Real time access to online immunization records and its impact on tetanus immunization coverage in the ED

The objective of this study was to evaluate the impact of online access to the state Immunization Information Systems (IIS) on the immunization practices of emergency department (ED) providers in a pediatric academic tertiary care center. Interoperability between Health Information Systems (HIS) such as Electronic Health Records (EHRs), Laboratory Information Systems (LIS), and health registries, maintained by various care providers (e.g., primary/specialty care, ED, inpatient hospital systems) and public health departments (e.g., IIS, formerly referred to as immunization registries) are required for full realization of healthcare reform, set forth by the Affordable Care Act [1], [2]. Pediatric immunization is mainly covered by the primary care providers, supplemented in certain circumstances by alternative settings such as the ED and hospitals. It is critical that updated immunization records of individual patients are available at the Point-Of-Care (POC), to help decide the need for an immunization, such as tetanus vaccination in trauma patients, and prevent over or under immunization. To provide up-to-date information about immunization administered to individual patients by all care providers, with a view to improve immunization coverage and reduce unnecessary and duplicate immunization, the Georgia Department of Public Health (DPH) created a population based IIS (Georgia Registry of Immunization Transactions and Services or GRITS) [3]. Children's Healthcare of Atlanta worked with the DPH to establish an interface between their EHR system and GRITS so that the updated immunization records could be accessed online within the EHR at POC. This online access could also be viewed as a golden opportunity to improve the Center for Disease Control (CDC) recommended Tetanus, Diphtheria and Pertussis (Tdap) coverage for the 11 to 19 year-old children, known to be difficult population to reach out to, to improve Tdap coverage targets. We compared the immunization coverage practices, based on CDC recommendations, in patients 10 to 20 years of age, presenting with trauma where tetanus immunization was indicated, pre-post availability of GRITS via EHR. At implementation onset, there was a significant increase in vaccination rates (2.3%, p=0.01), but, the increase was not sustained and the pre-implementation downward trend continued (p=0.91). There were only 4 patients who were seen more than once for trauma and ordered tetanus immunization (combined) twice; 2 patients before and 2 after the implementation. Both the pre-implementation patients were vaccinated twice, whereas only 1 patient was vaccinated twice in the post-implementation phase and the other patient's order was discontinued. While showing a short-term increase in ED based immunization post-implementation of GRITS, real time access to updated immunization records did not impact the overall long- term rates of updating Tdap immunization in the ED. As with many Quality Initiative (QI) efforts, improvements may be transient and further evaluation of GRITS and strategies to maintain the QI impact of this and other EHR systems are important. As suggested by some experts, providing appropriate interactive reminders and alerts at POC to reduce “missed opportunities” to vaccinate during all patient encounters are needed to reach the 90% target of Tdap coverage by 2020 set forth by the government [4].