pause this presentation by \_\_\_\_\_\_\_\_\_\_\_\_\_\_ at any time
and continue at a later time.

The topics that will be covered in this module are:

What are IIS?

IIS Benefits

Laws, Policies and IIS

History of IIS

Participation in IIS

How IIS Work

Guiding Documents for IIS

IIS Functional Standards

IIS Data Use

Future of IIS

Additional Resources

**Slide 8 - Chapter 1 Slide**

**What Are IIS?**

**Slide 9 - What are Immunization Information Systems (IIS)?**

Immunization information systems, or IIS, are population-based,
confidential, population-based, computerized information systems that
collect and consolidate vaccination-related data from multiple
healthcare providers.

A population-based IIS creates a record for every child born in its
coverage area at birth, often through a linkage with the state's
electronic birth records system. Immunization data sources include
electronic birth records, immunization providers, and other computerized
health information systems. The IIS then merges the data into a single
record for each patient in its system.

They can generate reminder and recall notifications and provide data
that can be used to assess vaccination coverage for a provider or within
a defined geographic area.  Initially IIS focused efforts on the child
population. Now, most IIS capture vaccination-related data on children,
adolescents and adults.

**Slide 10 -- Main Elements of IIS (Graphic)**

This graphic illustrates the major elements of an IIS:

We'll briefly discuss each of these elements, starting from the top
right-hand corner of this graphic.

-   Consolidated Records: IIS combine immunization information from
    different sources into a single record and provide official
    immunization records for school, day dare, and camp entry
    requirements.

-   Privacy and Confidentiality: IIS protect the privacy of all users,
    including children, families, and providers. They take measures to
    ensure that only those who are authorized to do so have access to
    IIS information.

-   Timely Immunization: IIS remind families and health care providers
    when an immunization is due or has been missed.

-   Clinical Decision Support: IIS recommend what vaccinations are
    appropriate based on a child's immunization history.

-   Data Exchange: IIS can exchange immunization information with health
    plans, hospitals, and providers. Data exchange between IIS and other
    electronic systems contributes to more complete immunization records
    in IIS. This helps ensure that IIS and other systems make accurate
    recommendations, that children get only the vaccinations they need,
    and that immunization providers can work more efficiently.

-   Program Support: IIS help state and local immunization programs
    identify populations at high risk for vaccine-preventable diseases,
    detect under-immunized populations, and target interventions and
    resources efficiently during outbreaks.

**Slide 11 -- Other IIS Capabilities**

While these aspects are key elements of IIS, they can offer additional
functions such as but not limited to:

-   The capacity to integrate with other electronic health information
    systems (e.g., newborn and lead screening, Women Infant and Children
    Program (WIC), Medicaid, office billing systems and electronic
    medical records)

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-   Help immunization programs and providers maintain accurate inventory
    counts of vaccine used, on hand and on order as well as Allow
    expeditious tracking of vaccines in case of vaccine shortages on
    vaccine manufacturer recalls

-   Forecast or recommend next appropriate vaccination(s) due, specific
    to each patient based on current ACIP recommendations, health
    history, and personal vaccine history.

-   Capture vaccination-related information for diseases such as
    smallpox and reported aggregate flu shot doses in the event of a
    public health emergency or pandemic flu.

**Slide 12 -- IIS Funding Sources**

Most IIS have been developed by public health departments at the state
or local level. They obtain financial support for their development
primarily from federal and state funding sources.

The largest source of federal grant funds for IIS is section 317(b) of
the Public Health Service Act; this is also the primary source of
funding for the 64 public health immunization programs' across the US.
The amount of funds available to these grantees through this grant for
IIS development and maintenance, program operations, and vaccine
purchases varies depending upon the annual amount appropriated by
Congress.

In addition to the section 317 Grant, funds from the Vaccines for
Children (or VFC) program may be used for IIS development and
maintenance to support the activities of the VFC program, such as:
vaccine accountability and management, VFC eligibility, VFC vaccine
distribution, and doses administered data.

Private sources, state and local funding may also be available to
grantees to support IIS activities. Examples of private sources include
private foundations, health plans, service clubs (Kiwanis and Rotary),
local and state immunization coalitions, state legislature, and State
Tobacco Dollars. Efforts to obtain such funds are the responsibility of
each immunization program and/or IIS. Health Resources and Services
Administration (HRSA) funding can be used in some instances for
integration of IIS with newborn screening.  Maternal and Child Health
block grant funds can be used in some instances\-\--e.g. for recall
efforts.

Also, the Centers for Medicare and Medicaid Services (CMS) provides
matching funds to states developing and maintaining IIS in collaboration
with Medicaid Management Information Systems (MMIS) in state Medicaid
programs.

**Slide 13 - IIS Stakeholders**

For IIS to be effective in addressing and meeting all immunization needs
and concerns, the input and support of partners and stakeholders is
required. These are persons or organizations who share an interest in
improving immunization services, increasing immunization coverage, and
reducing the incidence of vaccine-preventable diseases.

Examples of IIS partners are:

-   Public Health Agencies such as State Immunization Programs and the
    Indian Health Service, Medicaid/Medicare

-   Local, state and national health care providers such as
    Pediatricians, Family Physicians, Internists, OB/GYNs, Nurse
    Practitioners, Physician Assistants

-   Childcare facilities, schools, and universities

-   Private and Public Health plans

-   Vendors of clinical management or medical billing software

-   National Professional organizations: Every Child By Two, American
    Immunization Registry Association, Public Health Informatics
    Institute, Immunization Action Coalition, National Vaccine Advisory
    Committee, Association of Immunization Managers, American Academy of
    Pediatrics.

-   Regional Health Information Exchange Organizations

**Slide 14 - Chapter Slide**

**IIS Benefits**

**Slide 15 - IIS Benefit to Immunization Programs**

Immunization Programs receive significant benefit from the use of an
IIS. Aside from the obvious benefit of being able to retrieve
"real-time" immunization data for clients, immunization programs can
utilize IIS data to:

-   track and evaluate trends in coverage levels at the provider, local
    health department, county, and state levels.

-   monitor outbreaks and disease coverage levels.

-   monitor VFC vaccine usage and provider compliance, generate IIS
    reports to verify the usage of specific VFC vaccines while
    monitoring adherence to VFC guidelines and policies.

-   estimate adherence to a vaccine or adoption of a new vaccine in a
    given area.

**Slide 16 - IIS Benefits to Parents & Community**

IIS also offer many benefits to parents and the community. They:

-   Help prevent disease outbreaks by tracking and ensuring that all
    residents are up-to-date on immunizations.

-   Keep records safe in natural disasters such as hurricanes and
    wildfires.

-   Ensure children don\'t miss any shots or get too many shots

-   Remind parents by mail or telephone when their child need shots

-   Help determine pockets of need in a community.

-   Use mapping capabilities to determine where new clinics and provider
    offices need to be placed.

-   Maintain records of children in foster care so they can make the
    transitions into school much faster.

**Slide 17 - IIS Benefits to Providers**

IIS can offer many benefits to clinicians as well.  Using IIS can help
practices be more efficient by streamlining the immunization
administration process, saving staff time and office work flow. Some of
the major benefits of provider participation in IIS include:

-   consolidating the immunization information from patients' previous
    providers into one single centralized record.

-   instantly calculating which vaccines need to be given to patients in
    accordance with the latest ACIP vaccine recommendations and
    intervals.

-   automatically generating reminder and recall postcards and/or
    mailing labels to send out to parents to remind them when their
    child's immunizations are due or have been missed. 

-   decreasing time spent by your office staff seeking immunization
    histories from previous providers. Lists can also be generated to
    expedite school enrollment and eliminate individual calls from
    school personnel. 

-   And many more.

**Slide 18- IIS Benefits to Health Plans**

Many health plans use the performance measures from the Health Plan
Employer Data and Information Set (HEDIS) to illustrate the quality of
care they deliver. The measures in HEDIS reflect significant public
health issues such as immunization, cancer, smoking, heart disease, and
diabetes. This saves health plans time and resources that would
otherwise be needed to evaluate medical records to assess immunization
rates. HEDIS, without the benefit of IIS data, creates a financial
burden for the health plan and greatly inconveniences the provider by
having a record review conducted at the provider site.

**Slide -- 19 Chapter Slide**

**Laws, Policies and IIS**

**Slide 20 - Privacy and Confidentiality in IIS**

IIS are subject to laws, regulations and policies that maintain the
privacy and confidentiality of information in the IIS.  Privacy is the
legal right of a person to limit access to information about that
person. Confidentiality is the treatment of information that has been
disclosed in a trusted relationship in a manner consistent with the
understanding made at the time of the disclosure.  Both privacy and
confidentiality of the information in an IIS are governed by state and
federal laws and IIS policies.

**Slide 21 - State Laws Affecting IIS**

State law and policy govern many aspects of IIS operations.  Some states
laws allow the IIS to collect information only for children up to a
stated age.  Other states allow the IIS to collect data for all
ages\-\--this is called a life-long IIS.  Some states have laws that
mandate health care providers to report immunization information to the
IIS.  Individuals (or parents) can protect the privacy of their
immunization information by choosing whether to have their immunization
information in the IIS.   State law determines if that consent must be
obtained explicitly before putting information in the IIS (this is
called Opt-in), or if the information will go into the IIS unless the
individual acts to exclude it (this is called Opt-out).   

State laws and policies protect the confidentiality of information in an
IIS through specifying the persons and entities that can disclose
information to and access information in the IIS.  In addition, many
states have broader privacy laws that address sharing of immunization
and other health care information. States may also have specific laws
that deal with the privacy and confidentiality of other health care
information held by public entities that may be integrated with an IIS.
For example, most states have regulations about the use of vital
statistics information that may be used to populate the IIS.

Other state laws that may affect IIS operations are the state
immunization requirements for daycare, school and higher education. 
Many states allow exemptions from these requirements for medical or
philosophical reasons.

**Slide 22 - Federal Laws Affecting IIS**

Title II of the United States Health Insurance Portability and
Accountability Act of 1996 (HIPAA) deals with the standardization of
healthcare-related information systems. The Privacy Rule under HIPAA
governs the use and disclosure of protected health information by
"covered entities".  Health care providers, health plans and health care
clearinghouses are covered entities.   The Security Rule under HIPAA
governs the way that covered entities ensure that the electronic data
remain private and confidential.  Since most IIS do not perform
functions that make them a "covered entity" (e.g. direct service
payments), they are not required to comply with HIPAA.  Even though most
IIS are not governed by HIPAA, maintaining the privacy and security of
immunization data has been and continues to be a major priority of IIS
and public health personnel nationwide. 

The Community Immunization Registries Manual that is available on the
NCIRD website provides recommendations for minimum standards to protect
privacy and confidentiality.  To meet these minimum standards, each IIS
should have a written policy that addresses the following issues.  Each
IIS must clearly define who has access to IIS information, what
constitutes a breach of confidentiality, and what the associated
penalties are.  

The Family Educational Rights and Privacy Act (FERPA) is a federal law
that protects the privacy of student education records. The law applies
to all schools that receive federal funds under an applicable program of
the U.S. Department of Education and gives parents certain rights with
respect to their children\'s education records.   Generally, schools
must have written permission from the parent or eligible student to
release any information from a student\'s education record, including
immunization data.

**Slide 23 - Chapter Slide**

**History of IIS**

**Slide 24 - IIS Development**

Immunization Information Systems have been in development for some time.
Even though practice- or facility-based immunization registries were
under development in the 1980s, it was not until the early 1990s that
national leaders promoted population-based IIS as important tools for
ensuring appropriate immunization of children.

The Robert Wood Johnson Foundation first supported the development of
population-based IIS in 1992 with the initiation of the All Kids Count
program. As part of this program, two rounds of grants (Phase I, 1992
through 1997, and Phase II, 1998 through 2000) totaling more than \$20
million, were competitively awarded to a total of 26 state and local
health departments to develop and implement immunization registries for
preschool children in their target areas. These funds supplemented those
received from other sources, including federal immunization grants from
the CDC." The map represents the first few IIS developed in the United
States.

Since 1994 CDC has allocated funds to its immunization grantees for the
development and implementation of IIS under section 317(b) of the Public
Health Service Act. Currently 56 IIS are operational or in development
in all states and major cities in the US. In addition IIS are being
developed in 8 US territories. The territories are: American Samoa,
Federated States of Micronesia (FSM), Guam, Republic of Marshall
Islands, Commonwealth of the Northern Mariana Islands (CNMI), Palau,
Puerto Rico, and Virgin Islands. Each project is responsible for
designing, implementing, and maintaining their own IIS; there is no IIS
at the federal level.

**Slide -- 25 Chapter Slide**

**Participation in IIS**

**Slide 26 -- Child Participation (Graphic)**

This map displays preliminary data on levels of child participation in
IIS as of December 31, 2007.

In 2007 of approximately 23.3 million U.S. children aged \<6 years, an
estimated 16.5 million (71%) participated in grantee IIS. Fifteen (27%)
IIS grantees (Alabama, Arizona, Arkansas, Delaware, District of Columbia
(DC), Georgia, Louisiana, Michigan, Mississippi, New York City, North
Dakota, Oregon, Philadelphia, South Dakota, and Wisconsin) had \>95% of
children aged \<6 years participating in IIS. Fourteen (25%) other IIS
grantees (Colorado, Idaho, Illinois, Iowa, Minnesota, Montana, New
Mexico, North Carolina, Oklahoma, Rhode Island, Texas, Utah, Washington,
and West Virginia) had participation ranging from 81% to 94%.

In addition to these 56 grantees, 8 U.S. Territories and U.S.-Affiliated
Pacific Islands received 317b funding for developing and maintaining
IIS. They include American Samoa, FSM, Guam, RMI, CNMI, Palau, Puerto
Rico, and Virgin Islands. Territories data are reported separately and
are not included in the cumulative data reported for the 56 grantees for
comparison purposes.

In addition to IIS participation of children under the age of six, many
IIS are capable of capturing immunization-related data for adolescents
and adults. In 2007, forty-nine (88%) grantee IIS collected and stored
adolescent immunization data. Forty-three (77%) grantee IIS are lifespan
systems that collect and store immunization data from birth to death.
Approximately 21.6 million (40%) 11-18 year olds have two or more
immunizations and 45.8 million (23%) adults 19 and older have at least
one immunization recorded in IIS.

**Slide 27 - Provider Participation: Key to IIS Success**

IIS most valuable resource is its providers. Ensuring provider
participation in IIS is critical to attaining complete and accurate
electronic immunization records. However, many IIS struggle to recruit
and retain providers, especially private providers. Therefore,
cultivating and maintaining partnerships and improving provider
participation are key to IIS development and enhancement.

Negative perceptions of the IIS are a major barrier to participation.
Some of these perceptions and other barriers include:

1)  Participation requires too much cost and staff time.

2)  Practices have their own system for recording and monitoring
    immunizations.

3)  The IIS' technology is not compatible with the practice's existing
    office computers, automated data entry.

4)  Limited on-site technical assistance from IIS staff.

5)  The IIS will not keep information confidential.

6)  Some state medical or specialty societies do not support the IIS.

7)  Lack of support from the practice\'s nursing or administrative
    staff.

**Slide 28 - Chapter Slide**

**How IIS Work**

**Slide 29- Shot of IIS Record**

There are three major components of an IIS record: general information,
immunization status/immunization forecasting, and immunization history.
The exact information contained on the general information, immunization
status/immunization forecasting, and immunization history sections of an
IIS record may vary from state-to-state depending on the state's
required reporting mandates and confidentiality guidelines.

General Information included in an IIS record might include: the
client's name; nicknames or aliases; suffix (i.e.; Jr., Sr., II, III);
date of birth; gender; mother's maiden name; multiple birth status
(i.e.; twins, triplets); responsible party information and mailing
address.

**Slide 30- Shot of IIS Record**

The Immunization Status and Immunization Forecasting in an IIS record
provides the viewer with a current immunization status for the client:
when they are due for shots, overdue for shots, or whether they are
currently up-to-date on their immunizations. This screen may also
provide "forecasting" information concerning when the next doses of
required vaccines are considered due and/or overdue.

**Slide 31- Shot of IIS Record**

The Immunization History screen displays immunizations that have been
added to the client's IIS record. Along with being able to view specific
shot dates, you may also be able to view the specific antigen or vaccine
type administered; the vaccine manufacturer and lot number; the site on
the body where the shot was administered (i.e.; left thigh or right
arm); the method by which the vaccine was administered (i.e.; oral,
subcutaneous, intranasal, or intramuscular); the dose amount; the
administering physician, medical practice and/or nurse's name; and the
Vaccine Information Statement date.

**Slide 32- Sources of IIS Data**

In a population-based IIS, children are entered into the IIS at birth,
often through a linkage with state vital records systems. An IIS record
also can be initiated by a health care provider at the time of a
child\'s first immunization. Other sources of IIS data include:
electronic health records and Medicaid and insurance claims or billing
systems.

**Slide 33- Information in IIS**

The core IIS data elements are recommended by the National Vaccine
Advisory Committee (NVAC), and have been incorporated into CDC's plans
for IIS. The purpose of the core data set is two fold. First, these
elements represent fundamental attributes necessary for identifying
individuals and for describing immunization events. Second, they
facilitate record exchange between immunization information systems.

The core data elements fall into two categories: required and optional.
Required core data elements are listed in bold print. Required elements
are: patient name (first, middle, and last); patient birth date; patient
sex; patient birth order; patient race and ethnicity; patient birth
state/country; mother\'s name (first, middle, and last); the type(s) and
date(s) of vaccines given, address, phone number; and the date the shot
was given. A full list of these elements can be found on the CDC
website.

**Slide 34 - Chapter Slide**

**Guiding Documents for IIS**

**Slide 35- Guiding Documents for IIS**

There are five main documents that guide the development, implementation
and evaluation of federally funded IIS.

First, the 2008-2012 Immunization Program Operations Manual (IPOM) is
used by immunization programs and their staff in implementing
comprehensive immunization activities and serves as a guidance document
for developing objectives, activities, and evaluation measures that
maximize immunization program effectiveness. Most chapters have
integrated the use of IIS in every day immunization program activities.
You can access the consolidated list of IIS-related IPOM required and
recommended activities on the CDC website. Grantees can use this table
as a benchmark guide for future IIS program planning and enhancements to
their IIS activities.

Second, in 2001, NCIRD developed a 3-5 year strategic plan to ensure
reaching the national health objective for IIS -- to increase to 95% the
proportion of children (ages 0 - \<6 years) participating in a fully
operational, population-based IIS by 2010. The plan is broad in scope
and outlines all national activities required to meet the IIS objective,
many of the identified activities would be applicable to the state and
local levels. The plan can be found on the CDC website.

**Slide 36- Guiding Documents for IIS**

Third, in 2006, a detailed IIS business plan was required from IIS
requesting funds exceeding \$100,000. The IIS business plans summarize
the operational and financial objectives of an immunization program and
details activities and budgets, indicate how objectives should be
achieved. The Plan was designed to assist grantees in planning,
developing, and implementing IIS activities throughout the project
lifecycle.

Fourth, authorized under Section 317 of the Public Health Service Act,
federal funding for the 317 grant program was launched in 1963.
Forty-two years later, in 2005, CDC awarded \$431 million in federal
grants. The program helps assure the implementation of effective
immunization practices and proper use of vaccines to achieve high
immunization coverage, and it supports infrastructure for essential
activities such as IIS, outreach, disease surveillance, outbreak
control, education, and service delivery.

Fifth, all IIS are required to be compliant with the Public Health
Information Network (PHIN) standards. PHIN is a national initiative to
improve the capacity of public health to use and exchange information
electronically by promoting the use of standards and defining technical
requirements. CDC serves as the facilitator of the PHIN community and
the steward for PHIN resources.

**Slide -- 37 Chapter Slide**

**IIS Functional Standards**

**Slide 38- Functional Standards**

In 2001, NCIRD recommended minimum technical functions for IIS. These
standards were identified as the technical functions that \"at a
minimum, state- and community-based immunization registries must\"
implement. They are:

1)  Electronically store data on all NVAC-approved core data elements

2)  Establish a IIS record within 6 weeks of birth for each newborn
    child born in the catchment area

3)  Enable access to and retrieval of immunization information in the
    IIS at the time of encounter

4)  Receive and process immunization information *within 1 month* of
    vaccine administration

5)  Protect the confidentiality of health care information

6)  Ensure security of health care information

7)  Exchange immunization records using Health Level Seven (HL7)
    standards

**Slide 39- Functional Standards continued**

7)  Exchange immunization records using Health Level Seven (HL7)
    standards

8)  Automatically determine the routine childhood immunization(s)
    needed, in compliance with current ACIP recommendations, when an
    individual presents for a scheduled immunization

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

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

11) Produce official immunization records

12) Promote accuracy and completeness of IIS data

Detailed information on the minimum functional standards can be found at
on the CDC website.

**Slide 40- Forecasting**

One of the greatest benefits of an IIS, aside from having all
immunization information for a patient available in one spot, is its
ability to recommend future vaccines based upon the age of the patient
based on the Advisory Committee on Immunization Practices (ACIP)
schedule and what immunizations the patient has already received, and to
determine what vaccines they may need and when. This feature is often
called the IIS "forecasting algorithm" or forecaster, although it may
also be called a vaccine scheduler, immunization recommendation, or
immunization decision support.

While this is the greatest benefit of most IIS, the forecasting
algorithm is also the most complex part. It is generally very difficult
to create and maintain, especially when new vaccines are added or one
vaccine is recommended at different ages or different intervals based
upon age, or, in the case of the HPV vaccine, by gender!

To complicate matters, there is no federal or national standard for
forecasting algorithms nor a code set that are available to IIS,
although this has been expressed as a need by many states.

**Slide 41- Forecasting screen shot**

This is one example of a vaccine forecaster. You'll see all of the
immunizations currently recorded on the patient's record based upon the
patient's age and what he's been given, the recommendations at the
bottom reflect the immunizations he is currently due for. This
particular example is highlighting the HepB and Hib components because
the patient has been given Comvax, to alert the clinician to pay close
attention to the recommended dates.

**Slide 42- Reminder-Recall**

Another IIS function that benefits providers is the reminder-recall
system. Immunization reminder/recall systems are cost-effective methods
whereby children in need of vaccination are identified and contacted to
come to the physician's office. Reminder systems track future
appointments, whereas recall systems track missed appointments during
which immunizations would have been given. Combining reminder and recall
systems is a powerful method for ensuring appropriate and timely
immunizations. By utilizing these systems, physicians can increase
vaccination rates and promote other important clinical services, such as
lead and vision screening.

**Slide 43- Reminder Recall card screen shot**

A recent review of the literature showed that patient reminder systems
were found to be effective in improving immunization rates in 80% of 41
studies, irrespective of the baseline immunization rates, patient age,
setting, or vaccination type. Increases in immunization rates due to
reminders ranged from 5 to 20 percentage points. Reminders were
effective for childhood vaccinations, childhood influenza vaccinations,
adult pneumococcus or tetanus vaccinations and adult influenza
vaccinations. All types of reminders were effective (postcards, letters,
and telephones or auto dialer calls) with telephone reminders being the
most effective and costly.

**Slide 44- Data Quality**

Nothing diminishes a provider's confidence in IIS if data are not
correct. High quality data are accurate, timely, meaningful, and
complete. In IIS, data quality refers to focusing on the data coming in
to the IIS, and the checks and mechanisms in place to ensure that only
valid data gets in. At the simplest, it can be ensuring that the birth
date on an incoming record matches the existing record; if there are
discrepancies, then the IIS can handle them. More complex are
vaccine-specific checks such as a record shouldn't have more than 7
DTAP, or should not show PCV7 administered after age 5.

Data quality assurance (DQA) is used to verify the reliability and
effectiveness of data. Maintaining data quality requires going through
the data periodically and cleaning it. Typically this involves updating,
standardizing, and de-duplicating records to create a single view of the
data, even if it is stored in multiple disparate systems.

IIS have various mechanisms in place to ensure that the data are
accurate, complete, and timely and of high quality. The next few slides
will describe how IIS are working to maintain and improve high data
quality standards.

**Slide 45- Patient-level De-duplication**

The status of a patient is very important for clinical follow-up and
outreach; for the IIS to be able to run reminder or recall notices; and
for coverage assessments. Providers usually want to monitor coverage
level for those patients who are active to them.

Patient de-duplication is the process of identifying possible duplicates
in a system and preventing additional duplicates from being added, and
preventing two records that truly are unique, from being merged into
one. For instance, let's say there are two distinct patients both named
John Brown, one born on 2/14/1980 and the other born on 2/24/1980. The
IIS needs have mechanisms so that the records are accurate and remain as
two separate records.

Additional identifying information can be used to de-duplicate, the most
important being first name, middle name, last name and birth date.
Mother's maiden name and mother's first name are commonly used, along
with address, gender, race, birth order, social security number, drivers
license number and other numeric identifiers.

**Slide 46- Moved or gone elsewhere (MOGE)**

The Moved or Gone Elsewhere (MOGE) status and the other associated
patient status indicators are important in determining coverage
assessment and in determining which patients receive information for
reminder and recall procedures. The overall goal is that the integrity
of the information contained in IIS regarding MOGE and other patient
status will be consistent and comparable between and within state and
local operations.

Inappropriate classification of MOGE or other status may result in
inflated or under-inflated coverage assessments. The inconsistent
definitions among various immunization information systems will result
in poor data comparability and other data quality measures.

In 2005, the American Immunization IIS Association's MIROW group
compiled a document outlining the importance of MOGE and how IIS should
handle patient status. For more information on MOGE go to the American
Immunization Registry Association's website.

**Slide 47- Vaccine-level De-duplication**

Just as duplicate patients are a data quality concern, so are duplicate
vaccines. IIS are likely to receive data from several sources (*e.g.*,
the physician, the insurance billing system) sometimes resulting in a
patient having more than 1 vaccination record for a single vaccination
event. It is common for an IIS to receive different and sometimes
conflicting information on a vaccination event. Information for a
patient on two HIB vaccines may be reported on the same day or close to
the same day.

The decisions made during vaccination level de-duplication affect the
forecasting of vaccine administration according to ACIP recommendations.
It is important that input into the vaccine forecasting tool is an
accurately recorded immunization history, so that correct and clinically
meaningful immunization decisions can be made. Additionally, complete
and accurate information on the vaccination history of the patient is
essential for providers and analysts, so that accurate and up-to-date
vaccination history records can be produced.

For more information on vaccine-level de-duplication go to the American
Immunization Registry Association's website.

**Slide 48- Data Exchange**

While IIS try to make data entry as quick and easy as possible, it still
takes time. Therefore, IIS have developed methods of acquiring
immunization data through means other than direct data entry.

IIS can acquire data through an interface with another electronic
system, such as an insurance billing system or electronic medical
record. Importing and exporting data from another system to and from the
IIS can be done through various methods. Some examples are:

-   Encrypted e-mail

-   Secure File Transfer Protocol (FTP): A method to send and receive
    data over the internet securely

-   Https: Protocol enabling the secured transmission of Web pages

-   Health Level 7 (HL7): a common data exchange standard required by
    CDC for all IIS

The CDC HL7 implementation guide is available to IIS on the CDC website.

**Slide 49 - Chapter Slide**

**IIS Data Use**

**Slide 50-List of most commonly used IIS-generated reports**

Both immunization programs and providers have the ability to run reports
using IIS data. The type of reports run by each depends on the
robustness of their reporting module of the IIS. The following list
contains examples of most commonly used reports run by IIS users.

-   Reminder/recall reports. Generated to identify patients who are
    behind on shots (recall) or will be due for shots (reminder).

-   Vaccine usage. Lists patients, shots given, VFC status, etc., for a
    particular time frame. Can include detail or summary reports.

-   Coverage levels. These can be up-to-date reports by antigen or by
    combination.

-   Shows patients who received invalid doses due to interval or age
    constraints, extra immunizations, or age-inappropriate vaccines.

-   Monthly Doses Administered

-   Provider Profile Data Report

-   Profile Reports

-   Monthly Biologics and Ending Inventory Reports

**Slide 51- IIS Data use by immunization programs**

Immunization programs gain substantial benefit through the use of IIS
data. The information contained in an IIS can be used to help pinpoint
and prioritize immunization program objectives, define specific
program-related activities, measure program deliverables, and aid in
evaluating an immunization program's progress.

The data collected by IIS can also help manage vaccine inventory by
monitoring supply and demand, vaccine shortages and depicting trends in
new vaccine uptake and usage.

IIS data can also be used to perform quality improvement measures
through the use of integrated programs such as the Comprehensive Clinic
Assessment Software Application (CoCASA), which helps evaluate and
assess individual immunization practices' vaccine usage.

**Slide 52- IIS Data use by other health programs**

Other Health programs can also utilize the data collected in an IIS for
the evaluation and study of disease surveillance, making it possible to
more accurately monitor disease outbreaks and pinpoint trends associated
to these outbreaks: ethnicity, location, prior vaccine coverage levels,
under immunized communities, etc.

IIS data can help compare infection rates before and after new vaccine
implementation and monitor the adherence to new vaccine recommendations.

In the event of a natural or man-made disaster, such as Hurricane
Katrina, IIS can even provide reliable documentation for a person's
immunization history which would otherwise be lost.

**Slide 53- IIS Data use by healthcare providers**

Immunization information systems can offer many benefits to physicians.
As health care providers, they are in charge of making certain that all
of their patients receive quality care; however, the ever growing
complexity of the recommended schedule has made it increasing difficult
to determine which vaccines are required for patients at each visit.

The vaccine forecasting function of an IIS can instantly calculate which
vaccines need to be given to patients at each visit in accordance with
the latest ACIP vaccine recommendations and interval, thereby avoiding
over-and under-immunization. Vaccine forecasting is particularly useful
when parents do not bring their children's immunization records, making
it difficult for providers to determine which vaccines the children have
already received. Without official documentation, physicians are
required to vaccinate the child again to ensure they are protected
against disease.

IIS also have the ability to create lists of patients who are due for
vaccines on particular days or need to be brought back into the office
during a vaccine recall, shortage or incorrectly stored vaccine.

**Slide 54- Examples of how IIS have been used in various capacities**

In a recent CDC IIS Pandemic Flu Preparedness survey, 71% of responding
grantees stated that they have the regulatory authority or legal
authority to collect vaccine doses for *[all ages]{.underline}*; and 83%
of the respondents indicated that they would use their IIS for the
collection of vaccine doses for pandemic flu. Hurricane Katrina
disrupted and displaced more than 200,000 people who lost everything
including immunization records;

Healthcare providers for the displaced children found more than 56,000
immunization histories in the Louisiana IIS saving millions of dollars
in revaccination costs.

**Slide 55 - Chapter Slide**

**IIS Linkages**

**Slide 56- Data use through Linkages**

Through the exchange and linkage of multiple data sources with an IIS,
health information can be compiled and retrievable through a united data
source.

School and childcare centers can link with IIS to help streamline their
required immunization assessment and reporting processes. Through the
use of an IIS, these facilities can alleviate the task of verifying each
individual student's immunization record.

For parents, the IIS record can be used as an official immunization
required for school, daycare or camp attendance; and parents no longer
have to worry about personally tracking their child's immunization
history.

Providers benefit from data linkage by being able to view a complete
immunization history for their client, when shots may have been provided
at multiple medical offices. Because of the increase of data available
through data sharing and linkage, IIS increase the quality and accuracy
of their data and reduce the number of clients receiving unnecessary
vaccinations.

Aside from immunizations, other pieces of information that can be linked
through an IIS include, but are not limited to: Influenza high-risk
indicators, newborn and lead screening results, WIC and Medicaid
populations, and Perinatal Hepatitis B data. Data sharing and linking
also plays a vital role for Health Plans. Data contained in an IIS can
facilitate health plans in increasing HEDIS measures, reducing the
number of manual chart pulls they must perform, and improving the
quality of care and service delivered by their medical providers.

**Slide 57- IIS and Vaccine Management**

Along with retaining a client's immunization history, an IIS can provide
tools for vaccine accountability. By documenting required pieces of
immunization-related information in to an IIS (i.e.; manufacturer, lot
number, antigen, expiration date), IIS can track the number of vaccines
administered by a medical practice within a given timeframe; indicate
the quantity of vaccine currently on hand for a provider and establish a
cost analysis for those vaccines; track recalled vaccine lots, and
pinpoint individuals who require revaccination; and make notations
regarding any damaged or wasted vaccine.

Additionally, new advancements in IIS are now making it possible for
immunization providers to order vaccines through their IIS system. With
this new ordering capability, immunization programs have the ability to
monitor vaccine usage and storage, and trends in vaccine usage, and
adherence to VFC guidelines.

**Slide 58- Other types of health information systems**

Other types of health information systems with similar partnerships
exist, such as cancer registries. In each state, medical facilities
report these data to a central cancer IIS, and these data systems
collect, manage, and analyze data about cancer cases and cancer deaths.
States also operate Early Hearing Detection and Intervention tracking
and surveillance systems to help make sure that infants and children
with hearing loss are found and receive the hearing screening,
follow-up, and early intervention services they need. Linking with such
system can be an asset to IIS.

**Slide -- 59 Chapter Slide**

**Future of IIS**

**Slide 60- Future of IIS**

Since section 317 funding was first made available to IIS in 1996 (?),
IIS have grown considerably and immunization programs, providers,
patients, and parents have come to rely on them for their data and
services. Although they have made tremendous strides, IIS still have yet
to meet the program goal of 95% participation of all U.S. children under
six years of age in IIS by 2010. In order to help IIS meet this goal,
NCIRD will be working at the national level over the next several years
to:

-   Promote IIS data use to support immunization program activities.

-   Promote IIS data use by partners and stakeholders

-   Promote linkages with other health systems

-   Conduct independent objective analyses of IIS operations and select
    data quality measures.

-   Continue efforts to improve IIS accountability and performance
    measurement.

-   Implement and maintain IIS in accordance with the National Vaccine
    Advisory Committee (NVAC) functional recommendations/standards of
    operation, and

-   Develop IIS program evaluation tools.

**Slide -- 61 Chapter Slide**

**Additional Resources**

**Slide 62 - CDC/IIS Website Screenshot**

CDC has resources available to assist you in learning more about IIS.
You can visit NCIRD's IIS web page for information on the following
topics:

-   IIS Annual Report Data Legislation

-   Technical Development & Guidance

-   Software and Standards

-   NCIRD IIS Activities

-   Privacy, Confidentiality & HIPAA

-   Funding

-   State and City IIS [Contact
    Persons](http://www.cdc.gov/vaccines/programs/iis/contacts.htm) and
    Websites

-   Publications & Resources

...and many more.

**Slide 63- Subscribe for E-mail Notification of Updates**

In addition, on pages where you see this image, you may subscribe to
receive notification of updates to selected pages on our site. Once you
subscribe, you will receive e-mail notification of any changes made to
that web page.

**Slide 64- IIS-related documents**

You may also visit the following web page for access to all documents
referenced in this module at: (page not created yet, so I'm guessing
this will be the address)

**Slide 65- Partner Websites**

To learn more about our IIS partners, you may visit their web sites for
more information.

Key IIS partner web sites are:

-   The American Academy of Pediatrics (AAP):
    [www.aap.org](http://www.aap.org/),

-   The Association of Immunization Managers (AIM):
    [www.immunizationmanagers.org](http://www.immunizationmanagers.org/),

-   The American Immunization Registries Association (AIRA):
    [www.immregistries.org](http://www.immregistries.org/),

-   Every Child by Two, the Carter/Bumpers Campaign for early childhood
    immunization (ECBT): [www.ecbt.org](http://www.ecbt.org/), and

-   The Public Health Informatics Institute (PHII):
    [www.phii.org](http://www.phii.org/).

An expanded partner list can be found on the IIS web site at
<http://www.cdc.gov/vaccines/programs/iis/org-support.htm>.

**Slide 66 - Acknowledgments**

NCIRD would like to thank the following individuals for their
contribution to this module.