Five years ago, this journal featured a special focus on integrating child health information systems.1 Many of the articles highlighted the potential of linking systems such as immunization registries to other screening and care data repositories to allow parents and providers to see the full picture about a child's health status and needs.
[AQ1] Although much of this potential is still yet to be realized (B. Brand, personal communication, August 5, 2009), progress has been made in building interfaces for state immunization registries, facilitated in part by the addition of a criterion from the Certification Commission for Health Information Technology that requires electronic systems be able to synchronize immunization histories to the public registry.2 This trend will be furthered by the inclusion of requirements to send and receive immunization records in the criteria for “meaningful use” of electronic health records (EHRs), which will allow Medicare providers to receive extra payments under the American Recovery and Reinvestment Act.3
For many local health departments (LHDs), even electronically linking an EHR to the state registry is not yet a reality. In the National Association of County & City Health Officials' (NACCHO's) 2008 Profile of Local Health Departments,4 just 19 percent of LHDs surveyed had implemented an EHR and 57 percent used paper records for their childhood immunizations (in addition to manually entering information into a state registry).
One LHD's Experience
To investigate ways to rectify this situation, NACCHO is currently supporting two demonstration sites to look at how LHDs can use health information exchange to improve their work. Kittitas County Public Health Department (KCPHD), a small, rural county in Washington, is one of these sites and is implementing an EHR and practice management system that will allow the LHD to maintain a two-way exchange of information with healthcare providers. This grant from NACCHO also provides an opportunity to greatly improve the way immunization data are recorded and used in the county.
Providers in Kittitas County currently use a variety of means to record immunizations although most fall short of the ideals described above. One clinic records the procedure on a paper record and then manually enters it into the state's registry through a Web interface. One clinic makes use of an EHR system but still must manually enter data into the state registry, as there is no electronic link between the two. Just two clinics have a way of automatically capturing the record in the state registry; data are entered into the clinic's billing system, and a monthly batch output is sent to the state for entry. One of these clinics has an EHR system in place but cannot automatically link with the registry.
One result of these duplicative processes is that Kittitas County has the lowest level among all Washington counties for completeness of information in the state's immunization registry. This makes it difficult to obtain the full picture of a person's immunization status. For example, parents must complete a childhood immunization status form in order for their child to attend school, but during vaccine-preventable disease outbreaks, it has come to KCPHD's attention that these forms are often inaccurate. At the moment, data in the state registry cannot be relied on by school nurses to check the validity of the childhood immunization status forms.
The vision for the future
The goals for the new system are to capture all immunizations in the state registry and allow providers to easily retrieve records from the registry. This is being achieved by building an interface between the EHR system used by providers in the county and the state registry that will allow for near real-time exchange of immunization records.
When KCPHD begins using the same EHR, records of travel immunizations given at its clinic will be sent to the state immunization registry near real time. When same patients check in for their next appointment with another provider that uses the EHR system, a query will be sent to the state immunization registry and any new immunizations will be added to the patient's EHR, which will allow the physician to offer appropriate follow-up.
Benefits of the system
Making it easier to add information into the state registry will contribute to it being a much more complete repository of a person's immunization status. Creating easier access to the data contained in the registry will also have many benefits such as follows:
- Healthcare providers can be confident that the information in the electronic medical record system in up to date. This will help prevent overimmunization and the potential medical consequences that stem from it.
- There is increased potential to automatically generate reminders to physicians and parents that a child is due for an immunization.
- Parents will have easy access to their child's complete immunization record by contacting just one provider, rather than having to contact all of the places that their child has received a vaccination.
- School nurses will be able to verify the accuracy of childhood immunization status forms and reduce the risk of transmission of communicable diseases in schools.
Lessons learned so far
One of the key discoveries that KCPHD has made is that even something as simple sounding as building an interface for one system can be quite time consuming. Even with buy in from all the providers in the region, plus support at the state level, it has taken 16 months to get to the point of testing automatic entry into the registry. Retrieving information back from the registry has proved more difficult and this will continue to be worked on.
Achieving that buy in from providers is an important component for success in KCPHD's demonstration project. The health department has spent considerable time with providers during the EHR user meetings and has used the opportunity to highlight the anticipated benefits from the public health initiatives.
Not only do LHDs need to buy in from partner providers, but they also need to support from their internal information technology staff. For a small county like Kittitas, that may mean working outside the health department with county-wide information technology support.
As part of the NACCHO demonstration site project, KCPHD will more fully capture what it has achieved and some of the challenges that arose. NACCHO will make this resource available on-line by the end of 2009 for other LHDs to draw upon and consider how they could replicate the exchange of health information in their area.
NACCHO will also host a free Webcast in early 2010 to provide an interactive look at the achievements and lessons from the demonstration sites project. This will allow LHDs to pose their questions to their colleagues who have gone through the process. More information will be available on the NACCHO Web site at http://www.naccho.org/topics/infrastructure/informatics/index.cfm.
[AQ1] Please provide the highest academic degree for B. Brand and mention whether the communication was oral or written.
[AQ2] Ref 2 has been updated per the URL given. Change OK?
1. Novick LF, Hinman AR, Saarlas KN, Lloyd-Puryear MA, eds. Integrating child health information systems [special section]. J Public Health Manag Pract
4. National Association of County & City Health Officials. 2008 Profile of Local Health Departments
. Washington, DC: National Association of County & City Health Officials; 2009.