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How Does the Colorado Immunization Information System (CIIS) Benefit Colorado’s Public Health Efforts?

An Interview with Heather Roth, Deputy Immunization Branch Chief at the Colorado Department of Public Health & Environment

Immunization information systems (IIS), also CIISreferred to as immunization registries, are confidential, population-based, computerized databases that collect vaccination data within a geographic area. They are a confidential, secure, and centralized way for authorized users (i.e. healthcare providers, public health officials, schools) to enter immunization data, access immunization records for patients, identify missed immunizations, monitor gaps in immunization coverage important for outbreak response and targeting interventions, and to ultimately improve vaccination rates.

In 1993, the United States attempted to implement a national immunization registry, but an overarching system proved challenging for individual states whose resources and population needs differed. As a result, individual states were directed to implement their own locally-governed IIS to address specific local challenges. The Colorado Immunization Registry Act of 2007 designated the Colorado Immunization Information System (CIIS) as Colorado’s lifelong immunization record tracking system, operated by the Immunization Branch at the Colorado Department of Public Health and Environment (CDPHE).

As part of a collaborative project, Immunization Barriers in the US: Targeting Medicaid Partnerships, Colorado and other states participating in the project’s Community of Practice have been exploring lessons and best practices related to IIS functionality, funding, provider participation, and data sharing and utilization to assess immunization coverage specifically among children and pregnant women on Medicaid and inform programmatic decision-making across public  health and Medicaid agencies. CCIC sat down with Heather Roth, the Deputy Immunization Branch Chief at the Colorado Department of Public Health and Environment (CDPHE), to discuss the Colorado Immunization Information System (CIIS) and how it works to benefit Colorado’s public health response efforts, data exchange, and clinical decision making.

  1. What data does CIIS house?

CIIS collects and consolidates individual-level vaccine and exemption data for Coloradans of all ages. CIIS stores all CDC-endorsed Core Data Elements for IIS Functional Standards v4.0. CIIS can also capture insurance source, primary language, employment information, medical home information and school enrollment information.

  1. How does CDPHE primarily use the data in CIIS?

We primarily use CIIS data to measure immunization coverage at the county level. We generate county-level coverage assessments for our local public agency partners twice a year and post these coverage rates on our public-facing website. New this year, we added a two-visit rate and a weighted rate to these assessments to better account for denominator inflation.

  • Can you provide an example of when CIIS data has been especially important for public health reasons, like an outbreak investigation? CIIS has been an important tool in supporting Colorado’s ongoing hepatitis A outbreak response. Providers involved in outbreak vaccination efforts use CIIS to screen patients for their hepatitis A vaccination history and record doses of hepatitis A vaccine administered as part of outbreak response. Hepatitis A vaccine orders are also managed through CIIS, ensuring dose-level accountability of publicly-purchased vaccine.
  • Specific to this project, do you use CIIS data for any specific initiatives related to assessing immunization coverage among pregnant women and/or children on Medicaid? We are currently analyzing data to identify pockets of need in both of these Medicaid populations as part of this Community of Practice. We plan to generate immunization rates for both the Medicaid child and pregnant populations in Colorado, as well as identify Medicaid providers who bill for well-child visits but not immunizations. Once we have generated the rates, we will visualize them by county, local public health agency jurisdictions and Regional Accountable Entity (RAE) jurisdictions. This data will inform our engagement of partners in improving education and messaging around immunization and well-child visits, as well as recruiting and maintaining an adequate network of Vaccines for Children (VFC)
  1. What funding sources support CIIS, including any federal 90/10 HITECH funds?

CIIS is funded through a blend of State General Funds and Federal Funds from our department’s Immunization and Vaccines for Children cooperative agreement with the CDC. While Colorado also receives 90/10 funds, the majority goes to the Colorado Regional Health Information Organization (CORHIO) to support connecting providers to the IIS through the Health Information Exchange (HIE). The 90/10 funds our department receives support annual maintenance costs for our CIIS Resource Center: a one-stop-shop for HL7 pre-testing, IIS enrollment, interface onboarding and Meaningful Use management.

  1. How is CIIS data shared with other state agencies or other partners?

CIIS data shared with Colorado’s Medicaid agency, the Colorado Department of Health Care Policy (HCPF) is governed by an interagency agreement between the two departments. Under this agreement, HCPF sends Medicaid immunization claims data to CIIS weekly, and CIIS provides HCPF with an annual HEDIS match for Medicaid enrollees. CIIS data also supports several other public health programs co-located at the state health department, including: WIC, School-Based Health Centers, Refugee Health, Child Fatality Prevention System, and Vaccines for Children. Many of these data partnerships are governed by data use agreements approved by our department’s privacy board.

  • How did you address any HIPAA (and/or FERPA) concerns about data sharing? All of our data use agreements are reviewed by our department’s privacy officer to ensure compliance with HIPAA and any other statutes and rules for data use, privacy and confidentiality.
  1. How do you incentivize various types of providers to participate in CIIS?

Our recruitment activities changed greatly with Meaningful Use. For the first time ever, providers were contacting our department to get connected to the IIS. We continue to collaborate with partner organizations like the Colorado Chapter of the American Academy of Pediatrics and the Colorado Academy of Family Physicians to promote the use of CIIS. We try to incentivize CIIS participation by helping providers understand how the system can save them time and support their clinical decision-making. We actively recruit schools and child care providers for IIS participation, promoting CIIS as the gold standard for immunization documentation in Colorado.

  1. What are some of CIIS’s greatest capabilities and recent successes?

In late 2015, we completed a quality improvement (QI) project intended to decrease the length of time to develop electronic interfaces between CIIS and health care providers. The long-term goals of this project were to eliminate the backlog of more than 630 providers waiting for an interface and improve data completeness and timeliness within CIIS. Electronic data exchange with CIIS gives health care providers and public health agencies greater access to more complete immunization data for real-time decision-making. After several internal process changes were implemented and additional staff members were hired, the average time to develop a CIIS interface was reduced by 58% (9.5 months down to 4 months). Electronic Health Records (EHR) vendors and health care providers are now required to complete message pre-testing through our online, automated self-serve testing tool before they can move forward with establishing an electronic interface with CIIS. In addition, the CIIS interoperability team now uses several new tools to: (1) ensure health care providers are adequately trained on entering data into their EHR system; (2) identify “show-stopper” data quality issues earlier in the project; and (3) identify champions within the clinic to manage project expectations and gain ongoing commitment. We have reduced our wait list by 68% in the past 3.5 years.

  1. What are the biggest challenges you face related to CIIS data utilization, accuracy, quality and completeness?

One of our biggest challenges is denominator inflation. We currently have no documented process for identifying patients who may have moved out of Colorado or are seeking care across state borders. If we had a method for identifying these patients, we could inactivate them at the jurisdiction level within our IIS. Doing so would help in generating more accurate coverage assessments.

  1. What sort of CIIS enhancements would be most beneficial?

I would prioritize any enhancement to make CIIS more user-friendly and intuitive for our school and child care users. There is great functionality available in our school web application, but utilization of the functionality is hindered by the burdensome requirement of having to enroll students one at a time within the system.

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