INTRO

JESSICA

Public health informatics is the science and the art of taking raw data and turning them into useful information for health policies and programs. It takes all those data out there and turns them into knowledge of how people can live healthier lives, but how does this process work? My name is Jessica Hill, and I work at the Public Health Informatics Institute in Atlanta, Georgia. This podcast is my quest to learn about informatics and how it’s made people’s lives better, how has it made my life better, and really why does it matter. So I’m ready. Inform Me, Informatics.

JESSICA

Thanks for listening to Inform Me, Informatics. This is Jessica Hill. Today we’re going to talk about immunization information systems which are also called IIS.

MARY BETH

IIS are somewhat unique in public health and that the goal is not just to get the information into a data system. It’s really to get it in, get it synthesized, and processed, and then get it back out for clinical decision support on an individual level, but also population-based decision making on how best to impact the population.

JESSICA

That was Mary Beth Kurilo. We’ll get some more of our conversation in a minute, but first, here’s some background. If you’ve been vaccinated, think about that trip to the doctor. You got the shot, “Ouch.” Then what happened? Did your provider write it down in a file or maybe she had a computer or a tablet and she entered it directly into a digital record? That moment of collecting the information, that is the starting point for today’s episode because that information is extremely valuable in a lot of different ways.

Number one, it’s important to you so you can know what vaccines you’ve already had and when you maybe do for future ones. Number two, it’s important to your healthcare provider so she can give you good clinical care. If you’ve already received a vaccine from another clinic or hospital, that’s something your provider would wanna know. And number three, those data are valuable to local and national public health agencies so they can keep track of how much of a population is vaccinated against certain diseases and where there may not be good coverage. They also need to know how much of the vaccine they’ll need to have in the future. So how does public health keep track of all this information? Enter immunization information systems.

To help explain IIS and their public health implications, I spoke with Mary Beth Kurilo. Mary Beth is a consultant with the Public Health Informatics Institute and she also works for the American Immunization Registry Association. Mary Beth previously worked at the Oregon IIS for eight years and now she works with different programs across the country. We started off our conversation with some history about IIS.

MARY BETH

So Immunization Information Systems got their start back in the mid-90s when people recognized that vaccines were such a helpful health intervention, but we had a really hard time tracking what patients that had what immunizations. And so there was an initiative and the early Immunization Information Systems were funded by the Robert Wood Johnson Foundation. So there was an initiative to build an IIS or back then they were called Immunization Registries in every state and so many of the IIS got off the ground in the mid-90s. And at that point, their singular goal was to capture immunizations provided in a jurisdiction or a catchment area like a state and consolidate those records into one complete immunization record for that patient.

At the time they were really focused on childhood, so baby shots. So when you take your child in for their two-month or four-month visit capturing those shots that were given, making sure that if they received immunizations in two different doctors’ offices, those immunizations would be consolidated into one record, meaning both the patient information was merged together, and the vaccine information that may be reported multiple times. And then that information could be used to share back that consolidated record with the next provider who sees that patient. And even more importantly, to give them a forecast of immunizations due or past due so that they know what to actually give at the point of service.

JESSICA

I have this image in my head of the Manila folder that the doctor, like, goes through all the pages and pages. Is that the kind of record that you’re talking about like, your health record?

MARY BETH

So exactly. Back in the 90s, it was. So back then, we all saw doctors with paper folders and paper files, and paper records. And then the doctor would typically key enter the immunization information into an online form. And now, we’ve evolved to most of our providers keeping records in electronic form. So most doctors’ offices now have an electronic health record where they enter those data in for their own clinical record and then it’s those data that are sent into the immunization registry or IIS electronically.

So we’ve really moved a lot since the 90s when this system got started. So now more often, we’re getting those electronic files from doctors’ offices, pharmacies, sometimes health plans, really anyone who either provides an immunization or knows about that immunization, and sends it into the IIS where its consolidated into that accurate record. Over time, there are also a lot more functions that are embedded in these systems.

And so now they don’t just consolidate their record and create a forecast, but they also manage vaccine inventory and manage vaccine orders, and interact with CDC, who provides public vaccine for uninsured or the Medicaid population. They also… A lot of this information is also used really heavily for research and surveillance.

So we look at coverage rates at the, either clinic level or the population level to know how well the population is covered for a certain vaccine preventable disease or where pockets of need are, where there are certain counties or census tracts, or even neighborhoods that aren’t well immunized where public health can go out and target those people for immunizations. And then they also do a lot of special studies looking at the impact of vaccine shortages on how well the population is covered. They also link often with disease registries. So if there’s an outbreak in a given area, we can look at how well that population has been immunized. For example, in Oregon we recently had an outbreak of meningococcal disease and so we were able to…

And it happened actually at one of our large universities and so we were able to look in the registry and know how well that population was covered for meningococcal disease. And then provide vaccine to make sure some of those students who hadn’t yet been immunized could get immunized. And then that information was put back into the registry so that next time around, we have more of the population covered and we have quick information about who has had their vaccination.

JESSICA

What percentage of a population is generally represented in the registry?

MARY BETH

If you look at the childhood population, 0 to 6, we capture that population very well in IIS across the country. So over 90% of patients aged 0 to 6 are captured in an immunization registry. Once you get up into adolescence, that rate falls a little bit. I think we’re around 60% to 70% capture for adolescence and then once you get up into adulthood, that’s a growing captured of population. But we have a ways to go. I think we capture around 34% or 35% of the adult population. So definitely room to improve there, but I think we’re seeing it grow every year, we’re seeing it increase every year in terms of the percentage captured.

JESSICA

Okay. So you talked a little bit about that one example from an outbreak at a university, but I was wondering if you could talk a little bit more about a really exciting project or something that you’re particularly proud of from the time that you worked at Oregon ALERT.

MARY BETH

So there were a lot of things that I was really proud of when I worked in Oregon, but I think the piece that really stands out in my mind is how closely the Oregon IIS team worked with our research and surveillance team. We are lucky to have some really great epidemiologists who were able to mine this very rich data set that we had and come up with some very interesting studies, and great sort of special studies to dive into. One of the things that we were able to do as more and more health systems transition to electronic health records and then set up real-time data feeds with us, we were able to look in near real time about flu vaccination uptake across our state.

So we were able to publish weekly rates around how much of the population had received their flu vaccine and we were able to compare, I think this was in 2012 and 2013 that we were doing this project. So we were able to compare 2012 uptake with 2013 uptake, and then we could see how the population responded when there were outbreaks of flu or as flu cases or influenza like illness was reported, how that impact to the population actually going in to get their flu vaccination.

JESSICA

That was interesting.

MARY BETH

So it’s a really interesting near real-time study of how the population was responding to different public health messages.

JESSICA

So is near real time like a week boarding period?

MARY BETH

So it was about a week turnaround before we couldn’t send it out and I think that, you know, with the more interoperability that we’re seeing across healthcare, the more EHRs that are reporting within…sometimes within seconds of actually immunizing someone and entering that shot into their EHR, it’ll come across into the IIS. As that gets faster and faster, we’re able to do things faster and faster, and use the data in new and different, and better ways. But that I think was a really good example of how we could take the data and transform it into information that the public health system could use very quickly to respond and how they are messaging to the general population around influenza.

JESSICA

So thanks to an IIS, providers can send important health information to public health agencies and then that information can also be sent back to providers. There are programs like the centers for Medicare and Medicaid Meaningful Use program that incentivize providers to use electronic health records that will automatically share data with systems like Immunization Information Systems. Such data sharing requires different information systems to be able to easily exchange information which is a concept called interoperability. I asked Mary Beth to explain interoperability in the context of an immunization information system.

MARY BETH

So really, when I talk about interoperability, all I am talking about is two data systems talking to each other. So if you walk into a pharmacy and they give you an immunization, they put that into their computer system and then they transfer that information in a standardized way into an immunization registry where we then merge those data with other data on you, on that same patient. And so that’s really all interoperability is. It’s two data systems that can talk to each other and communicate back and forth. And recently, we’ve had a lot of initiatives around health information technology and health IT, and having better access to information. And I think it’s kind of amazing to me that we’re not using this technology more than we are because there’s so much good information out there.

And I think in the back of our minds, we sort of assume that all these systems are talking to each other that if I walk into an emergency room in Atlanta, Georgia, they’ll have some access to my health record somehow back in Oregon. And in the absence of interoperability, that’s not true yet. And so we’re getting to the point now where health systems are able to talk to each other, to query each other where an ER in Atlanta could ask a question of my primary care doctor system back in Oregon and pull my information across. That’s really the ideal. Immunization registries or IIS have sort of been at the forefront of saying, “Hey, EHRs, let’s talk to each other in a standardized way. Let’s use this message format, let’s use this transport vehicle to get a message from point A to point B.” And it’s allowed us to get further than some other areas of public health right now that are still trying to figure out those communication mechanisms.

JESSICA

Why isn’t it so easy? Why isn’t it like, okay, everybody has their vaccine records, they’re available, they’re housed in one place, but we can query that data or those data, and be able to use it? Why isn’t it that simple?

MARY BETH

I think in part because many of these systems, both on the IIS side and on the EHR side grew up before there was a strict adherence to standards and so we started capturing things in slightly different ways. And back when immunization registries first got their start, it was sort of like a thousand points of light. It was, they were encouraged to be innovative and creative, and certainly, every state also has its local laws and policies that it has to adhere to. And so some of those local laws and policies created differences. And so these systems themselves sort of grew up differently and then over time, those standards developed and were adopted, but they’re adopted in systems that already exist. And so it’s sort of a catch up time to make sure the systems are now adhering to standards and are doing things in a really standardized way. So we’re getting there and I think the electronic health record system is the same way.

Many, many electronic health systems grew up with everyone having their own idea of the best way to capture data and capture information. And then over time because of things like meaningful use and stronger standards, they have decided to do things in the same way. But there’s sort of a catch up time now where we’re getting out of the thousand points of light in different ways of capturing data to consolidate around one standardized way of capturing data. So that’s part of it. I think what we’ll see though is that as the standards are adopted, it will get easier for systems to talk to each other and I think over time as well, hopefully some of the jurisdictional differences between states will also change.

And one example of what I mean by jurisdictional differences is, you know, one state may have an opt-out approach with their data in their registry system. So what that means is that a clinic can send me data unless that patient opts out and decides not to be in a registry. In another state, they might have an opt-in policy where patient needs to actively stay, “Yes, I want my data to go into this system.” And so those two states have a different jurisdictional policy that may affect how they share data or how they share information. So we’re also working on having better best practices around local policies and laws as well to help the information flow more easily.

JESSICA

So is there an example you can share around either a public health program or initiative that you were able to do in Oregon or another state was able to do because you had an IIS registry that was more developed? Like, maybe you were able to do it in 2015, but it wouldn’t have been possible in 2005. MARY BETH I think that’s a great question. One of the big sort of litmus tests for IIS happened in 2009 when H1N1 hit and there was a lot of interest in tracking H1N1 vaccine which was a new, a novel influenza disease, and then a vaccination that came shortly after. And I think that CDC was really interested in using IIS to track not only how vaccine got sent out, but then how it was administered across the country.

MARY BETH

And I think that in Oregon, we were lucky to have a strong IIS that was able to actually track and provide information not only back to CDC, but also to our local public health department around how well vaccine was being administered across the state. I think what we did in 2009 showed what was possible, what we would be able to do in 2015 would far exceed that in terms of the speed at which we could track that information. And not only the vaccine coming into the state, but going out to providers. And then what actually happens with that vaccine, who it gets administered to. The speed at which we can do that, the level of accuracy that we can do that is so much higher now because of interoperability because systems are able to talk to each other.

So I think we were all pleased with the way IIS were able to perform and function within the public health system in 2009, and now we would be off the charts with being able to play an important role in that. I think another example though that really has daily applicability is the way pharmacy systems now reports to immunization registries or IIS.

Most of the pharmacy systems track their information in their own version of electronic health record and most of those data feed into IIS so that if a patient moves from their primary clinic to a pharmacy, and back to their primary clinic, their provider still know what vaccinations those patients have had. And that I think has helped not only to make sure that all of those data are captured and someone doesn’t receive an immunization twice, but also makes sure that providers are using the best clinical decision support at the point of care and giving that patient what they need.

JESSICA

So has there ever been a time in your personal life when you saw informatics in action where you were like, just walking down the street being there? And maybe just you’re always like, “I’m always thinking about informatics.” But all the sudden it was like, “Whoa, here’s an example of like, how information was used for better health.”

MARY BETH

I actually for the first time got my flu shot at a pharmacy and used it as an opportunity to talk to the pharmacist about the registry. And in Oregon, pharmacists are required not only to submit immunizations, but to check the registry prior to immunizing. And so I was able to do a quick check in with the pharmacist about, “So how’s that going,” you know, “Is it working?” And he said, “It’s great. It’s access to so much information on the patients that walk in our door. We then can give them immunizations. Not only the immunization they’re asking for, but we can also say, ‘Hey, by the way, you need your pneumococcal today,’ or, ‘You need your Zoster vaccination today.’” And so for pharmacists, there’s also sort of the return on investment to make sure that they’re giving all the immunizations that patient is due for and from a public health perspective that makes sure that the population is that much more covered. And so I think it was a good example of good real life use case of not only how informatics is being used in that environment, but also how the registry is supplying really useful information at the point of care.

JESSICA

Many thanks to Mary Beth Kurilo for talking with us about immunization information systems. I learned a ton from our conversation and I’m really grateful for the time that she spent with us. Mary Beth had so many great stories about her own professional life that we couldn’t fit them into this episode. So next time, we’ll bring you a special bonus installment about how Mary Beth first got involved in the IIS community.

MARY BETH

You know, in your career trajectory there are just those times where you realize something really excites you and they have a lot of passion behind it. And that was it for me. I really liked that intersection of public health theory and technology, and using technology to further the goals of public health. So it was a perfect fit for me.

JESSICA

Thanks to Kathleen Turaski of Resonance Marketing, who designed our logo. Our theme music is called Carnivale Intrigue, and was composed by Kevin MacLeod. Inform Me, Informatics is a project of the Public Health Informatics Institute and the Informatics Academy. Come find out more at phii.org. Hey, you can also find us on Facebook and follow us on Twitter, @PHInformatics. If you like this podcast, please consider rating us on iTunes. The ratings help other people find out about us and more importantly, more people find out about informatics. Finally, many things our production team, especially our awesome producer and editor, Piper Hale. I’m Jessica Hill, and you’ve been informed.

BUTTON

JESSICA

I’ve decided, I wanna be soothing this episode. Immunization.