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									             Evaluating IIS
 Best Practice Operational Guidelines:
   Emerging Trends and Challenges
             Warren Williams, MPH
            Lead Public Health Analyst, CDC,
National Center for Immunization and Respiratory Diseases

       The 44th National Immunization Conference
         Hyatt Regency Hotel, Atlanta, Georgia
            Tuesday, April 20, 2010, 4:00 PM
              International Ballroom North

             National Center for Immunization and Respiratory Diseases
             Immunization Information Systems Support Branch
      Presentation collaborators
• Elaine Lowery, JD, MSPH - Senior Public Health Advisor,
  Public Health Informatics Institute
• David Lyalin, PhD - Consultant, Northrop Grumman - CDC
  Information Technology Support Contract
• Nichole Lambrecht, MSc - Project Manager, Kansas
  Immunization Registry – KSWebIZ
• Sherry Riddick, RN, MPH - Immunization Registry
  Operations Manager, CHILD Profile
• Cynthia Sutliff - Executive Director, American Immunization
  Registry Association (AIRA)
• Vikki Papadouka, PhD, MPH - Director of Research and
  Evaluation, NYC Department of Health and Mental Hygiene

            The findings and conclusions in this report are those of the author(s)
            and do not necessarily represent the views of the funding agency
• The Modeling of Immunization Registry Operations
  Workgroup (MIROW) of the American Immunization
  Registry Association (AIRA) develops Best Practices for
  IIS functionality.
• MIROW Goals
   – Promote operational consistency
   – Foster communication and collaboration
   – Increase credibility of IIS
• MIROW Approach
   – Facilitated collaboration of contributing IIS experts to
     evaluate and combine various operational practices
     and achieve a consensus regarding best practices.
   – Use of business analysis and modeling techniques to
     support development of best practices .                 3
         Why is consistency of
       IIS operations important?
• Inconsistency among IIS negatively affects overall
  data quality and usefulness of registry information.
• MIROW guidelines are intended to support
  uniform alignment of IIS operations.

            How MIROW works
• MIROW efforts are guided by the Steering Committee
   – Warren Williams, Co-Chair, wxw4@cdc.gov
   – Elaine Lowery, Co-Chair, elaine.lowery@comcast.net
• Operational topics for analysis are selected based on
  feedback from IIS community (assessments, surveys,
  ad-hoc meetings at NIC)
• Panel of experts is assembled for each topic
• A combination of face-to-face analysis sessions and
  web-based teleconferences
• External reviews of developed guidelines
• Assessments and surveys on implementation in IIS

MIROW participants
             • Subject matter
             • Steering Committee
             • Facilitation Teams
             • AIRA staff
             • State IIS
             • External Reviewers
             • Technical Editors at

         Guidelines developed
• 2008-2009: Reminder/Recall in Immunization
  Information Systems
• 2007: Data Quality Assurance in Immunization
  Information Systems: Incoming Data
• 2006: Vaccination Level Deduplication in
  Immunization Information Systems
• 2005: Management of Moved or Gone Elsewhere (MOGE)
  Status and other Patient Designations in Immunization
  Information Systems
• 2004-2005: (Pilot) IIS-VAERS Collaboration for Vaccine
  Adverse Events Reporting
Recommendations documents are available for download
at the AIRA web site: http://www.immregistries.org/pubs/mirow.phtml
                          Guideline Face-to-face Experts’ Guideline document
   Topics                 document     meeting    panel          highlights
                           released                size
Reminder/Recall in IIS    April     October 2008   13    29 Principles
                          2009      2.5 days             23 Business rules
                                    Tampa, FL            30 General
Data Quality Assurance in February  August 2007    11    13 Principles
IIS: Incoming Data        2008      2.5 days             32 Business rules
                                    Atlanta, GA

Vaccination                December    May 2006      20   9 Principles,
Level Deduplication in IIS 2006        2.5 days           20 Business rules,
                                                          23 Illustrative scenarios
Management of               December   August 2005   16   6 Statuses defined on the
Moved or Gone Elsewhere 2005           2.5 days           Provider level,
(MOGE) Status and other                Atlanta, GA        5 Statuses on the
Patient Designations in IIS                               Geographic Jurisdiction
IIS-VAERS Guide           April        June 2004     21   10 Functional standards,
(pilot project)           2005         1.5 days           8 Business rules,
                                                          11 Alternative scenarios
                                                          (process)          8
          What do the MIROW
        recommendations offer?
• Peer-reviewed practical guidelines
   – Experts from 24 IIS participated in MIROW sessions since
     2005, as well as many IIS partners and stakeholders from
     public health programs, federal agencies, regional and
     county health departments, IT vendors, consultancies, and
     private registries.
• Guidelines include:
  1. A set of agreed upon terms and definitions
  2. General principles, specific business rules and
     recommendations to apply
  3. Illustrative examples and templates
  4. Strategies on how to address problems, issues, and barriers
  Promoting the MIROW guidelines
• Presentations, workshops, and organized ad-hoc
  meetings at annual national immunization
• Brochure-style mini-guides summarizing each of
  the guideline documents - to encourage IIS staff to
  learn more about the best practices
• Self-assessment tool for the data quality assurance
  guidelines - for gap identification between current
  IIS practices and the MIROW best practice
  recommendations (has been presented at an AIRA
  webinar)                                         10
         Evaluation approaches
• After every workshop, a questionnaire was
  completed by participating experts to gather
  feedback on various aspects of the best practice
  development efforts.
• Questions regarding utilization of MIROW
  guidelines were included in the Immunization
  Information Systems Annual Report (IISAR).
• A web-enabled survey was conducted to examine
  awareness and use of the patient status

      Evaluation results summary
• Use of MIROW guidelines by IIS according to
  IISAR data:
      - 46% in 2007
      - 76% in 2008
• Web survey results
      - response rate: 41% (30/74)
      -18/19 participants familiar with guidelines
        found them to be at least somewhat useful
• Average satisfaction among MIROW contributors:
      - 3.56 / 4

                   Expert’s surveys:
          conducted after face-to-face sessions
                     Want to do it again

                      Able to implement

                   Willing to implement

        Developed Recommendations

                       Facilitation Team

                     Process Diagrams

                       Domain Diagram

                         Business Rules

                     Business Modeling

                  Preparatory Materials
Scale 1 – 4: 4 – highest/most positive,
             1 – lowest/least favorable     3            3.2        3.4             3.6            3.8           4

                 2005 Patient Status       2006 Deduplication   2007 Data Quality         2008 Reminder/Recall
            Results: Implementation
                    13 out of 19 of the respondents who were familiar
                    with the Guidelines have implemented or attempted
                    to implement the Guidelines

                    7 out of 13 of the respondents who had attempted to
                    implement the Guidelines encountered one or more
                    barriers to implementation

                   Implementation Barriers:
        54%        BR inconsistent with other programs and/or business
                   Lack of staff time to reconcile competing business
                   Competing funding priorities
                   Considering implementation in application upgrade

Response rate = 41% (30/74)                                               14
 MIROW activities being carried out
      by IIS Sentinel sites
                                     Project Sites

MIROW Activities           AZ   MI   ND NYC      OR      WI

Data Quality Improvement   X    X     X              X   X

Vaccine De-duplication     X    X           X            X

Moved Or Gone Elsewhere    X    X     X

   Implementations in KS and WA
• The Kansas IIS (KSWebIZ) team developed new
  reports at both the provider and system levels to
  enhance overall data quality measures in accordance
  with the MIROW best practice guidelines on data
• Using a team/workgroup approach, the Washington
  IIS reviewed the MIROW data quality guidelines to
  compare current data loading and quality check
  practices with the best practices guidelines. As a
  result, 21 of the 32 MIROW data quality business
  rules were adopted and then current IIS business
  processes, policies and procedures were revised and
  improved to support the adopted business rules.
       AIRA regional forums
– Upcoming in CO: Half day to focus on the
  MIROW Data Quality and the MOGE/Patient
  Status Best Practice Guidelines
– The Data Quality Best Practices guidelines
  were discussed at the Midwest and the
  Southeast Regional Forums
– MIROW mini-guides on all Best Practice
  Guidelines are distributed at all Regional

• Facilitated collaboration of contributing IIS experts
  resulted in development of common consensus-
  based guidelines. That have lead to support of
  immunization program activities with better IIS
• Implementation barriers related to limited resources
  and competing priorities occur locally and have to be
• While IISAR results indicate awareness and
  recognition of the MIROW best practice operational
  guidelines in the IIS community, additional studies are
  needed to evaluate specifics of guidelines’
  acceptance and utilization.
Next MIROW topic: IIS-VFC/AFIX Collaboration
• A primary focus is resolving and tracking
  VFC eligibility status and history
• Face-to-face meeting scheduled for June 15-
  17, 2010 in Atlanta, GA
• 16 experts from state IIS and VFC programs,
  federal VFC program, vendors, and
  consultants will participate
• Expected guideline release – end of 2010

   Copies of the MIROW recommendations
documents can be found at the AIRA web site:
                          Contact Information:
                           Warren Williams
   For more information please contact Centers for Disease Control and
   1600 Clifton Road NE, Atlanta, GA 30333
   Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
   E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

                National Center for Immunization and Respiratory Diseases
                Immunization Information Systems Support Branch

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