eHealth Meeting, Washington DC18 November 2011

M. Carolina Danovaro, MD, MScRegional Immunization Advisor – PAHO

eHealth for Immunization Programs in the American

Region

eHealth for ImmunizationeHealth for Immunization

Record management systems, mobile technology, technology for identification, barcodes, and multimedia, provide potentially useful tools to improve:

– immunization and surveillance data collection, quality, and timeliness of reporting;

– individualized follow-up of schedules; – monitoring of events supposedly attributable to vaccines

and immunization (ESAVI); – continuing education and training; – social mobilization, and – a more efficient management of vaccines and other

supplies, and the cold chain

eHealth for ImmunizationeHealth for Immunization

Immunization Information Systems– Nominal Immunization Registries– Systems for monitoring events supposedly attributable to

vaccines and immunization – Vaccine and supply stock management

Tools for training and for social communication– Multimedia– Web 2.0

TAG Recommendations 2009TAG Recommendations 2009

TAG reaffirms the recommendation (since 2002) that systematic and periodic assessment of coverage data accuracy, consistency, completeness, and timeliness should become a regular activity within national immunization programs.

– This assessment should be conducted within the context of regular on-going evaluation and supervisory activities.

Monitoring numerator trends by month and year and calculating drop-out rates between all doses, including DTP2, and monitoring denominator variations should be done systematically at all levels.

Immunization programs should be aware of the conduction of surveys that, among other health indicators, calculate vaccination coverage in order to ensure that questionnaires are adequate and interviewers properly trained to assess vaccination status, and that the results are internally consistent between biologicals.

TAG Recommendations 2009TAG Recommendations 2009

Countries using national computerized nominal immunization registries should document their experiences, successes, and lessons learned in order to share them with other countries – Re-issued in 2011

PAHO should continue supporting countries to improve their immunization data quality by promoting the evaluation of the quality of their immunization data and information systems.

– PAHO should also support the implementation follow-up of the recommendations resulting from such assessments.

PAHO’s immunization program should develop guidelines regarding coverage monitoring and data quality, and establish strategic alliances with entities specializing in vital statistics and demography to promote the generation and availability of accurate denominators figures to calculate vaccination coverage.

Current Systems to Monitor Vaccination Coverage

Current Systems to Monitor Vaccination Coverage

Example of EPI Data FlowExample of EPI Data Flow

• Vaccination Registry in forms predetermined by variables of:• Age• Sex• Vaccine• Dose• Region of residency

Local Level (Post/Health Center/all sectors)

Weekly (monthly in remote areas) flow, from the local to national levelInformation includes data from weekend and is reported on Tuesday

Vaccination CardsVaccination Cards

Tally sheets or equivalentTally sheets or equivalent

Individual Nominal RecordsIndividual Nominal Records

Dockets or other clinical chartDockets or other clinical chart

Computerized systems for number of doses

Computerized systems for number of doses

Monthly

aggregated

Reports

HEALTH

CENTER

District

NATIONAL

LEVEL

Monthly

aggregated

Reports

RegistersTally SheetsClinic CardMCH Month Reports

Example of EPI Data Flow

PRIVATE

PRACTITIONERSBy 5th working day of the following month

RevisedDenominators

Denominators

Quarterly feedback

Second week of the following month

Computerized Nominal Immunization Registries (NIRs)

Computerized Nominal Immunization Registries (NIRs)

HEALTH FACILITY

DISTRICTPrivate Sector

NGOs

Social Security

Informe

MensualNominal

Registry

Nominal

Registry

Other vacc. providers

Na

tion

al C

om

pu

teri

zed

N

om

inal

Imm

un

iza

tion

Re

gis

try

SUB-NATIONAL

NACIONAL

Topic of current interestTopic of current interest

Dec 2010 – European meeting on nominal imm. registriesJan 2011 – Bill Gates raises the issue of mobile technologiesFe 2011 – PAHO workshop on nominal immunization registries

James L. Goddard, M.D., M.P.H., 8th CDC Director,

1962 – 1966CDC Public Health Image Library (PHIL) 

“…perhaps in the rather distant future, the capabilities of electronic computers for storing and retrieving information could greatly facilitate our immunization programs…A nationwide computer system could put us well on the road to efficient national follow-up of births for maintenance of immunization levels.”

2nd National Immunization Conference, 1965

Topic “dreamt about” in the 1960’sTopic “dreamt about” in the 1960’s

Information for action:– Appointments, (SMS) recall-reminders– Deal with migration and internal mobility– Lot tracking down to people receiving the vaccine– Vaccination records can be printed– Integration with epi surveillance and other health data

• Cohort studies vaccine effectiveness and safetyAllows a detailed analysis of who is not getting vaccinated,

facilitating developing tailored strategiesAllows detailed analysis of vaccination timeliness (more

and more important to maximize vaccination benefits)

Expected Benefits of Imm. Info SystemsExpected Benefits of Imm. Info Systems

Expected Benefits of Imm. Info SystemsExpected Benefits of Imm. Info Systems

Data Quality:– Better, more complete and timely data

Dynamic monitoring of vaccination coverage by cohort (rather than annual targets) – If exhaustive registry

– More precise monitoring of vaccinated people by facility may improve vaccine and supply forecast and stock management

Supply chain management – vaccines in the right place at the right time

If well designed and implemented, may be easy to use and well accepted and can make data collection at point of vaccination more efficient

Potential Problemas Administrative System vs. Nominal Imm. RegistryPotential Problemas Administrative System vs. Nominal Imm. Registry

Administrative– Errors(non-intentional and

intentional) in dose registration

– Errors in data aggregation– Errors typing data into a

computerized system– Inaccurate denominator

(target population)– Doses given in private

sector and other “special” sectors not included

Nominal Registry – Errors(non-intentional and

intentional) in dose registration

– Errors typing data into a computerized system

– Inaccurate denominator (specially if not complete)

– Doses given in private sector and other “special” sectors not included

Challenges – Nominal Imm. RegistriesChallenges – Nominal Imm. Registries

Costs – development, implementation and maintenance Need for frequent updates Training, training, training Time for data entry – particularly new records Acceptability and transition from current systems to nominal

ones (current systems “work”) Risk of having an incomplete registry Data flow and data security: where to enter the data, (hardware,

maintenance, security), data transmission (connectivity) or timely database consolidation if not on-line, managing duplicates

Confidentiality – risks of misuse of personal data

Linking mHealth to Nominal Imm. Registries

Linking mHealth to Nominal Imm. Registries

Data entry– For other interventions, evidence that improves data quality

and time– May reduce number of records completed at time of

vaccination

Recall-reminder systems for immunization– Proven to work in developed countries– For other interventions, evidence that sending SMS reduces

missed appointments

Mobile Services Evolution 2008-2018, Chetan Sharma, June 2008

Mobile Use Distribution1998-2018

Global Penetration 5% 55% 96%

3G+ penetration 0% 18% 90%

Speed <50Kpbs Up to 2 Mbps Up to 1 Gbps

Dispositive cost $200 $130 <$20

Smartphone penetration

<1% 10% 40%

Battery life time avg. 2 hours 2.5 hours 24 hours

Health post/ health care worker

Health facility

District / Department

National Level

-SMS-MMS-GPRS

Slide by Heather Zortnetzer, SSI

Access to DataAccess to Data

I.I.S.1. Web application 2. Mobile application

3. Paper flow

Slide by Jan Grevendonk, PATH

Mobile use for Recall-RemindersMobile use for Recall-Reminders

IIS

National Database Engine (YAWL) Mobile ap(openXdata)

Info on people vaccinated

Message management by schedules

Slide by Jan Grevendonk, PATH

mVAC consorcio

mHealth+immunization: examples

• 2 countries- Ghana, India

• Based on mobile phones and open source code

• Focus on maternal-child health

• back end = OpenMRS

• primary users include HCWs and families

• Linked to birth registration

• Collaboration: Ghana Health Service, Grameen Foundation,

• Columbia U., U. Southern Maine

• $ = Gates Foundation

MoTECH

• Several sites in 5+ countries- Norway, Pakistan, India, Uganda, Nicaragua

• Based on mobile phones and PDAs and open source code

• Focused on cold chain and stock management

• Flexible and interoperable with other registries and back-end systems

• Some tools integrate with OXD (barcode, GPS, etc.)

• Several primary users

• Coordinated by Bergen University, Norway

• $ = Norwegian Research Council

Slide by Heather Zortnetzer, SSI

Looking to the Future – TAG Recommendations 2011

Looking to the Future – TAG Recommendations 2011

TAG welcomes the progress on the development and implementation of national computerized nominal immunization registries (NIRs) in the Region.

Countries and PAHO should continue documenting and exchanging experiences on the development and implementation of computerized NIRs

NIRs should aim at ensuring interoperability with other information systems.

PAHO should work in coordination with other sectors and initiatives related to e-government, information and communication technologies (ICTs), birth registration, among others.

Next StepsNext Steps

Consolidating and documenting the experiences using NIRs in the Americas

Linking NIRs with other immunization info systems– Vaccine stock management, ESAVI monitoring, surveillance

Evaluating their effectiveness and cost-effectivenessWorking on a framework that takes into consideration

PAHO’s eHealth resolutionImplementing pilots for mHealth solutionsEvaluating use of biometrics for unique identification

Acknowledgments Acknowledgments

Countries of the Americas– In particular, immunization programs

PAHO Immunization colleagues

Jan Grevendonk, PATH

Heather Zortnetzer, SSI

WHO colleagues– In particular, Marta Gacic-Dobo, Tony Burton

Global Immunization Division, CDC

THANK YOU!THANK YOU!

www.paho.org/immunization

Visit PAHO’s Immunization Newsletter: www.paho.org/inb

Electronic Health Record Status, USA 2007 Electronic Health Record Status, USA 2007

DesRoches et al published “Electronic Health Records in Ambulatory Care – A National Survey of Physicians” in NEJM in July 2008 and concluded that of about 1,800 physicians surveyed:

– EHRs were more prevalent with younger physicians; larger practices; and in the western United States.

– < 20% of the physicians responding to the survey had a fully functional or basic EHR.

– Barriers to adoption of EHRs included: cost; ability to meet practice needs; ROI; and application life cycle.

– Facilitators to adoption of EHRs included: incentives for purchase; payment for use; and liability protection.

• President Obama’s administration introduced the HITECH Act which was passed by Congress in 2009 to support the adoption and use of Electronic Health Records (EHRs)

• The purpose of HITECH is to achieve significant improvements in care through meaningful use of EHRs by health care providers.

• Established incentive payments to eligible professionals and hospitals to promote the adoption and meaningful use of interoperable HIT and qualified electronic health records (EHRs)

Health Information Technology for Economic and Clinical Health Act (HITECH)

Health Information Technology for Economic and Clinical Health Act (HITECH)

PAHO strategies to improve vital statistics and health information systems

PAHO strategies to improve vital statistics and health information systems

2007: PAHO RESOLUTION CSP27.R12 – Strategy For Strengthening Vital And Health Statistics in the Countries of the Americas

–http://www.paho.org/english/gov/csp/csp27.r12-e.pdf

2008: PAHO RESOLUTION CD48.R6 – Regional Plan of Action for Strengthening of Vital and Health Statistics

–http://www.paho.org/english/gov/cd/cd48.r6-e.pdf

2011: PAHO RESOLUTION CD51. eHealth2011: PAHO plan for the implementation of the recommendations from the

Commission on Information and Accountability for MCH (recomm 1-3)Initiatives: Several alliances to assess and improve health info systems in

the Americas (HMN, MEASURE-Evaluation, USAID, HMN-TSP, PRISM)PAHO cooperation with ECLAC (Latin America and Caribbean

Demographic Center)–Data use, analysis and revision of population estimates and mortality tables