using an immunization registry to enhance immunization program core functions: the new york city...
TRANSCRIPT
Using an Immunization Registry to Enhance Immunization Program Core Functions:
The New York City Experience
NYC Department of Health and Mental HygieneBureau of Immunization
2003 National Immunization Registry ConferenceAtlanta, GA
October 28, 2003
Presented by: Sheila L Palevsky, MD MPH
Staten Island
Brooklyn
Queens
Bronx
Manhattan
New York City
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
NYC - Child Health Providers
• 1,257 provider sites with over 3,000 clinicians
– 87 public/municipal sites
– 1,170 private sites
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
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
New York City - MCOs
• 30 managed care plans
– Of these, 17 include Medicaid managed care plans
NYC DOHMH Bureau of Immunization (BOI)
AssistantCommissioner
Medical Director
Registry (CIR)
Program Operations Director (CDC)
Surveillance
Perinatal Hep B
Imm Clinics
Adult Unit
Provider Liaison
Assessment Unit
Program SupportServices
Vaccine Supply
CommunityOutreach & Education
WIC Schools
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
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
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
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
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
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
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
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
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
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
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
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
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
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”
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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)
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
it doesn’t need to be a perfect registry –
incomplete data are useful
Thanks to all of the staff participating in this project
Stephen FriedmanJane ZuckerFrank RoldanYnolde Andrews-GillanSam Anim-AddoDileep SarechaKarin Seastone-SternKaren FernandezToby KellerJane Tubridy
Amy MetrokaShirley HuieVicky PapadoukaAngel AponteLennon TurnerNicholas GagliotiAlison ChiRenee SimmsEdward WakeStephanie Bershad
Sheila L. Palevsky, MD MPHMedical Specialist – Provider LiaisonBureau of ImmunizationNew York City Department of Health and Mental HygienePhone: 212-676-2264Fax: [email protected]