1. School Nurses and Immunization Registries: A Partnership for Success Judy Greene Louisiana Department of Public Health Janet Balog Scientific Technologies Corporation March 5, 2007

2. Registries and Physician Recruitment An average of 44% of private provider sites submitted data to Immunization Information Systems during the last six months of 2005 Issues surrounding private provider participation Reluctant to add workload to staff Reluctant to add workload to staff Won’t pay the cost for electronic transfer of data to IIS Won’t pay the cost for electronic transfer of data to IIS Data quality from billing systems Data quality from billing systems Many converting to Electronic Health Records Many converting to Electronic Health Records 1 of 4 using EHR; 1 of 10 using for treatment decision Smaller practices less likely to have electronic Smaller practices less likely to have electronic data systems

3. History of Schools and Registry Unreliable source of data Use of non-clinical staff for data entry Transfer from paper records Transfer from paper records Legibility of record Legibility of record No knowledge of the immunization schedule No knowledge of the immunization schedule Didn’t question suspicious dates Didn’t question illegible dates No supervision by nursing No supervision by nursing Limited computer skills & Internet access

4. School Facts 27.8% of US Citizens are 5 – 19 yrs. old 59,982,652 immunizations* 59,982,652 immunizations* Kindergarten to Grade 12** Public school Public school 48 million children (9 out of 10) 2014 projections → 49,993,000 Private school Private school 6 million 2014 projection → 6,695,000 * 2005 US Census ** 2005 National Center for Education Statistics

5. School Facts School vaccination laws Vary from state to state Vary from state to state Allow for medical, religious and philosophical exemptions Allow for medical, religious and philosophical exemptions Failure to vaccinate results in fines, exclusion from school, up to criminal penalties Failure to vaccinate results in fines, exclusion from school, up to criminal penalties

6. School Facts 2010 Health Objective → Achieve and sustain ≥ 95% vaccination coverage for children K – 12 Hepatitis B DiphtheriaTetanusPertussisPolioMMRVaricella 2005-06 school year, more than 50% of schools have exceeded 95% coverage rate

7. Documentation in Schools Parents must provide documentation for first time enterers Kindergarten Kindergarten First Grade First Grade Transfer to a new school Transfer to a new school Some states require on official form Becomes part of official student school record Reported to state DOH and CDC

8. Documentation in Schools Paper Electronic School Health Records Free-standing Free-standing “Home Grown” “Home Grown” Part of a larger student record management system Part of a larger student record management system Subject to Federal Education Reform Privacy Act (FERPA) regulations Few commonly used applications

9. School Nurses

10. Student Ratios National Association of School Nurses → 1 nurse to 750 students Ratio varies according to resources Responsibilities Education Education Acute Care Acute Care Assessments Assessments Referrals Referrals Reporting Reporting Patient Advocacy Patient Advocacy

11. School Nurses and Registry National Association of School Nurses’ position statement on Registry Supports registry development in every state Supports registry development in every state “…helps sustain high immunization rates and low disease levels through efficient immunization information management.” “…helps sustain high immunization rates and low disease levels through efficient immunization information management.” “important tool to facilitate immunization compliance” and “help prevent duplication of vaccines when records are lost or misplaced.” “important tool to facilitate immunization compliance” and “help prevent duplication of vaccines when records are lost or misplaced.”

12. School Immunization Reports Annual reporting requirements Reportable to state department of health and / or the Department of Education Due by mid-November annually School funding tied to immunization coverage rates Public health involved in this activity in some states

13. Outcomes: Case Study 1* 1999 Wausau County, WI school district study 1999 Wausau County, WI school district study 56 hrs. sending cards to parents 90 hours entering data into their school system 25 hrs. filing cards 95 hrs. generating non-compliance letters 30 hrs. calling providers to attain records _______________________________________ 296 hrs. TOTAL (1 person 7.4 weeks) * “Linking to Schools: What Benefits Can Schools Expect to Receive from Using Immunization Information System?” Every Child By 2. 2006 https:www.ecbt.org/registries/schools.cfm

14. Outcomes: Case Study 1 2000, integrated data with local registry (Regional Early Childhood Immunization Network – RECIN) Outcome Reports reduced from days to minutes Reports reduced from days to minutes Generated non-compliance letters in 1 hour Generated non-compliance letters in 1 hour Discovered many invalid doses of vaccine Discovered many invalid doses of vaccine Manual review missed any interval errors

15. Outcomes: Case Study 2* Multinomah County Education Service District, Oregon 89,285 students 7,278 needed additional vaccinations ALERT registry 2,737 students (37.6%) had additional vaccines 2,737 students (37.6%) had additional vaccines 1,411 students (52%) of those students were complete with no additional vaccines 1,411 students (52%) of those students were complete with no additional vaccinesneeded. *”Connecting Health and Education: Annual Report 2005-2006.” School Health Services. Department of School Health Service District, Multnomah Education Service District. Oregon. 2003

16. Outcomes: Case Study 3* Washington D.C. Immunization Registry 2000 – 55,000 students did not meet school requirements 2000 – 55,000 students did not meet school requirements 20,000 students identified in registry 20,000 students identified in registry High percentage of Medicaid children missing vaccines High percentage of Medicaid children missing vaccines Cooperative agreement between school corps and Medicaid Managed Care to direct students to medical home for vaccines Cooperative agreement between school corps and Medicaid Managed Care to direct students to medical home for vaccines 2003 – 2,100 (5%) students deficient 2003 – 2,100 (5%) students deficient * “Annual Report 2002.” Office of School Health Programs. District of Columbia Public Schools. 2003. Retrieved October 2006

17. State Registries Working with Schools* Read Only Arkansas Arkansas Colorado Colorado Delaware Delaware Georgia Georgia Houston Harris Co. TX Houston Harris Co. TX Idaho Idaho Indiana* Indiana* Maryland Maryland Minnesota Mississippi Missouri Nebraska Nevada New Jersey New York State North Carolina North Dakota Oregon Oregon Rhode Island Rhode Island San Antonio, TX San Antonio, TX Tennessee Tennessee Utah Utah Washington Washington West Virginia West Virginia Wisconsin Wisconsin Wyoming Wyoming Virgin Islands Virgin Islands * AIRA Registry Profile http://www.immregistries.org/public.php/ImmRegs/regMain.php

18. State Registries Working with Schools Read and Add Data** California California Kentucky* Kentucky* Louisiana Louisiana Michigan Michigan New Mexico* New Mexico* Oklahoma Oklahoma Pennsylvania Pennsylvania * Registry laws in place ** AIRA Registry Profile http://www.immregistries.org/public.php/ImmRegs/regMain.php

19. Barriers Federal Education Rights and Privacy Act (FERPA) FERPA not HIPAA regulates school information FERPA not HIPAA regulates school information Requires parental consent unless state law / rules specifies reporting to registry Requires parental consent unless state law / rules specifies reporting to registry Consent added to general student consent signed at outset of academic year Consent added to general student consent signed at outset of academic year

20. Barriers Double data entry Multiple school Multiple schoolapplications Cost of interfaces Cost of interfaces Level of IT staff in Level of IT staff in schools not capable of doing interface work internally Nurse may not be entering data

21. Advantages Frequently first to encounter child from out of state Required to collect immunization data School nurses are active registry users → “Ultimate Win Win” Connection to families / siblings → Outreach opportunities → Source of immunization record for many Access to adolescents

22. Advantages Role in disease surveillance and outbreak management Active members in community Pan Flu / BT response planning Active members in community Pan Flu / BT response planning Schools frequent site for disease outbreaks Schools frequent site for disease outbreaks Expanded use School based clinics School based clinics Employee health Employee health College / University Student Health Centers College / University Student Health Centers

23. The Louisiana Experience School nurses adding data into LINKS since March 2005 Through January 2007, schools have entered 277,782 new immunizations Through January 2007, schools have entered 277,782 new immunizations School nurse data “marked” in LINKS Working on bi-directional interface with school application used in 42-parish schools

24. LINKS facts* As of December 31, 2005 81% of children < age 6 had at least two immunizations recorded 81% of children < age 6 had at least two immunizations recorded 100% public providers participating 100% public providers participating 51% private providers participating 51% private providers participating 1.5 million people of all ages 1.5 million people of all ages 14 million individual immunizations 14 million individual immunizations * Immunization Information Systems Use During a Public Health Emergency in the United States; Urquhart Gary, MPH; Centers for Disease Control and Prevention

25. After Katrina Estimated 200,000 displaced persons View only or HL7 links to other state registries allowed queries into LINKS Displaced children and adolescents enrolling in school were initially exempt from school immunization laws

26. Results 21,295 successful external queries were made into LINKS between August 29 and October 11, 2005 44 states, 5 cities and Washington, D.C. 44 states, 5 cities and Washington, D.C. Queries breakdown 30.7% for children 0-5 years old 30.7% for children 0-5 years old 39.6% for children 6–10 years old 39.6% for children 6–10 years old 30.7% for adolescents 11-18 years old 30.7% for adolescents 11-18 years old Houston Harris County registry alone responded to 17,000 requests for immunization records Est. $850,000 savings in unnecessary shots Est. $850,000 savings in unnecessary shots

27. Vaccine Totals Estimated Revaccination Costs if LINKS Data Was Not Available Vaccine Doses documented by query to LINKS Vaccine costs* Vaccine admin costs † Total costs DTaP$1,141,412$757,250$1,898,66213,569 Polio$723,178$567,938$1,291,11617,875 MMR$709,975$378,625$1,088,60013,167 Hib$596,047$567,938$1,163,98518,443 Hep B$642,683$567,938$1,210,62118,389 Varicella$1,112,664$189,313$1,301,976 8,618 PCV 7$3,457,456$567,938$4,025,394 6,341 MCV$1,448,060$189,313$1,637,373 38 All Vaccine Totals $9,831,476$3,786,251$13,617,72796,440 * Vaccine Costs = mean VFC vaccine cost/dose x total # patients aged 0-18 in LINKS † Vaccine Administration Costs = mean vaccine administration cost/dose x total vaccine doses given if not documented by LINKS

28. Vaccine Totals Estimated Revaccination Savings Due to Vaccination Data in LINKS Vaccine Doses documented by LINKS query Vaccine costs ‡ Vaccine admin costs § Total costs DTaP$445,925$295,841$741,76713,569 Polio$427,058$335,384$762,44217,875 MMR$323,898$172,733$,496,63113,167 Hib$330,982$315,373$646,35518,443 Hep B$354,233$313,035$667,26718,389 Varicella$450,291$76,614$526,905 8,618 PCV 7$661,725$108,698$770,423 6,341 MCV$2,584$338$2,922 38 All Vaccine Totals $2,996,696$1,618,016$4,614,71196,440 ‡ Vaccine Costs = mean VFC vaccine cost/dose x total # patients aged 0 – 18 vaccinated by dose and documented by LINKS § Vaccine Administration Costs = mean vaccine administration cost/dose x total vaccine doses documented by LINKS

29. Summary 45,000 school nurses working in United States Schools hold immunization data that mirrors or exceeds what is held by private providers School nurses are motivated to work with registries → many would do double data entry Schools play a critical role in disaster, disease outbreak and Bio Terrorism plans

30. Contact Information: Janet Balog, BS, RN Public Health Specialist Scientific Technologies Corporation (520) 488-9593 Janet_Balog@stchome.com Quan Le Registry Coordinator Immunization Program Louisiana Office of Public Health (504) 838-5300 qle@dhh.la.gov