Michigan Department of Health and Human Services
MDHHS Division of Immunizations

Michigan Care Improvement Registry/MCIR

Ongoing Data Quality Improvement Plan

Version 1.0

July 22, 2015

Ongoing Data Quality Improvement Plan1

Error! Use the Home tab to apply Version Number to the text that you want to appear here. December 11, 2014<Pub Date>December 11, 2014

MDCH Division of Immunizations

Table of Contents

Table of Contents

1.Introduction

2.Assumptions/Constraints/Risks

2.1 Assumptions

2.2 Constraints

2.3 Risks

3.Data Quality Principles

4. Organizational Roles and Responsibilities

5. Data Quality Tools

6. Routine MCIR Data Quality Processes

7. Data Quality Processes and Schedules

8. ACRONYMS

9. Referenced Documents

10. Record of Changes

Ongoing Data Quality Improvement PlanVersion 1.01Michigan Care Improvement Registry/MCIR

1.Introduction

There are many advantages to maintaining immunization data in a statewide Immunization Information System (IIS) such as the Michigan Care Improvement Registry (MCIR).MCIR allows authorized organizations to print immunization histories without pulling medical charts; it allows automated forecast of “immunizations due” based on the child’s age, history, and recommendations put forth by the Advisory Committee on Immunization Practices (ACIP) through the ACIP schedule. The MCIR; makes immunization histories transportable if the person seeks care elsewhere; and makes it possible for medical practices, counties and the State of Michigan to assess immunization coverage and generate recall notices at all of these levels. The IIS can also be used for surveillance activities.

However, all these benefits depend on the quality of the information in the MCIR. The information in MCIR should be a true reflection of all of the immunizations a person has received. ForMCIR to be a robust and useful immunization information system, stakeholders must be able to have confidence in the data it contains.

The accuracy of immunization records is a decisive factor in improving the health of persons. Both public health decision-makingand healthcare clinic operations rely on the accuracy of the MCIR. Inaccurate immunization records may result in increased morbidity and mortality. It is the responsibility of the MCIR program and the stakeholders to ensure the reliability of data stored in the registry. Data are entered into the MCIR from a variety of external sources; it is especially critical to establish standards for validating incoming data at the data entry point. Accurate, complete, and timely data in MCIR promotes participation among healthcare providers, health plans, schools and others. Higher participation in the registry results in complete immunization records for persons. Benefits of higher data quality include:

  • Increased provider trust
  • Increased use of the data
  • Improvements in clinical decisions
  • Improved personhealth
  • Improved public health

Poor data quality could result in a loss of confidence in MCIR and could create an incomplete picture of a person's immunizations, and possible erroneous forecast recommendations. Incomplete and inaccurate data could impact provider participation in the MCIR. Program and public policy decisions could be impacted by inaccurate summary dataasorganizations move towards increased electronic data sharing capabilities. It is critical that all users and stakeholders in the system adopt a consistent approach to data quality.

2.Assumptions/Constraints/Risks

2.1 Assumptions

MCIR is designed to:

  1. Create or support effective interventions such as clinical decision support, reminder and recall activities.
  2. Generate and evaluate public health responses to outbreaks of vaccine-preventable disease.
  3. Facilitate vaccine management, vaccine ordering and accountability.
  4. Determine a person’s vaccination status for decisions made by clinicians, and schools.
  5. Aid in surveillance and investigations of vaccination rates, missed vaccination opportunities, invaliddose administration, and disparities in vaccination coverage.

2.2 Constraints

The state immunization program, allusers and stakeholders of the system are required to support the MCIR design criteria listed above.

2.3 Risks

The advancement of electronic health records (EHRs), MCIRand the interoperability between the systems has and will continue to decrease the use of the general MCIR user interface for direct vaccine submission and personquery. Fewer users will view data submissions at the time of entry, which could increase duplicate person and vaccine record submissions.

3.Data Quality Principles

Table 1: Data Quality Principles

Principle / Condition / Examples
Consistency / The conditions (criteria) for validating data items should be the same regardless of how the data items have been reported to MCIR. / Regardless of a data item’s source and the method of data reporting (e.g., direct user entry or via HL7 reporting), the data item should go through the same set of data validation checks.
Rejected data / When information is rejected by MCIR, the following actions should occur:
  • Electronicimport logserrors and notifies submitters
  • HL7 userscan generate an Electronic Submission Summary Report (ESSR)
  • User Interface (UI)displays an error message, offering user opportunity for error correction
/
  • The MCIR Electronic Submission SummaryReport andDoses Administered Report, along with available inventory reports, assist the end user in finding, correcting and resubmitting data errors.
  • UI users receive edit checks verifying information on the screen, before data submission.

Internal consistency / Characteristics of the vaccination history should not contradict one another. This includes reported data as well as existing MCIR data. /
  • This principle is a basis for all crosscheck validations.
  • This principle covers cross-validations between characteristics of multiple vaccination events that comprise immunization history, as well as cross-validations between characteristics of individual vaccination events.
  • Vaccination history includes demographics, and information on all recorded vaccination events.

Accuracy / The data recorded in MCIR should match exactly what happens in a clinical encounter, whether or not it is clinically appropriate. /
  • Recommended for MCIR staff to periodically audit a random sample of incoming data to verify that it matches clinical records.
  • Submitters should periodically audit a random sample of data to verify that it is correctly documented in MCIR.

Appropriate vaccination / The vaccinations reported by a provider should be appropriate for the population served at the clinic. / MCIR Doses Administered Report (DAR)
Vital Records / Vital Records is the definitive source for:
  • Date of Birth
  • Date of Death
  • Adoption
  • Validation of correct demographic information
  • Management of duplicate EBC records
/
  • It is possible that an incorrect birth date or death date is transmitted from vital records, but those are rare occasions.
  • Currently, approximately 90% of birth dates come from the electronic birth certificate records.
  • End users may flag a person as deceased.
  • A feed from vital records also provides an electronic file of official death records to MCIR.
  • Adoption records are managed at the regional level.

Validation priority / The importance of validating a data item is related to the data item’s significance in clinical decision-making, public health assessments, and research. / Critical high priority data items are:
  • Vaccine Type
  • Vaccination Encounter Date
  • Eligibility
  • Lot number
  • Manufacturer
  • Date of Birth
  • Zip Codes

ACIP recommendations principle: / Deviations from ACIP recommendations and U.S. licensure may indicate data quality problems
MCIR does not accept immunization data prior to person DOB / If a date of birth is modified on a MCIR record,it could result in some vaccine encounter dates being documented before the date of birth.
Timeliness / Michigan Department of Health and Human Services requires immunization data to be entered into MCIR within 72 hours of administration for children less than 20 years of age. / To be useful for clinical decision support and health policymaking, immunization data should appear in the MCIR soon after the clinical event occurs.
Completeness / The information submitted to MCIR must contain the minimum/mandatory set of data items in order to be accepted by MCIR. /
  • Required data fields and the minimum/mandatory data setsfornecessary MCIR function and operation
  • Relevant data is optional and of value in improving MCIR function.The goal is to capture all relevant data on persons and their vaccination events.

Supremacy of medical records / Person medical records are of greater reliability in collecting immunization data than personbilling records (CPT codes).
MCIR has not accepted billing data since 2003. / MCIR accepts vaccine (clinical) data

4. Organizational Roles and Responsibilities

Table 2: Organizational Roles and Responsibilities

Organization / Role / Quality Responsibility
Immunization Provider / To provide accurate person level and vaccine data to MCIR within 72 hours of administration. /
  • Ensure that the data recorded in MCIR should match exactly what happens in a clinical encounter, whether or not it is clinically appropriate
  • Generate required data quality reports on a weekly basis allowing data quality errors to be corrected in MCIR
  • Conduct reminder and or recall mailings and update person addresses from returned reminder or recall mail notifications

Health Plan / To increase immunization coverage level of members. /
  • Assure participating provider meet Healthcare Effectiveness Data and Information Set (HEDIS) measure and comply with ACIP
  • Document address changes on members and flag possible duplicate records in MCIR
  • Conduct reminder and or recall mailings and update person addresses from returned reminder or recall mail notifications

Health System / To provide accurate person level and vaccine information to MCIR within 72 hours of vaccine administration /
  • Ensure that the data recorded in MCIR matches exactly what happens in a clinical encounter; whether or not it is clinically appropriate
  • Generate required data quality reports on a weekly basis and fix errors related to data quality in a reasonable amount of time
  • Assess clinic-level compliance and coverage rates, and ensure clinical-level compliance with the 72 hour mandate

Schools and Childcares / To ensure accurate immunization coverage levels by school building and to maintain compliance with local health department (LHD) reporting requirements
  • End users add immunization data to students’ records, as necessary
  • School/Childcare data and immunizing provider data are separated in MCIR
  • School/Childcare data is not viewable to immunizing providers
  • Local health departments are able to verify school/childcare data, after which it become accessible (viewable) to immunizing providers
/ Report duplicate student and vaccination records, and request required data corrections to student records
Local Health Departments(LHDs) / To provide accurate person level and vaccine data to MCIR within 72 hours of administration. Assure immunizations are given appropriately and timely in their jurisdiction
To oversee the Vaccine for Children’s Program at the local level /
  • Ensure that the data recorded in MCIR matches exactly what happens in a clinical encounter; whether or not it is clinically appropriate
  • Enter all historical information on a person to assist with increasing immunization coverage levels in the jurisdiction
  • Routinelymonitorthe quality of data being submitted and make the necessary corrections inMCIRwithin a reasonable amount of time
  • Conduct reminder and or recall mailings and update person addresses from returned reminder or recall mail notifications
  • Recommend data quality strategies to immunization providers in their jurisdiction
  • Monitor data quality assurance (DQA) for provider adherence to eligibility requirements, vaccine ordering and inventories
  • Referrals to MCIR staff for data quality reviews and training
  • Referrals to LHD’s for inventory management issues
  • Monitoring DQA for vaccine/antiviral ordering and distribution

Health Information Exchanges (HIE) / To transport accurate person level data to MCIR / Assure that the required fields in the message header are populated and formatted correctly
Accountable Care Organizations / To increase the immunization coverage level of members /
  • Assure participating providers meet HEDIS measures and comply with ACIP recommendations for immunizations
  • Document change of addresses on members and flag duplicate persons in MCIR
  • Conduct reminder and or recall mailings and update person addresses from returned reminder or recall mail notifications

Electronic Health Record (EHR) Vendor / To develop electronic medical records (EMR)that meet healthcare organization requirements, and federal requirements for required documentation support for immunization services / Develop and support HL7 interface requirements according to MCIR specifications for their customer’s specifications
Michigan Department of Health and Human Services (MDHHS)Division of Immunizations
Division Director / To provide oversight of the State of Michigan Immunization Program / Provide oversight of MCIR data quality policies
MDHHS Division of Immunizations
MCIR Coordinator / To provide oversight of the Michigan Care Improvement Registry program / Promote, develop and monitor MCIR data quality policies
MDHHS Division of Immunizations
MCIR Regional Coordinators / To monitor, recruit and train immunization providers, health plans and health systems.
To generate and create Business Objects(“ad hoc”) reports on behalf of MCIR users
To develop and update regional forms and training materials, as necessary
To monitor data submission and immunization rates for the region
To assure all regional users are updated on MCIR system changes and procedural changes
To develop strategies to increase private provider enrollment and participation in MCIR
To maintain listing of providers and users trained for the region
To operate and manage regional help desk activities.
To monitor data quality, including the performance of person and vaccine level de-duplicate measures
To monitor adoption records added to MCIR and perform the required data issue measures /
  • Perform required MCIR record quality assurance measures
  • Work with LHDs to establish an internal process to assure persons who have died within their county are appropriately flagged in IIS
  • Refer EBC and NICU data quality issues to PHBPP for required follow-up
  • Train providers on submitting HL7 messages and generating theMCIR ESSR report
  • ProcessMCIR Petition for Modification requests
  • Generate routinereports to monitor and identify MCIR data quality issues:
  • Electronic data submission
  • 72-hour submission (accreditation report)
  • Active site listing
  • Profiles
  • Inventory Controls
  • First time HL7 submitters -production
  • First time HL7 submitters- onboarding
  • Weekly HL7 message count
  • Sites with no weekly HL7 activity
  • Offer DQAbest practice strategies to providers
  • Refer DQA issues to appropriate stakeholders: LHDs, Assessment, Feedback, Incentives and eXchange (AFIX), Peer Education Program and/or State MCIR Program
  • Provide tier 1 helpdesk support to MCIR end users
  • MCIR UAT testing

MDHHS Division of Immunizations
Vaccines for Children (VFC) program / To provide access to vaccines (recommended by the Advisory Committee on Immunization Practices) to children whose parents or guardians may not be otherwise able to afford them, helping to ensure that all children have a better chance of receiving recommended vaccinations on schedule. /
  • Monitor data quality assurance for provider adherence to eligibility requirements, vaccine ordering and inventories
  • Referrals to MCIR staff for data quality reviews and training
  • Referrals to LHD’s for inventory management issues

MDHHS Division of Immunizations
Assessment, Feedback, Incentives and eXchange (AFIX) program / To raise immunization coverage levels, reduce missed opportunities to vaccinate, and improve standards of practice at the provider level through quality improvement processes /
  • Assist with monitoring data quality at the clinic level
  • Refer providers to MCIR regional staff for data quality improvement training

MDHHS Division of Immunizations
Perinatal Hepatitis B Prevention Program (PHBPP)*
*Established in 1991 / To prevent hepatitis B transmission from pregnant women to their infants, household and sexual contacts.
To coordinate the sharing of preventative perinatal hepatitis B transmissioninformation between primary care providers, hospitals, laboratories, the state and local health departments /
  • Monitoring Hepatitis B vaccine compliance in birthing hospitals, including NICUs
  • Identifying duplicate person records
  • Correctinformation identified as missing or requiring correction in the MCIRElectronic Birth Certificate (EBC)record
  • Monitor and perform necessary follow-up on Hospital Worksheet’s Unknown Hep B immunization and Unknown Immune Globulin (IG) data

MDHHS Division of Immunizations
Immunization Nurse Educators (INEs) / To provide free immunization education*, performed by INEs from both the Michigan Department of Health and Human Services and LHDs, to Michigan provider offices statewide
*The educational modules are developed and maintained by a core group of MDHHS-based nurses. Registered LHD nurses meeting the established qualifications and requirements, and completing the INE orientation are approved to teach these immunization educational programs within their LHD jurisdiction(s). /
  • To educate and promote data quality improvement strategies to immunization providers.
  • Identify data quality issues and referprovider offices to MCIR Regional Staff for data quality improvement training.

MDHHSOffice of Public Health Preparedness (OPHP) / To protect the health of Michigan citizens before, during and after an emergency through the integration of public health and medical preparedness initiatives and by leveraging diverse partnerships
To maintain a dual role in both preparedness planning and in emergency response activities encompassing all hazards, including natural and man-made disasters, acts of bioterrorism, infectious disease outbreaks and other emergencies that impact the health of the public / Monitoring data quality assurance for vaccine/antiviral ordering and distribution
MDHHS Division of Immunizations
Epidemiologists / To conduct ad-hoc queries, for the MDHHS Division of Immunizations, used to identify pockets of need, and trends in vaccination coverage /
  • To develop queries and identify data quality issues in the MCIR database.
  • To provide recommendationsto the Division of Immunizations for business rules or best practices to increase the quality of data in MCIR.

MDHHS Division of Immunizations
Adolescent program / To monitor adolescent coverage rates for the State of Michigan
To develop campaigns to increase adolescent immunization rates /
  • Promotion of MCIR to adolescent service providers
  • Promote use of Person Status, complete immunization records documented in MCIR
  • Promote MCIR Reminder/Recall activities

MDHHS Division of Immunizations
Technical Team / To provide technical infrastructure and related support
To develop IIS enhancements and newly identified functionality /
  • To conduct testing of the MCIR web application, as needed
  • To coordinate and monitor Health Plan data loads forHEDIS reporting
  • Tier 3 state-level MCIR help desk support for the Michigan Public health Institute (MPHI)
  • Quality assurance related to provider onboarding

MDHHSDivision of Vital Records / To compile and store records of:
  • Michigan births, deaths, adoptionsand marriages filed as early as 1867
  • Michigan divorces filed as early as 1897
/
  • To provide the MCIR with complete and accurate electronic birth records
  • To provide timely and accurate death record information to MCIR

MDHHSDivision of Lifecourse Epidemiology Genomics
Newborn Screening (NBS) program / To identify babies with rare but serious disorders who require early treatment*, as identify by Michigan law
*All babies are tested in order to find the small numbers who have a rare medical condition. / To flag duplicate person records in MCIR
MDHHS Division of Lifecourse Epidemiology Genomics
Early Hearing Detection And Intervention (EHDI) program / To assist in identifying infants with hearing loss
Tofollow the identified infants to enrollment of early intervention services
To work in collaboration with hospitals, clinics, parents, and audiologists / To flag duplicate personrecords in MCIR
MDHHS Early Periodic Screening Diagnosis and Treatment (EPSDT) / To offer early and periodic screening, diagnosis, and treatment (EPSDT) services to Medicaid eligible beneficiaries younger than 21 years of age, as required by Federal regulations / To flag duplicate personrecords in MCIR.
MDHHSCenter for Medicaid and Medicare Services (CMS) / To support shared services that are utilized by the MCIR program, e.g. the Master Person Index, MPI,and the Data warehouse /
  • To share known duplicate person records found in the MPI with MCIR
  • To share Medicaid Person ID’s with MCIR on a monthly basis

Michigan Department of Technology, Management and Budget / To manage all Information Technology (IT) services within state government / To provide database management services and disaster recovery services for the Division of Immunizations
MDHHS Division of Women Infant and Children (WIC)
WIC program / To provide supplemental foods, health care referrals, and nutrition education* to low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and infants and children up to age five who are found to be at nutritional risk
*funded throughfederal grants to the WIC Special Supplemental Nutrition program /
  • To flag duplicate person records in MCIR.
  • To share WIC ID’s and clients addresses with MCIR on a monthly basis

Michigan Public Health Institute (MPHI) / To provide technical and programmatic assistance to MDHHS Division of Immunization to successfully develop, deploy, and support statewide use of the MCIR /
  • To provide testing and approvalfor electronic file submission, according to MDHHS-approved policy & procedure. To update the MCIR Vaccine Code List and to identify system bugs and enter them into bug tracking software.
  • To maintain a second-tier helpdesk for technical support of the MCIR web application. To maintain a first-tier helpdesk for technical support of school and childcare usage of the MCIR.
  • To conduct testing of the MCIR web application as needed.
  • Provide tier 2 state-level helpdesk support to MCIR end users (i.e., providers) statewide
  • Provide quality assurance service on new functionality programmed into MCIR.

Center for Disease Control and Preventions (CDC)
National Center for Immunization and Respiratory Diseases (NCIRD) Immunization Information Systems Support Branch (IISSB) /
  • To maximize protection against vaccine-preventable diseases by leading the advancement of IIS, including the capture of accurate data on which to make informed immunization decisions.
  • To facilitate the development, implementation, and acceptance of IIS, whereby immunization providers will have access the data required to make informedclinical decisions
/ To develop national standards to ensure the quality of data in an IIS
American Immunization Registry Association (AIRA) / To promote the development and implementation of IIS as an integral tool in the prevention and control of vaccine preventable diseases, through collaborative interaction of the nation’s IIS / Develop performance measures for IIS data quality compliance and best practices to achieve the recommended standards developed by CDC
University of Michigan
Child Health Evaluation and Research (CHEAR) Unit / To conductprojects, which involve both primary data collection and secondary data analysis, and utilize both quantitative and qualitative research methods where appropriate / To provide data quality analysis and recommendations for improved MCIR data, through a contract with the MDHHSDivision of Immunizations

5.Data Quality Tools

Table 3: Data Quality Tools