Progress on the horizon to implement ‘lifelong’ immunization registries

Immunization registries are an important public health tool. Besides serving as a way for health care providers to determine what vaccines their patients need, they provide data on vaccine coverage rates, which guide initiatives to improve immunization rates.

The benefits do not stop there. Documenting the vaccines that a person receives in a permanent record serves many important purposes, including knowing whether a person is protected in cases of outbreaks and exposure to vaccine-preventable diseases. They also help save money because they can prevent double immunization — receiving the same vaccine twice because there is no record of the first. Providers in some states also use registries to manage vaccine inventory.

Immunization registries are run by individual states. Across the country, each of the 50 states, as well as five cities and Washington, D.C., maintain their own registries. Although this is may not seem problematic, there are some issues that must be addressed.

“With more than 50 different registries, there is a spectrum of completeness, a spectrum of accessibility and a spectrum of functionality among the registries,” William Schaffner, MD, professor of preventive medicine at Vanderbilt University and a member of the Infectious Disease News Editorial Board, said in an interview. “Another point is that the registries are state specific and often don’t communicate with each other. That’s a problem, as we’re a society that is on the move and people receive medical care in different states.”

L.J. Tan, MS, PhD, of the
Immunization Action Coalition,
said providers need access to
vaccination records to avoid
giving duplicate vaccinations.

Photo courtesy of Tan LJ

The appeal of immunization registries is obvious for physicians and patients. Infectious Disease News spoke with several opinion leaders to find out the vast potential of immunization registries, the issues that pertain to registries and to discuss the direction they are going in the future.

Tracking coverage

According to a report by the National Vaccine Advisory Committee, one of the goals of the Childhood Immunization Initiative of 1993 was to develop a system to maintain high levels of immunization coverage. To accomplish this, President Clinton initiated a plan to work with states on an “integrated immunization registry system.” As a result, implementation of state registries began in the mid-1990s, and at the time, the focus was on childhood vaccines.

Not every state currently has an adult immunization registry, according to Kelly Moore, MD, medical director for Tennessee’s Immunization Program. Although most of them accept information on children and adults, two registries still only accept information on children.

“We need a way to keep track of the adult vaccines that are needed one time only, like the herpes zoster and pneumococcal vaccines, so that adults aren’t needlessly over-immunized because of the lack of records,” Moore told Infectious Disease News.

However, adult immunizations are becoming increasingly important. The CDC recommends that adults aged at least 60 years receive herpes zoster (Zostavax, Merck) vaccine and that adults aged at least 65 years receive pneumococcal polysaccharide vaccine (Pneumovax, Merck). There are additional recommendations for various populations, such as immunocompromised individuals.

The opportunity to begin documenting adult immunizations in Tennessee arose with the 2009 influenza H1N1 pandemic, when state registry was expanded to include patients of all ages. Since then, Tennessee has been recording information on adults in the registry.

“Many registries are moving to lifelong registries because of the value of immunization documentation for adults and because of pandemic preparedness,” Moore said. “Our immunization registry is the centerpiece in our vaccine ordering in the case of a severe influenza pandemic.”

Focus on adults

Adult immunization rates are below the Healthy People 2020 goals. According to the CDC, the rate of pneumococcal vaccination among adults aged at least 65 years was about 60% in 2012 — no change compared with the 2011 rate. The rate of herpes zoster vaccination among adults aged at least 60 years was only about 20% in 2012 — an improvement from the 15.2% in 2011, but still an abysmal rate, according to several experts.

Recording adult information in immunization records would go a long way to help increase the rates of adult immunizations, according to L.J. Tan, MS, PhD, chief strategy officer for the Immunization Action Coalition. The adult market for immunizations is very different than for pediatric patients, Tan said, where a family doctor or pediatrician most often is the exclusive provider.

“Adult patients have a diverse group of potential providers, including pharmacies, community centers, churches and public health departments, in addition to traditional providers, some of whom are specialists,” Tan told Infectious Disease News. “All of these providers need to have confidence that they can access vaccination records so that they’re not giving duplicate vaccinations.”

But registries at only the state level, while beneficial, are also limited.

“Adults travel and it’s critical that providers are able to access the data wherever the adult goes,” Tan said. “Even kids are moving more than they used to, and having this information stored at the state level is not convenient for parents and school districts.”

For children, more advanced registries have a vaccine forecasting tool that shows a provider what vaccines a child is due for or overdue for based on the vaccine schedule. Some systems even provide reminders and recalls to patients, Moore said.

“If these vaccine forecasting tools were available for adults, providers would be prompted to administer the vaccines as needed,” Moore said. “This is a big part of increasing adult immunization rates. We really should consider these lifelong registries, and not just child registries or adult registries.”

Immunization neighborhood

Adults can get their required vaccines from a variety of providers, including retail pharmacies. Because pharmacists are not eligible for Meaningful Use grants, they are not required to use EHR systems that submit data to state registries. Requirements for reporting to registries vary by state and some states do require all immunizations to be reported. But whether this requirement is routinely enforced is unknown.

“Immunization neighborhood” is a term coined by the American Pharmacists Association. The neighborhood involves “the collaboration, coordination, and communication of immunization stakeholders who are dedicated to meeting the immunization needs of the patient and protecting the community from vaccine-preventable diseases.”

The various members of this neighborhood are all trying to provide the best possible care for a patient, Moore said. For some patients, it may be more convenient or affordable to receive a vaccination at a pharmacy, compared with a doctor’s office.

“We want these patients to go wherever it’s best for them to receive an immunization because if we make it difficult for them, we know they generally won’t be motivated to overcome difficulties and be vaccinated,” Moore said. “Those of us in the immunization community are good neighbors when we put information into an immunization registry, where all of the other neighbors can readily access it and see what a patient has received.”

Communicating information

Ideally, all of the individual state systems would communicate and immunization records would be available to providers throughout the country. From a pure technical standpoint, it is possible.

According to Gary Urquhart, MPH, chief of the CDC’s Immunization Information Systems (IIS) Support Branch, the IIS helps to facilitate development and implementation of immunization registries for CDC-sponsored programs, which includes the 56 registries in the United States. One role of the IIS is to standardize all of the systems, so that they use functional standards and best practices that are the same.

Almost all of the registries adhere to these standards and they are expected to adhere to these standards, Urquhart said. Because the registries have the same functional standards and are technology neutral, they have the ability to communicate. But many times, they do not.

“The major reasons that there are problems with interstate data exchange are primarily administrative,” Urquhart told Infectious Disease News. “States have statutes on privacy and confidentiality and data disclosure that prevent it. It can be done if people are willing. This problem isn’t just with immunization registries. Any public health information, and even vital records, also aren’t exchanged electronically. This is a big issue with government systems.”

Urquhart said the 10th Amendment allows states to control their own public health issues, including the data in immunization registries, even though the systems are sponsored by the US government. States want to have control over their data, partly to ensure that the data remain secure.

Meaningful Use

The American Recovery and Reinvestment Act of 2009 allows the CMS to provide incentives to health care professionals and hospitals that demonstrate meaningful use of electronic health records (EHR) technology. These providers are eligible to receive grants if they demonstrate that they are using their EHR technology in a way that positively affects patient care.

Meaningful Use incentives are being rolled out in stages. In stage 1, providers are required to adopt an EHR that is capable of communicating with Health Level 7 (HL7) standard protocol version 2.3.1 or higher. In stage 2, EHRs are required to submit data to the state immunization registries and the HL7 version 2.5.1 is endorsed as the standard technology for this process.

Stage 3 has not yet been implemented, and according to the CDC, it is expected to be rolled out in 2016.

“When Meaningful Use came along, one aspect that helped us standardize the systems was certifying the EHR products,” Urquhart said. “Some of the messaging standards used in these systems were developed by the CDC. There has been a lot of activity surrounding the interoperability between EHR products and immunization registries, and over the past few years, we have spent a lot of money to make that happen more efficiently. Standardized EHRs is one of the positive things that came out of Meaningful Use.”

Because of Meaningful Use, state registries are on track to be a valuable source of information for vaccine providers in a state. But that does not solve the problem of the lack of communication between the individual state registries for those who receive care in different states, according to Urquhart.

Kelly Moore

With the standard HL7 messaging system, they will have the capability to do so, but it is unknown whether it will actually happen, especially if states want to regulate their own data for security issues.

Access to records

Although the implementation of EHR programs makes it easier to send information to the registries, health care providers do not have the option of querying the state registries through the programs to determine whether a patient has received a vaccine from another provider. This bidirectional messaging is supported by the technology required for Meaningful Use incentives and this capability may be a facet in implementing stage 3 of the incentives.

“EHRs and registries need to be integrated so that data can go not only from the EHR to the registry, but also from the registry to the EHR,” Tan said. “It’s a two-way street and it’s electronically possible. We just need more political will to make it happen.”

Because this capability is lacking, giving a duplicate vaccine is not just a possibility — it’s inevitable.

“One example is when patients aged older than 65 are admitted to the hospital during influenza season,” Schaffner said. “The physicians are obliged to offer these patients the pneumococcal vaccine before they are discharged, but it’s difficult to ascertain whether or not they’ve ever received it.”

Moore said duplicate vaccine doses could be prevented, and at the same time, health care providers would know the patient has the protection they need, if all providers who administer vaccines send that information to the registry.

“With the re-emergence of measles and other contagious, vaccine-preventable diseases, having documentation of vaccination immediately accessible to people investigating outbreaks makes an enormous difference,” Moore said. “In a specific outbreak investigation, there is no time to wait and hunt for records. If we were able to run those records and see that people were vaccinated, we could save a lot of time and money that is spent on unnecessary immunizations.”

Potential for national registry

Opinions are divided on whether there will ever be a national immunization registry that will eliminate the problem of lack of interstate communication between the state registries.

“The states want to own their own data,” Tan said. “I would argue that there is little likelihood that we will get to the point where we have a national registry. It’s just too challenging.”

Tan said one idea would be to have a cloud-based national registry that is linked to the state registries. This would allow all the data to consolidate and be accessible anywhere in the world.

According to Urquhart, although there is no case today for a national registry, there will be in a few years, depending on how well the Affordable Care act is implemented. In Australia, for example, there is a national registry that works well, he said, but the difference is that Australia has a national health care system with unique identifiers for the patients.

Then there is the concern surrounding information security and information sharing within a national system, especially in today’s political climate.

“Allowing every health care provider, everywhere, to have access to immunization records on every patient regardless of where he or she received the immunization would be fantastic for patient care,” Moore said. “However, I can understand the concern people have about information security. There will be a tradeoff between information security and sharing information. A lot of work would need to be done to make sure that people’s information is well protected in such a system.”

Work in progress

Despite their benefits, immunization registries are not perfect. Some providers have not started using them yet, especially in those states where it is not mandatory to do so. In addition, there is no surefire way to know whether a lack of information in the registry means that a vaccine was not received.

“The more complete a record is, the more valuable it is for everyone,” Moore said. “When there is an absence of evidence of immunization, it is not necessarily evidence of absence of immunization.”

In addition, immunization registries do not keep track of those who do not receive immunizations, although there would be a public health benefit if they did population-based tracking, rather than just tracking those who receive immunizations, Urquhart said.

“Almost all of the systems in this country are lifetime registries and have the ability to track the population from cradle to grave,” Urquhart said. “It’s a question of getting more providers on board to do this reporting.”

“Almost all of the systems in this country are lifetime registries and have the ability to track the population from cradle to grave,” Urquhart said. “It’s a question of getting more providers on board to do this reporting.”

The more that health care providers and public health officials support immunization registry improvements and participate in immunizations, the more quickly they will improve and become invaluable to patient care, Moore said.

“Immunization registries are a lot like mass transit systems,” Moore said. “There are early adopters, but initially, the system is very limited. But the system grows until there is a tipping point where you can’t NOT use it. Things are getting better and I’m quite confident that within 5 to 10 years, we won’t be able to do our job without them.” — by Emily Shafer

References:

National Vaccine Advisory Committee. Development of Community- and State-Based Immunization Registries. Available at: archive.hhs.gov/nvpo/report071100.pdf. Accessed June 26, 2014.
Rothholz MC. The role of community pharmacies/pharmacists in vaccine delivery in the United States. Presented at: CDC Advisory Committee on Immunization Practices meeting; June 20, 2013.

Williams W. MMWR. 2014;63:95-102.

For more information:

Kelly Moore, MD, can be reached at: 615-741-7247.
William Schaffner, MD, can be reached at: william.schaffner@vanderbilt.edu.

L.J. Tan, PhD, can be reached at: lj.tan@immunize.org.

Gary Urquhart, MPH, can be reached at: iisinfo@cdc.gov.

Disclosure: The authors report no relevant financial disclosures.

Perspective
Sandra A. Fryhofer

Sandra A. Fryhofer

  • Immunization registries must be streamlined and a national registry would help achieve this.

    Recent media headlines of measles outbreaks and pertussis epidemics, as well as the recent CDC health alert for international travelers to countries with polio outbreaks, highlight resurgence of vaccine-preventable diseases. Immunization schedules are becoming more complex and comprehensive, especially for adults. These vaccines don’t come cheap. The Affordable Care Act’s new requirement that plans cover all ACIP-recommended vaccines adds another layer of incentive for vaccine coverage documentation. We don’t want patients to “miss” vaccines, but at the same time we don’t want patients to receive vaccines they “don’t need” (or may have already received).

    Patients no longer live in the same town with the same physician all their lives.  We are now a mobile society. Work (and leisure) travel is more international. At home, and abroad, we need the kind of protection that vaccines give. For the primary care physician or travel medicine physician, figuring out which vaccines someone has received is both time intensive and cumbersome. A national immunization registry should be a top priority wish list, but input will always be local at the time the vaccine is given. Current state immunization registry input must be streamlined and made user-friendly, so as not to become another barrier to immunization strategies. It is hard for me to understand that with all the time and money spent on developing EHRs, there is no requirement that all EHR’s link to state immunization registries.  

    Communicating vaccine coverage through a standard lifetime national immunization registry could help streamline this process. A National Immunization Registry is an opportunity yet fulfilled, and should be part of our healthcare prescription for our nation.

    • Sandra A. Fryhofer, MD
    • Internal medicine physician in private practice
      Clinical adjunct professor of medicine, Emory University
  • Disclosures: Fryhofer reports no relevant financial disclosures.
Perspective
Stephen Gluckman

Stephen Gluckman

  • There should be a national system for all medical records.

    There should be a single national computer system for all medical records, including a vaccine registry. People do move around. It has been well-documented that the adult population is under-vaccinated for everything. Vaccine-preventable diseases result in significant morbidity and mortality and they should not happen. Anything that would help facilitate vaccination in adults is good. In terms of preventing disease, after having safe water, there is no bigger “bang for your buck” than vaccines. Having readily available access to a person’s vaccine history would hopefully make a health care provider a more likely to ensure a patient is up to date. I don’t know why a person would be opposed to a national vaccine registry, except for the paranoia about “big brother.” I don’t see any down side at all. Our electronic health records programs flag all preventive care that a patient needs, including immunizations, and have the capability to send that information to a registry. Even within one city, it’s really difficult to get medical information on a patient who received care at another hospital in the same city. That can be a very time-consuming, and occasionally frustrating process. It is not a good use of time that should be spent on caring for patients. Patient care would be improved with a national, computerized medical record for everything.

    • Stephen Gluckman, MD
    • Professor of Medicine, Perelman School of Medicine, University of Pennsylvania
  • Disclosures: Gluckman reports no relevant financial disclosures..