# Presentation: 829039

## Immunization Information Systemsand Their Role in Response Management

**Testimony of **
**Gary A. Urquhart, MPH**
**Immunization Information Systems Support Branch**
**Immunization Services Division**
**National Center for Immunization and Respiratory Diseases**
**Centers for Disease Control and Prevention**

**Before the American Health Information Community**
**Washington, D. C.**
**June 15, 2007**

**Notes:**
Good morning, my name is Gary Urquhart and I am from the Centers for Disease Control and Prevention in Atlanta, GA. Thank you for the invitation to provide testimony on Immunization Information Systems (also known as Immunization Registries) to the Population Health and Clinical Care Connections Work Group. 

My testimony will focus on the role of Immunization Information Systems (IIS) in assisting with the management of a public health emergency event. More specifically, I will discuss the IIS role in responding to public health preparedness requirements; how past use of IIS during a public health emergency is being leveraged for pandemic influenza response planning; and how the Community may be able to help facilitate these efforts.

Let me begin by providing a brief overview of IIS; their role in public health and clinical practice; and the current status of IIS.

## Immunization Information Systems Overview

**IIS Status as of December 31, 2006: **
**Almost 15 million U.S. children < 6 years of age (65%) with 2 or more immunizations are participating in an IIS**
**Almost 37,000 provider sites (71% of public provider sites and 47% of private provider sites) ****are participating in an IIS**

**Immunization Information Systems Overview**

**Notes:**
First a definition of Immunization Information Systems or IIS:   IIS record all shots on all children given by all providers in a geopolitical catchment area; have functions and features needed by an immunization program (e.g. vaccine inventory management, adverse event reporting etc.); and have interoperability with other health information systems including Electronic Medical Records (EMR).

IIS supports parents, immunization providers, and public health with data to : consolidate immunization histories; provide an official immunization history; reminder-recall functions; prevent extra-immunization immunization; provide decision support for immunization schedules and new vaccines; provide data to develop policy and priorities, and evaluate programs.

The status of selected performance measures reported from the 2006 Immunization Information System Annual Report include:   75% of grantees reporting have a population-based IIS; 76% of grantees reporting collect immunization data for all ages; 49% of grantees can process and return an HL7 message as well as process and upload a record consistent with HL7 standards; almost 15 million U.S. children < 6 years of age (65%) with 2 or more immunizations are participating in an IIS; and almost 37,000 provider sites (71% of public provider sites and 47% of private provider sites) are participating in an IIS.

Now, I would like to discuss the IIS role in responding past public health emergencies and more recently to public health preparedness planning  requirements.

## Immunization Information Systems Role with Public Health Emergencies

**Hurricane Katrina caused massive destruction in Louisiana, Mississippi and Alabama but an IIS offered some assistance to the victims.**
**After Hurricane Katrina, the Louisiana Immunization Network for Kids Statewide (LINKS) remained operational via a backup server in Baton Rouge. **
**Two recent papers describe the role of IIS in this public health emergency**
**A Pediatrics study described the Houston-Harris County Immunization Registry connection to LINKS using HL7 messaging standards. An estimated cost savings of more than $1.6 million for vaccine alone and $3.04 million for vaccine plus administration fees was found.***

- * Boom, JA, Dragsbaek, AC, Nelson, CS. The Success of an Immunization Information Systems in the Wake of Hurricane Katrina. Pediatrics.  2007; 119:1213-1217.

**Notes:**
Hurricane Katrina caused massive destruction to everyone in Louisiana, Mississippi and Alabama and an estimated 200,000 persons were displaced including 60,000 children. Despite the devastation, an IIS offered some assistance to the victims by meeting the clinical and administrative need for immunization histories of displaced children. 

After Hurricane Katrina, the Louisiana Immunization Network for Kids Statewide (LINKS) remained operational via a backup server in Baton Rouge. An estimated 60,000 children were displaced to all 50 states and Washington DC. Most families with children had lost all records of immunization but still needed proof of immunization to enter school.

Within days after Hurricane Katrina, the Houston-Harris County Immunization Registry was connected to the Louisiana Immunization Network for Kids Statewide using HL7 messaging standards. This linkage provided immediate access to the immunization records of children who were forced to evacuate the New Orleans, Louisiana, area representing an estimated cost savings of more than $1.6 million for vaccine alone and $3.04 million for vaccine plus administration fees.* 

* Boom, JA, Dragsbaek, AC, Nelson, CS. The Success of an Immunization Information Systems in the Wake of Hurricane Katrina. Pediatrics.  2007; 119:1213-1217. 

## Immunization Information Systems Role with Public Health Emergencies

**Another recent paper describes a CDC assessment of more than 21,000 successful electronic immunization queries of children and adolescents displaced to virtually all states estimated that more that $4.6 million was saved in revaccination expenses.****
**Both papers illustrate that:**
**CDC-required functional standards for IIS worked to facilitate inter-state exchange of data during a public health emergency.**
**The interoperability of IIS allow public health and clinical data exchange to promote decision support and the protection of the community.**

- ** Urquhart GA, Williams W, Tobias J, Welch FJ. Immunization Information Systems Use During a Public Health Emergency in the United States. J Public Health Management Practice (in press).

**Notes:**
A CDC assessment (in press with the Journal of Public Health Management and Practice) of more than 21,000 successful electronic immunization queries of children and adolescents displaced outside Louisiana State boundaries from virtually all states estimated that more that $4.6 million was saved in revaccination expenses.** 

Both papers illustrate how an IIS met clinical and administrative business needs and that:

CDC-required functional standards for IIS (including the use of HL7) worked to facilitate inter-state exchange of data during a public health emergency.
The interoperability of IIS allow public health and clinical data exchange to promote decision support and the protection of the community.

IIS have been funded and implemented over the past 13 years using the core data elements and functional standards recommended by the National Vaccine Advisory Committee. Our next slide describes the core data elements required for IIS by CDC.

** Urquhart GA, Williams W, Tobias J, Welch FJ. Immunization Information Systems Use During a Public Health Emergency in the United States. J Public Health Management Practice (in press). 

## IIS Data Requirements

**National Vaccine Advisory Committee (NVAC) recommends and CDC requires IIS grantees to use the following core data elements:  **
**patient name (first, middle, last); patient birth date; patient sex; patient birth state/country; mother's name (first, middle, last, maiden); vaccine type; vaccine manufacturer; vaccination date; and vaccine lot number.**
**A subset of this information will be needed for the need to support pandemic influenza doses administered data.  Aggregated data is expected to be reporting from public provider systems into the CDC through a variety of options**

**Notes:**
One of the questions asked in the appendix sought clarification on the information used by registries. The National Vaccine Advisory Committee (NVAC) recommends and CDC requires IIS grantees to use the following core data elements:  patient name (first, middle, last); patient birth date; patient sex; patient birth state/country; mother's name (first, middle, last, maiden); vaccine type; vaccine manufacturer; vaccination date; and vaccine lot number.

More recently NVAC recommended changing the following data variables from optional to required status:  patient race/ethnicity; and patient birth order for multiple births. 

A subset of this information is typically used for preparedness' related responses, for example in Pandemic influenza response, collecting doses administered data the information will be aggregated from patient level data collected either by the IIS, or the CDC-CRA  application. 

The next slide illustrates the potential flow of this information 

## Pandemic Flu (early stages): 3 options for handling the data flow ofadministered doses

**Use of IIS**

**Pandemic Flu (early stages): ****3 options for handling the data flow of****administered doses**

**Notes:**
In the early stages of a pandemic, doses administered data will be reported to Federal authorities.  There are three options for making this happen.  For those IIS systems that are mature enough, we anticipate that IIS will be used to report aggregate data for monitoring doses administered data in a pandemic. 

The focus of the IIS and CRA at this point has been on the tracking and reporting of pandemic influenza vaccine doses administered. It is expected that further consideration will be given to the use of systems to address issues regarding vaccine efficacy and safety.

## IIS Use of SDO-Endorsed Standards

**The Health Level 7 standard is a program requirement.**
**Hurricane Katrina: the HL7 standard was used to bridge compliant IIS in less than 24 hours**
**Pandemic Influenza: the HL7 standard is one of the proposed for use as a data exchange standard with the CDC application**

**Notes:**
One of the questions we were asked to respond to was the IIS use of SDO endorsed standards for preparedness issues. 

As mentioned in earlier slides, IIS have adopted and implemented the use of the Health Level 7 standard for many years. Specifically, these have been used in a public health emergency situation to improve the connectivity between IIS systems.  

As mentioned earlier, Dr. Julie Boom and colleagues recently reported in Pediatrics (June 2007) that it took less than 24 hours to establish a connection between the Louisiana IIS and the Houston Harris County Immunization Registry.  

Additionally,  these standards are used to improve the interoperability between provider sites and the IIS.  

Currently IIS use the HL7 2.3.1 standard and are migrating to the use of the HL7 2.5 versions. 

## Further AHIC Collaboration on Key Issues:

**Use IIS experience to leverage EHR development and implementation and in preparedness planning for public health emergencies.**
**Facilitate the development of national administrative or legal approaches for routine inter-state immunization data exchange.**
**Continue the development of EMR standards to enhance interoperability with IIS.**
**Ensure that priorities are established for immunization programs to address the use of IIS for emergency preparedness activities. **

**Notes:**
AHIC collaboration on key issues to ensure complete and accurate information within IIS will help make these tools more useful when used in an emergency response:

IIS have immunization records that represent a microcosm of an Electronic Health Record (EHR) and over the past 13 years have struggled to address most of the same issues that the Community is addressing. This experience is not being tapped by the Community.

The events following Hurricane Katrina have shown that inter-state exchange of data can take place during a public health emergency because of IIS use of functional standards. The Community should facilitate the development of national administrative or legal approaches for routine inter-state immunization data exchange.

Interoperability with clinical systems will be crucial for IIS and other public health data systems to realize the goal of an EMR.  The Community should foster the development of EMR standards to enhance interoperability with IIS.

To date, limited funding has been dedicated to IIS for the pandemic preparedness planning. The Community should help ensure that adequate funding is available to CDC grantee IIS to address pandemic influenza preparedness planning.

## Further AHIC Collaboration on Key Issues:

**Work with the National Vaccine Program Office (NVPO) to deliberate on the pros and cons of legislative and other approaches to increase provider participation in an IIS.**
**Assist NVPO and CDC to deliberate on the pros and cons of provider performance incentives based on the completeness of immunization data available in an IIS.**
**Help NVPO and CDC to ensure that IIS reporting standards are incorporated into Electronic Medical Records that receive federal funds or that are certified by the Office of the National Coordinator on Health Information Technology (ONC).**

**Notes:**
Increased provider participation in IIS will help facilitate the development of EMR and public health emergency preparedness planning. The Community should work with the National Vaccine Program Office (NVPO) to deliberate on the pros and cons of legislative and other approaches to increase provider participation in an IIS.

Similarly, national implementation of provider performance incentives will help facilitate the development of EMR. The Community should assist NVPO and CDC to deliberate on the pros and cons of provider performance incentives based on the completeness of immunization data available in an IIS.

At present, IIS interoperability with EMR must be developed on an ad hoc basis with each EMR vendor which is inordinately expensive. The Community should ensure that IIS reporting standards are incorporated into EMR that receive federal funds or that are certified by the Office of the National Coordinator on Health Information Technology (ONC). 

Once again, thank you for the invitation to provide testimony on Immunization Information Systems. I will be happy to respond to any questions.