Immunization Registry in San Diego Looks to Improve Public Health

The San Diego Beacon Community (SDBC) is a partnership of health care providers, clinics, hospitals, emergency medical services and public health organizations. SDBC’s goal is to improve the quality of health care delivered for all San Diegans using health information technology (IT). The SDBC’s largest investment is creating a health information exchange (HIE) to support an electronic network that allows doctors to obtain patient health information from participating sites. In addition to creating the HIE, SDBC has a number of other goals and objectives, including increased provider participation in the San Diego Immunization Registry (SDIR).

The San Diego Immunization Registry (SDIR) is an immunization information system, which is part of the California Immunization Registry (CAIR), and is a voluntary registry under California law. SDIR is housed in the Immunization Program of the Division of Public Health Services (PHS) in the County of San Diego Health and Human Services Agency. It is maintained under the authority of the San Diego Public Health Officer and is a collaborative effort between specific County of San Diego programs and clinics, physicians, schools, and child care providers. SDIR provides an electronic record of all immunizations given to an individual by participating providers in both the public and private sectors. It is a web-based tool that helps doctors with immunization practice management, increases patient satisfaction by decreasing unnecessary immunizations, and decreases vaccine preventable diseases by improving adherence to recommended shot schedules. SDIR also allows PHS, as the local health department, to monitor immunization rates, one of several essential public health services. The integration of SDIR into the HIE is one of the key projects involving public health in SDBC.

The SDIR has been in operation in San Diego since 1997. The immunization registry has a robust infrastructure and is currently accessed by more than 300 sites in the county. Most providers enter immunization information data manually, which can be a significant staff burden. Although many providers had no electronic health record (EHR) or practice management system (PMS) when SDIR first began, more providers are now utilizing these technologies. This means that increasingly providers face the prospect of dual data entry into both SDIR and their own EHR or PMS systems. Although SDIR gives providers clinical decision support (CDS) tools that help clinicians to accurately identify needed immunizations for individual patients, the reliance on manual data entry represents a significant barrier to wider participation in the registry.

Starting in 2008, SDIR rolled out a small number of interfaces that enabled connectivity between provider’s EHR or PMS and the immunization registry, allowing providers to enter their information into only one system. With this capacity, providers are also able to access immunization information through SDIR’s online tools and reports, while maintaining one patient record within the EHR. SDIR currently has interfaces with eight provider systems. Although these multiple interfaces have solved the problem of duplicate data entry for many providers, some sites are still unable to interface with SDIR. Additionally, each interface is expensive; therefore, having multiple interfaces becomes very costly.

“To compensate for the burden of manual data entry, our providers get a significant benefit: Clinical Decision Support. That sets San Diego apart from the rest of California.” –OPH

Including SDIR in the SDBC HIE may broaden registry participation and reduce duplicate data entry. SDBC’s public health goals include increasing the percentage of health care organizations contributing data to the registry and improving immunization rates in the county.

As stated, SDBC is focused on enabling HIE in San Diego County. The model that SDBC will use for the HIE is a “hub and spoke” framework.

• SDBC serving as the “hub,” or conduit of all information, and county health care stakeholders, including clinics, individual physicians, hospitals, and public health, serving as the “spokes.”
• In terms of easing issues of duplicate entry and burdensome costs, the new system will allow one interface to connect all EHR systems to SDIR (as opposed to the current system that uses separate interfaces for different EHR products).
• The new interface will also directly transport all information contained in SDIR into the HIE, allowing for interconnectivity not only between SDBC-planned providers and SDIR, but eventually with other providers, schools, childcare organizations, and other stakeholders in the county.
• In a future phase, the SDBC will be able to query SDIR for patient vaccine history to determine what vaccines need to be administered during an office visit. To do this, SDBC HIE will transmit either a continuity of care document (CCD) or a vaccine HL7 Version 2 message to SDIR’s third-party vendor who will do the appropriate transformations before entering the information into the registry.
• These new systems will not only streamline information exchange, but will also decrease cost and burden on providers, as the number of required interfaces between providers and the registry are reduced. This flexibility will also allow more providers to qualify for Meaningful Use dollars.

“The new system has a central hub, as opposed to our old system of a massive spider web. It is much cheaper, faster and more efficient.” –OPH

Education: It will be critical to work with providers to offer information and education about the new system, and show how HIE technologies can improve workflow and patient outcomes. SDIR providers will be informed that existing interfaces will eventually be channeled through the SDBC HIE once existing interfaces are migrated.

Security: The SDIR system within the HIE does retain immunization and patient data, but it is the only aspect of the SDBC system to do so. No other elements of the HIE retain patient-related data outside of a master catalog of patients for the patient locator service (Master Patient Index). Currently, participating providers in SDIR will want assurances that this new system is just as secure as the existing one, and that all the benefits, plus those accurately identify needed capabilities discussed above, still apply. SDIR and SDBC will work with the community and other initiatives funded by ONC to assure providers that immunization and other medical information are securely managed in the HIE as the system matures into the future.

Resources: Another issue the SDBC and SDIR have faced is that there are currently many health IT initiatives in which providers want to be involved, but limited resources often mean they must choose to focus only on a few activities. Local provider education has centered on benefits of the HIE and urged providers to prioritize participation in this effort; however, both SDBC and SDIR have limited resources and must implement a phased approach to accommodate all providers who want to participate.

Consent: Additionally, SDBC and SDIR have been working together to develop an appropriate consent management system for SDIR and the HIE. This has been challenging in that a patient has to opt-in to allow a provider to enter his/her information into the SDBC HIE. Conversely, SDIR operates under California law as on an opt-out system. To simplify this process for the patient, a patient now simply has the option to opt-in to both systems. If a patient declines to do so, he or she would be opted out of both systems.

SDBC and SDIR will continue working together to help providers around the county utilize the immunization registry and the new HIE. Both entities are pleased with their collaboration thus far, and are excited to see what the future holds.

“It is exciting to see the demand from providers to participate in the new system. While resources are limited, we look forward to the eventual participation and phasing in of all who are interested.” –OPH