1. Using an Immunization Registry to Enhance Immunization Program Core Functions: The New York City Experience NYC Department of Health and Mental Hygiene Bureau of Immunization 2003 National Immunization Registry Conference Atlanta, GA October 28, 2003 Presented by: Sheila L Palevsky, MD MPH

2. Staten Island Brooklyn Queens Bronx Manhattan New York City

3. New York City -Background Population of ~8,000,000 Annual birth cohort of ~125,000 – ~340 births per day Large immigrant population Mobility of the population within the city

4. NYC - Child Health Providers 1,257 provider sites with over 3,000 clinicians –87 public/municipal sites –1,170 private sites

5. Public Sites 11 public hospital OPDs 6 Diagnostic & Treatment Centers (DTC) 23 Community Health Centers (FQHC) 41 public child/adolescent health clinics 6 DOHMH Bureau of Immunization clinics Total: 87 sites

6. Private Sites 49 private hospital OPDs 24 hospital faculty private practices 22 voluntary foster care agencies 10 non-public child/adolescent health clinics 1,065 private practices (solo and group) Total: 1,170 sites

7. New York City - MCOs 30 managed care plans –O f these, 17 include Medicaid managed care plans

8. NYC DOHMH Bureau of Immunization (BOI) Assistant Commissioner Medical Director Registry (CIR) Program Operations Director (CDC) Surveillance Perinatal Hep B Imm Clinics Adult Unit Provider Liaison Assessment Unit Program Support Services Vaccine Supply Community Outreach & Education WIC Schools

9. The Citywide Immunization Registry (CIR) Mandatory reporting of all immunizations administered to children < age 7 since January 1, 1997 Voluntary reporting of immunizations for children 8-18 years of age Birth certificates loaded weekly into the CIR All children born in NYC are routinely enrolled Currently over 2 million children and over 14 million immunizations entered into the CIR

10. The Citywide Immunization Registry (CIR) High compliance with reporting to CIR, but data is incomplete –100% of public providers report (87/87) –78% of private providers report (913/1,170) –63% of children entered in the CIR have 2 or more immunizations; of these, the average is 11 immunizations per child

11. CIR Access Internal interface for DOHMH staff –Powerful search capabilities External interface for providers based on the web-based on-line registry –Stricter searching criteria

12. Volunteering To Be A PROW Demonstration Site To focus more attention on the need to integrate CIR functions more fully into the BOI core functions To make integration of the CIR with program functions a priority for both the BOI and CIR

13. PROW Process The engagement process –Program operations director was designated to partner with CIR director –These two directors met individually with the unit chief of each BOI program unit to assess current relationships and future integration with CIR –PROW self-assessment tool used by all participants –Unit chiefs expressed strong interest in integration with CIR

14. Assessment Findings Low to moderate level of integration of CIR into most core program functions Partially or fully met PROW standards in Levels I, II and III for each program component

15. Vaccine Management - 1 4/14 total PROW standards partially or fully met –Generate doses administered reports by provider – these reports are used by VFC staff to adjust quantity of doses of vaccine shipped –Capture VFC eligibility status –Improve accuracy of VFC eligibility reports by age group - VFC staff reviews usage reports categorized by age/dose over time for VFC site visits –Use provider/clinic information for broadcast fax service - used by BOI to regularly send fax alerts to 2,900 providers

16. Vaccine Management - 2 Strong support for further integration –High priority for both VFC program and CIR –Funding allocated for CIR enhancements to link with VACMAN –Further enhancements, i.e., CIR inventory module, under development

17. Provider Quality Assurance - 1 13/17 total PROW standards partially or fully met –Provide easy links to information - CIR has links to BOI and CDC websites for info for parents, providers –Use registry data as part of AFIX visits - CIR gives assessment team a list of patients associated with provider, within age range and over time period, and charts are pulled for review based on that list –Use registry data to highlight practice issues for provider education - use practice/facility data in grand rounds, conferences, and training sessions –Monitor trends in immunization practice - CIR is a CDC Sentinel Site - quarterly reports reflect immunization coverage and timeliness of data for ~10,000 children

18. Provider Quality Assurance - 2 –Send recall notices to providers - done only for Medicaid managed care cohort who are not UTD (~42,000 children aged18-30 months - a 1 year birth cohort) –Send reminder notices to parents - done for Medicaid managed care cohort for those who are not UTD after information is obtained from PCPs –Enroll birth facilities to capture birth dose of HBV –In the electronic birth record, include HBV and transfer into CIR - HBIG is not included in our electronic birth record –Use CIR to track HBV series completion for infants born to HBsAg+ mothers - the Perinatal Hep B unit regularly uses the CIR to review data and in their follow-up

19. Provider Quality Assurance - 3 –Include grace period in prediction algorithm - CIR immunization calculation engine is in compliance with ACIP guidelines and NYC school regulations –Highlight invalid doses - based on a forecasting algorithm –Display the reason a dose is considered invalid

20. Provider Quality Assurance - 4 The future –Plans are being considered to include links to health alerts on NYC DOHMH website –As registry data becomes more complete calculation of coverage rates will be possible

21. Service Delivery - 1 7/10 total PROW standards partially or fully met –WIC access - WIC sites have telephone/fax access to CIR for assessing UTD status for WIC clients –School access - schools have telephone/fax/ Internet access for assessing student compliance –Identify providers not part of VFC - provider/ facility lists maintained by CIR and VFC are compared and non-participating providers are identified

22. Service Delivery - 2 –CIR used to identify delayed individuals for outreach - done for the Medicaid managed care cohort –Identify children without a medical home - done for the Medicaid managed care cohort - ~6,000 children identified by providers as “not my patient”

23. Service Delivery - 3 –Provide individual immunization reports to WIC based on a WIC supplied roster –Long-term care facilities participate - pediatric long term care facilities are reporting to the CIR regularly; the CIR is not collecting adult immunization data

24. Service Delivery - 4 The unmet standards –Practice-specific reminder-recall system in development based on provider-specific patient lists; periodic email alerts to be sent to the provider that patients may be due for recall – however requires active participation by provider –No plan to use day care enrollment rosters to identify children not UTD

25. Consumer Information - 1 4/6 total PROW standards partially or fully met –Generate official immunization records for families –Generate or link to variety of consumer educational materials - consumer education materials linked on consumer website pages –CIR promotional materials to include general immunization information - consumer CIR website has links to immunization information; plans have been discussed to include these links in print materials

26. Consumer Information - 2 –Disseminate consumer alerts through the registry - the consumer website has links to the BOI web pages where updated immunization information and alerts are available

27. Consumer Information - 3 For the future –To develop on-line access for consumers to the registry in a secure mode –To be able to send families electronic notices

28. Surveillance - 1 2/7 total PROW standards partially or fully met –Provide immunization histories to disease investigators - CIR provides immunization histories for disease/outbreak investigation –Enable updating of immunization history by surveillance staff - staff may add documented immunization histories not in CIR

29. Surveillance - 2 –Show which provider gave shots and when, in case further medical record follow-up is required by surveillance investigation - CIR records the provider of record for each immunization given to a child

30. Surveillance - 3 Plans for the future –There is no plan to track adverse events in the CIR; there will be a link to VAERS from the CIR –A link to NEDSS is under development –A provider portal is under development by the NYC DOHMH MIS department that will link to the CIR on-line application

31. Assessment - 1 5/12 total PROW standards partially or fully met –Use registry data to validate reports for school assessments - CIR may be used to supplement data gathered for school survey for compliance with immunization regulations –Assess coverage among WIC participants - CIR data is used to supplement WIC assessments

32. Assessment - 2 –Registry access to Medicaid and MCOs - CIR supports batch file data exchange with Medicaid and non-Medicaid MCOs on a regular basis; MCO medical directors have on-line access to the CIR –Tracking vaccine for occupational reasons - a separate CIR database tracks smallpox vaccination by employer

33. Assessment - 3 Unmet standards –CIR data is not sufficiently complete for coverage assessment or to identify pockets-of-need –CIR data is not sufficiently complete to support geographic analysis –Administrative decision not to expand the registry to include any adult immunizations at this time

34. Priorities for Integration - 1 Least resource intensive –Provide DOHMH front-end access to CIR to BOI staff in the main office Installed application on Program Support Service (WIC/Schools) staff desktop PCs and provided training immediately following PROW assessment Provider quality assurance staff already have access –Provide CIR on-line registry access to BOI staff in the field Perinatal Hep B and Surveillance staff already have online access Plan to provide access to Immunization Clinic staff by 12/2003

35. Priorities for Integration - 2 More resource intensive –Automated link of CIR to VACMAN to strengthen VFC vaccine management and accountability – target date 12/2003 –Expanding CIR provider and facility tables to support broadcast communications to adult as well as childhood immunization providers

36. Benefits of Integration - 1 Reduces the time spent by surveillance staff to locate immunization histories for disease/ outbreak control Reduces the time spent by the assessment team in identifying a provider’s patient population for sampling Supplements data gathered for WIC assessments; staff gets a more accurate picture of coverage Supplements data available for compliance with school immunization requirements

37. Benefits of Integration - 2 Assists in accounting for use of VFC vaccine by providers Enables VFC program to adjust quantities of vaccine shipped to avoid wastage Enables identification of practice-specific patterns for provider education Increases staff understanding of the interrelationships of all program components

38. Challenges Clinic staff may not have computers available with Internet access Finding time for joint planning and training Funding for further enhancements to CIR Shifting CIR staff focus from external (providers, MCOs, schools, WIC) to internal (BOI program colleagues)

39. Now and in the future Allows for colleagues to better understand all program components Promotes collaboration between and among BOI units More effective use of resources More coordinated and effective services to the providers and the patients they serve

40. it doesn’t need to be a perfect registry – incomplete data are useful

41. Thanks to all of the staff participating in this project Stephen Friedman Jane Zucker Frank Roldan Ynolde Andrews-Gillan Sam Anim-Addo Dileep Sarecha Karin Seastone-Stern Karen Fernandez Toby Keller Jane Tubridy Amy Metroka Shirley Huie Vicky Papadouka Angel Aponte Lennon Turner Nicholas Gaglioti Alison Chi Renee Simms Edward Wake Stephanie Bershad

42. Sheila L. Palevsky, MD MPH Medical Specialist – Provider Liaison Bureau of Immunization New York City Department of Health and Mental Hygiene Phone: 212-676-2264 Fax: 212-442-8091 spalevsk@health.nyc.gov