Informatics Lessons from Using a Novel Immunization Information System David K. Vawdrey, Karthik Natarajan, Andrew S. Kanter, George Hripcsak, Gilad J. Kuperman, Melissa S. Stockwell

NewYork-Presbyterian Hospital (NYP) NYP is composed of six main facilities located in and around New York City – Columbia University Medical Center – Weill Cornell Medical Center – 2,600 patient beds; 118,000 discharges yearly

NewYork-Presbyterian Hospital (NYP)

Immunization Challenges Nearly one in five U.S. toddlers do not receive the prescribed basic immunization series Children are more likely to be under-immunized if they are members of a racial or ethnic minority, are poor, or live in inner-city or rural areas Thousands of children are over-immunized because records of previous vaccinations are not available National, state, and local area vaccination coverage among children aged months--United States, MMWR Morb Mortal Wkly Rep. Sep ;56(34): Feikema SM, Klevens RM, Washington ML, Barker L. Extraimmunization among US children. JAMA. 2000;283(10):

Fragmentation of Immunization Records About 25% of U.S. children see more than one immunization provider in their first three years of life, leading to fragmented and incomplete vaccination records Feikema SM, Klevens RM, Washington ML, Barker L. Extraimmunization among US children. JAMA. 2000;283(10): Yusuf H, Adams M, Rodewald L, et al. Fragmentation of immunization history among providers and parents of children in selected underserved areas. Am J Prev Med. Aug 2002;23(2):

Fragmentation of Immunization Records

NewYork-Presbyterian Hospital (NYP) Immunization Information System (EzVac) Includes all children and adults receiving care at hospital and affiliated ambulatory clinics – In use since 1999 – Over 2 million vaccines for more than 260,000 individuals Functions – Aggregates data from multiple EHRs – Provides comprehensive immunization records – Allows documentation of historical vaccines – Prepares schools, daycare and other immunization forms – Public health reporting – Consumer access

NYP Immunization Management Slide here with architecture of EzVac etc plan

Clinician View

EzVac CIR

Exchanging Information: Informatics Challenges Patient matching Duplicate information – Class-level (not vaccine-level) de-duplication process – Considered to be “duplicate” if two identical vaccines were given within 10 days Adequacy of standards – CVX, MVX, HL7 Provenance – E.g., patient-recorded data from PHR?

Can Informatics Tools Help Improve the Management of Immunization Information? NYPNew York City New York State U.S months 86.3%74.9% ± % ± % ± 7.8 Percent of children seen in NYP Ambulatory Care Network clinics who were up-to-date on 4:3:1:3:3:1 immunizations compared to national, state and local data from the National Immunization Survey (NIS) Jan-Dec Percent of children months up-to-date on immunizations

Disseminating Immunization Decision Support (OpenMRS)

EHR Decision Support: FluAlert

Text Messaging Immunization Reminders …a higher proportion of children and adolescents in the intervention group (43.6%; n=1653) compared with the usual care group (39.9%; n=1509) had received influenza vaccine (difference, 3.7% [95% CI, 1.5%-5.9%])

Success Factors in Immunization Information Sharing Forward-thinking leadership from institution and from NYC health department Clinical, informatics and IT expertise for creating a local infrastructure to support information exchange – Limitations of vendor EHRs (import data— automated or manual reconciliation, provenance) – Terminology standards are inadequate (CVX codes don’t represent vaccine classes)

Future Directions in Immunization Information Management U.S. – “Meaningful Use” Stage 3 proposes bi-directional information exchange with local systems – Local systems seldom communicate with one another Decade of Vaccines – Shared vision endorsed by 200 nations – Extend the benefits of vaccines to every person by 2020 and thereby save more than 20 million lives WHO Global Vaccine Safety Initiative – Hundreds of millions of vaccinations are administered each year in developing countries – Few vaccination programs “have the ability to monitor and assure the safe use of vaccines.”

Funding support: AHRQ HRSA CDC Microsoft Recent Publications: Exploring pregnant women’s views on influenza vaccination and educational text messages. Prev Med Jan;52(1):75-7 FluAlert: A Qualitative Evaluation of Providers' Desired Characteristics and Concerns Regarding Computerized Influenza Vaccination Alert. Prev Med Mar-Apr;52(3-4): Text Message Reminders to Promote Human Papillomavirus Vaccination. Vaccine Mar 21;29(14): Timeliness of 2009 H1N1 Vaccine Coverage In A Low-Income Pediatric and Adolescent Population. Vaccine Apr 12;31(16): Text4Health: Text4Health: Impact of Text Message Reminder-Recalls for Pediatric and Adolescent Immunizations. Am J Public Health Feb;102(2):e Effect of a text messaging intervention on influenza vaccination in an urban, low-income pediatric and adolescent population: a randomized controlled trial. JAMA Apr 25;307(16): Acknowledgements

Informatics Lessons from Using a Novel Immunization Information System