eHealth Meeting, Washington DC 18 November 2011 M. Carolina Danovaro, MD, MSc

1. eHealth Meeting, Washington DC 18 November 2011 M. Carolina Danovaro, MD, MSc Regional Immunization Advisor – PAHO eHealth for Immunization Programs in the American Region

2. eHealth 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

3. eHealth 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

4. TAG 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.

5. TAG 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.

6. Current Systems to Monitor Vaccination Coverage

7. Example of EPI Data Flow Weekly (monthly in remote areas) flow, from the local to national levelInformation includes data from weekend and is reported on Tuesday

8. Vaccination Cards

9. Tally sheets or equivalent

10. Individual Nominal Records

11. Dockets or other clinical chart

14. Computerized systems for number of doses

15. Monthly aggregated Reports Monthly aggregated Reports Example of EPI Data Flow NATIONAL LEVEL Second week of the following month Revised Denominators Quarterly feedback District PRIVATE PRACTITIONERS By 5thworking day of the following month Denominators HEALTH CENTER Registers Tally Sheets Clinic Card MCH Month Reports

16. Computerized Nominal Immunization Registries (NIRs)

19. Informe Mensual Nominal Registry Nominal Registry Social Security NACIONAL SUB-NATIONAL National Computerized Nominal Immunization Registry NGOs DISTRICT Private Sector HEALTH FACILITY Other vacc. providers

20. Topic of current interest • Dec 2010 – European meeting on nominal imm. registries • Jan 2011 – Bill Gates raises the issue of mobile technologies • Fe 2011 – PAHO workshop on nominal immunization registries

21. Topic “dreamt about” in the 1960’s “…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 James L. Goddard, M.D., M.P.H., 8th CDC Director, 1962 – 1966 CDC Public Health Image Library (PHIL) 

22. Expected Benefits of Imm. Info Systems • 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 safety • Allows a detailed analysis of who is not getting vaccinated, facilitating developing tailored strategies • Allows detailed analysis of vaccination timeliness (more and more important to maximize vaccination benefits)

23. Expected 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

24. Potential 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

25. Challenges – 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

26. 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

27. Mobile Use Distribution1998-2018 Mobile Services Evolution 2008-2018, Chetan Sharma, June 2008

28. Health post/ health care worker -SMS -MMS -GPRS Health facility District / Department • Slide by Heather Zortnetzer, SSI National Level

29. Access to Data I.I.S. 1. Web application 2. Mobile application Slide by Jan Grevendonk, PATH 3. Paper flow

30. Mobile use for Recall-Reminders National Database Mobile ap(openXdata) Engine (YAWL) IIS Info on people vaccinated Message management by schedules Slide by Jan Grevendonk, PATH

31. mHealth+immunization: examples mVAC consorcio MoTECH • 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 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

32. 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.

33. Next 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-effectiveness • Working on a framework that takes into consideration PAHO’s eHealth resolution • Implementing pilots for mHealth solutions • Evaluating use of biometrics for unique identification

34. 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

35. THANK YOU! www.paho.org/immunization Visit PAHO’s Immunization Newsletter: www.paho.org/inb

36. 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.

37. Health Information Technology for Economic and Clinical Health Act (HITECH) • 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)

38. 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. eHealth • 2011: 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