9/11/2012
OKLAHOMA STATE STRATEGIC PLAN TO INCREASE IMMUNIZATION RATES
AMONG CHILDREN, ADOLESCENTS and ADULTS
INTRODUCTION
One-in-four of Oklahoma’s children are inadequately protected against the basic series of vaccine preventable diseases, as defined by the Centers of Disease Control and Prevention (CDC). A recent analysis of Oklahoma’s immunization databy the National Immunization Survey (NIS) reveals that just one more dose of the recommended 4:3:1:3:3 vaccination (4 DTaP, 3 Polio, 1 MMR, 3 Haemophilus influenzae b, 3 Hepatitis B) series would have a significant increase on the coverage rate of Oklahoma children. Findings from the National Immunization Survey (NIS) and analysis of OSIIS data will be reviewed as they become available to determine vaccine coverage trends by antigen type, age group and other variables. 2012 NIS results reported that 77.3% of Oklahoma's two year olds were up-to-date with the 4-3-1-3-3-1 series compared to the national average of 79% up-to-date.
The Oklahoma State Department of Health (OSDH) Immunization Strategic Targeted Action Team (STAT) was created in January 2010 and charged with developing objectives and an action plan to improve immunization coverage rates among children 19-35 months of age. The Team, in conjunction with the Oklahoma State Immunization Advisory Committee developed the Oklahoma State Strategic Plan to Increase Immunizations among Children 19-35 Months of Ageand continues to addresses the following components: improving legislative and state agency policies, creation of a redesigned Oklahoma state immunization registry (OSIIS), efforts to improve parental outreach and access to immunization services, engaging communities with the lowest immunization rates to initiate improvement strategies, and improved public education and marketing.Consideration of vulnerable populations (racial and ethnic) is also included in the plan.
Strategic Goal:
Increase 4:3:1:3:3:1 immunization rates of children 19-35 months from 77% to85 % by 2017.
Existing Policies Impacting Children age 0-35 Months
Oklahoma has set in place several policies designed to enhance and support immunization coverage improvement, including:
- Oklahoma Childcare Rules – All children attending licensed childcare must be age-appropriately vaccinated. Current rules cover the primary 4:3:1:3:3:1:4 series (includes one varicella and 4 pneumococcal conjugate). The OSDH is responsible for establishing rules butenforcement is provided through the Oklahoma Department of Human Services (ODHS). The OSDH Immunization Service also conducts vaccine assessments in at least 600 daycare centers annually.
- Oklahoma First Dollar Coverage Law – Enacted in 1997, this statute provides that health benefit plans cover all state required vaccines for their members who are <19 years old. This law also stipulates that required immunizations must be offered in the absence of co-pays and deductibles. Companies that participate in self-insured plans are exempted under this law.
- OK By One Immunization Schedule – Implemented in 2004, the OK by One schedule was adopted to “simplify” the childhood schedule for parents and providers and promote children receiving the 4th DTaP as early as 12 months of age as an acceptable practice. This campaign also stresses thatit takes just 4 visits and immunizes against 13 vaccine-preventable diseases by 12 months of age. This schedule is compatible with the recommendations of the Advisory Committee on Immunizations Practice (ACIP) of the US Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP).
- A vaccine for Children Program Delegated Authority – Beginning in 1995, Oklahoma was the first state to designate underinsured children as eligible for Vaccines for Children (VFC) vaccine in county health departmentclinics through a delegated authority arrangement with a Rural Health Clinic. This practice will continueto affect thousands of children statewide each year due to a new agreement with county health departments recently signed in April, 2012.
Temporary Aid to Needy Families (TANF) – The current national policy is to restrict financial assistance if children are not up-to-date on vaccinations. This policy is enforced by Oklahoma Department of Human Services (ODHS). TANF clients will receive a 25% reduction in benefits if their children's immunization status is not current at the time of recertification.
- VFC Participation among Medicaid Providers – In 2006, the Oklahoma Health Care Authority (OHCA) adopted a policy requiring that all Medicaid participating primary care providers serving children will be enrolled in the VFC program.
- Participation in Oklahoma State Immunization Information System (OSIIS) among Medicaid Providers – In 2009, the OHCA required their immunization service providers to document all childhood vaccinations in the OSIIS registry.
Objective 1: Reduce or eliminate coverage disparities by race, ethnicity, and socioeconomic status. Increase the 4:3:1:3:3:1 rates among children 19-35 months old in identified areas of disparities to align with the national average.
Reports will be developed through the Oklahoma State Immunization InformationSystem (OSIIS) to analyze zip code specific data to identify areas ofdisparities with 4:3:1:3:3:1 rates for children 19-35 months old below thestate average and target these areas with strategies for improvement.Operation Buzzer Beater and OSIIS reminder RECALL activities will beimplemented in these identified areas. These reports will be delegated to therespective Immunization Field Consultants (IFCs) and to the seven agencies under contract with the OSDH toattempt contact with the parents. A phone call reminder will be made; if nophone contact is accomplished or a working number is unavailable, a mailvaccination reminder will be sent. This will be an ongoing monthly activity. The Oklahoma State Immunization System (OSIIS) will be used to determinethe percent of children at least four months old and under six years of agethat are complete for all age-appropriate ACIP-recommended vaccinations,primarily using 4:3:1:3:3:1 criteria complete by 35 months of age.
Objective 2: Increase the number of providers using the Oklahoma Immunization Information System (OSIIS) to automatically generate a reminder RECALL for all clients not current in the registry from 75% to 85% by 2017.
Considerable effort will be devoted to increasing provider participation in the use of reminder RECALL system in theOklahoma State Immunization Information System (OSIIS) to automaticallysend postcard reminders to guardians of clients that are not current on theirreported immunizations.This can be completed from the central office with the provider’s permission which should be a big boost to increased coverage of infants and adolescents statewide.
Objective 3: Promote evidence-based strategies. Decrease the number of missed opportunities on annual Oklahoma State Immunization Information System (OSIIS) missed opportunities reports overall by 10% by 2017.
All Immunization FieldStaff will begin to document (to ensure consistency of message) that they emphasized at least four officepractices providers can implement to eliminate missed opportunities and ensure children receive allrecommended vaccines during their office visit. These points will be emphasized beginning in 2012 during AFIXfeedback sessions (80% of all VFC providers targeted each year).Enhanced training will initiate at the provider's annualAFIX feedback session and continue during quarterly provider temperature check site visits.Immunization Field Staff will continue to emphasize efforts to reduce missed opportunities. Evaluationdata will be generated from the state immunization registry (OSIIS) which can produce missedopportunity reports on VFC Providers every 3 months. At the end of the first year of this intervention,missed opportunity reports will be analyzed to determine if there has been a reduction in missed opportunities statewide.
Objective 4: Work with VFC providers on quality improvement processes to increase coverage levels and decreases missed opportunities using AFIX components, as appropriate, and move toward use of OSIIS as the primary source of data for provider coverage level assessment by the end of the project period.
Assessment procedures and protocols for conducting AFIX visitswill be revised and maintained annuallyalong with reporting requirements for documenting assessment findings. QA/AFIX visits will be conducted annually in 80% of all VFC provider offices emphasizing education on decreasing the number of missed opportunities to vaccinate in provider offices. A database will be maintained annually to monitor changes in coverage levels and missedopportunities for providers that receive AFIX visitsto assess immunization coverage levels.A plan to use OSIIS as the primary source from which records are used to assess immunization coverage levels with goals for eachyear of the five-year project periodwill be emphasized annually with providers.
In2012, 83% of children < 6 years of age in the immunization registry (OSIIS) have atleast two or more immunizations recorded. During VFC/AFIX site visits, OSIIS users will be encouragedby Immunization Field Consultants to enter immunization records for non-VFC eligible children intoOSIIS. Work towards developing a Master Person Index (MPI) and the reduction of duplicate recordsis continuing, but will not be achieved in 2013. Work towards OSIIS data exchange procedures usingHL7 standards is ongoing although completion is still a few years away.
Objective 5: Track school vaccination and exemption requirements.
An electronic statewide assessment of school-specific coverage levels for each vaccine appropriate forkindergarten entry will be conducted each year using a CDC-approved methodology and submitted in PAPA by the April 30th deadline. Reports indicate that 94% of public kindergartners are up-to-date on required immunizations at the time of the self-reported survey in 2012. Public and private kindergartens will be reported separately. A total of 84% of reported private kindergartners were up-to-date in 2012. The number ofmedical, religious and philosophical exemptions will be monitored each[s1] year in an effort to track the distribution of philosophical exemptions throughout the state and enable educational interventions in areas with increasing rates.
Objective 6: Improve adolescent immunization coverage levels; Tdap from 66% to 72% by 2017; Meningococcal from 55% to 65% by 2017, and HPV >3 doses from 28% to 40% by 2017.
Trends in NIS data will be annually reviewed to evaluate adolescent rates to identify and target interventions to improve rates. Oklahoma State Immunization Information System (OSIIS) data will be analyzed annually to monitor changes in vaccine rates at the county level. Work will continue with partners to support the establishment of an adolescent platform for adolescent immunizations. Meetings will be held at least twice yearly with key partners to discuss ways to increase adolescent immunizations and to monitor and document progress. (Oklahoma Immunization Advisory Committee, Immunization Program Staff, OSDH Adolescent Staff)
Continued enrollment of all practices that see VFC-eligible adolescents in the VFC program will be a high priority in the next five years.The new requirement for Tdap vaccine for students entering the 7th grade was implemented in the2011-2012 school year. Public awareness activities will continue to be conducted and materials related to the school requirement for Tdap vaccination will be distributed to VFC Providers, local health departments,and parents each year. Vaccination coverage and exemption levels forTdapat 7th grade entry will continue to be assessed each year according to state requirements, using a CDC-approved survey methodology. The statewide 7th grade level for compliance with the Tdap requirement was 65% for the 2011-2012 school year. The proportion of adolescents aged11-17 years that have 2 or more immunizations recorded in OSIIS is at 45%.
Objective 7: Enroll and sustain a network of VFC and other providers to administer federally funded vaccines to program-eligible populations according to CDC/ACIP and NVAC standards.
Written policies and protocols to recruit and enrollnew VFC Providers will be updated each year. In 2006, the Oklahoma Health Care Authority (OHCA) adopted a policy requiring that all Medicaid participating primary care providers serving children be enrolled in the VFC program. New providers, including non-traditional providers,providers serving adolescents, and newly licensed providers or newlyestablished in areas serving VFC-eligible children will continue to be identified and recruited in the VFC Program.Collaboration with medical societies, state licensing boards, and theOK Medicaidagency will continue to assist in identifying providers to recruit and enroll in the VFC Program. VFC providers will also be required to complete and submit provider enrollment and profileforms annually.
Objective 8: Monitor and ensure administration of the hepatitis B birth dose and HBIG to all infants born to HBsAG+ mothers including case management to ensure that at least 85% percent of infants born to HBsAG+ mothers receive hepatitis B vaccine and HBIG within 12 hours of birth.
Continue to work with Oklahoma birthing hospitals to achieve universal hepatitis B birth dose coverage in infants born to mothers with HBsAG+ and/or HBsAG unknown status within 12 hours of birth and document the birth dose of hepatitis B in the Oklahoma Immunization Information System (OSIIS) in compliance with Oklahoma Statue 310:667-13-5 (Universal birth dose hepatitis B vaccination). Continue to work with public and private providers to ensure the receipt of the complete series of hepatitis B in children born to HBsAG+ and HBsAG unknownstatus mothers by 15 months of age through comprehensive case managementdirected by the OSDH Perinatal Hepatitis B Coordinator.
Objective 9: Encourage OSIIS participation among VFC providersto ensure 90 percent of public/private and complementary[s2] immunization provider sitesroutinely submit immunization events to the OSIIS.
OKLAHOMA STATE IMMUNIZATIONREGISTRY (OSIIS) ENHANCEMENTS
The Oklahoma State Immunization Information System (OSIIS) is a statewide registry for persons of all ages. Implemented in 1995, OSIIS is utilized by 955 full service providers and 1,411 ‘read-only’ providers (including over 1,100 schools and 200 childcare facilities). The Oklahoma Immunization Service has achieved the Healthy People 2010 objective of two or more vaccines recorded in OSIIS for over 90% of the population under 6 years of age. An estimated 57% of Oklahoma children less than 6 years of age have 14 or more vaccines recorded in OSIIS.
The OSIIS registry provides multiple benefits to clinical practices utilizing the system including vaccine forecasting, ability to print an immunization record, automatic vaccine ordering for VFC providers and reminder/recall for children due or past due for vaccines. Additionally, the system is used as the primary management tool by the OSDH Immunization Service for vaccine accountability, provider quality assurance, immunization coverage assessment, policy development, billing,[s3] and targeting pockets in need of immunization services.
OSIIS System Modifications
Although OSIIS is nationally acknowledged as a premiere immunization registry, it currently lacks some interoperability capabilities that would allow for the electronic exchange of immunization records among providers utilizing electronic medical records or other alternative systems that capture immunization data. A new .net OSIIS system is currently being developed that will include the following enhancements:
- Modules for childcare and school tracking;
- Immunization scheduling/forecasting software for children, adolescents and adult vaccines;
- Modules that would allow for improved monitoring and evaluation of immunization interventions (i.e. – Operation Buzzer Beater and Missed Opportunities Evaluation Project);
- Development of a data warehouse that allows for direct assessment of vaccine coverage levels for children, adolescents and adults at the practice, regional and state levels; vaccine uptake and vaccine forecasting;
- Improved processes for de-duplication;
- Interoperability between other Immunization data systems and OSDH systems (i.e. - VACMAN, Comprehensive Clinic Assessment Software Application{CoCASA}, Public Health of Oklahoma Client Information System {PHOCIS}, Vital Records, C-1, WIC)
- Development of modules for documenting immunization exemptions and adverse reactions; and
- Expanded reminder/recall system for adolescents and adults.
The new OSIIS registry is scheduled to be completed in[s4] the spring of 2013 and implemented statewide by the end of 2013.Continue to promote and encourage the use of the new Oklahoma State ImmunizationInformation System (OSIIS) by providers for record entries of non-VFCeligible children and by VFC providers who are identified as not using OSIISfor record entries during QA/AFIX/VFC site visits conducted by ImmunizationField Consultants targeting 85% of all VFC providers each year. Continue to incorporate dose-level accountability into OSIIS functionality so that information can be received andstored. (Dose-level accountability includes assigning a provider-determined program eligibilitycategory for a patient to each administered dose of vaccine.) Continue to collect data through the registry (OSIIS) to accurately account for all publiclypurchased vaccine. Continue to monitor this information using standardized protocols toassure that provider’s vaccine orders are consistent with the provider’s annualprofile and to determine the amount of vaccine lost or wasted on an annual basis. Continue to providetechnical assistance to providers when problems are identified by theIFCs[s5] and Regional Immunization Coordinators (RICs), and implement corrective action plans as needed during VFCsite visits. Develop a written five-year OSIIS strategic plan (2013- 2017) to include a needsassessment, vision and goals, compliance with NVAC functional standards,and a monitoring and evaluation plan by March 31, 2013.[s6]
Objective10: Develop a new immunization information system (OSIIS) that has full capacity for electronic data exchange.
Currently OSIIS is undergoing a significant transition to a .net platform which is not scheduled for full operation until June, 2013. OSIIS supports 2.5.1 VXU message format and accepts test messages and Production messaging from providers seeking to attest to meaningful use Stage One. Immunization service staff will continue to collaborate with the Interoperable Public Health Information System (IPHIS) in strategic planning. The IPHIS will include solutions for assigning unique identifiers, integration, and interoperability. Short term goals for the next five years related to immunization and electronic data exchange include maintaining national data standards; deduplication of individuals and immunizations across all data systems containing immunization data including the VXU repository;implementing interoperability across OSIIS-web, OSIIS-PHOCIS, and the VXU repository; to develop and implement a provider registry; and incorporate inventory management into electronic messaging.
To support providers, hospitals, and other partners in electronic data exchange, OSDH supports a website for eligible providers and hospitals to register to submit immunization test messages for Meaningful Use Stage 1. OSDH is collaborating with the three local Health Information Exchanges to receive electronic immunization messages through the HIEs. In addition, a new start-up HISP-like company has approached OSDH to collaborate in working with providers and EHR vendors to submit immunization messages.