Presentation on eHealth and Immunization by PAHO Nov 2011


Presentation on eHealth and Immunization by PAHO Nov 2011
eHealth for Immunization Programs
in the American Region
eHealth Meeting, Washington DC
18 November 2011
M. Carolina Danovaro, MD, MSc
Regional Immunization Advisor – PAHO
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
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
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.
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 – Reissued 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
Example of EPI Data Flow
Weekly (monthly in remote areas) flow, from the local to national level
Information includes data from weekend and is reported on Tuesday
District Level
• Vaccination
Registry in forms
predetermined by
variables of:
• Age
• Sex
• Vaccine
• Dose
• Region of
Local Level
Center/all sectors)
(Health Unit attached to
Health Department of
the Region)
• Aggregates data
in the forms that
are stratified y
variables of:
• Age
• Sex
• Vaccine
• Dose
• Region of
• Health Center
• Municipality data
is computed into
the database: EPI
Visual Software.
The variables of
the aggregates
are maintained.
Regional level
National Level
(EPI Office)
• Receives
information in
PDF format via
the internet,
aggregates the
information, and
maintains the
variables of the
loaded data.
Municipalities are
vaccinated in
Vaccination Cards
Tally sheets or equivalent
Individual Nominal Records
Dockets or other clinical chart
Computerized systems for number of
Example of
EPI Data Flow
Second week
of the
following month
By 5th working day of
the following month
Tally Sheets
Clinic Card
MCH Month Reports
Computerized Nominal
Immunization Registries (NIRs)
Social Security
Private Sector
National Computerized
Nominal Immunization
Other vacc. providers
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
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
James L. Goddard, M.D., M.P.H., 8 th
CDC Director, 1962 – 1966
CDC Public Health Image Library (PHIL)
2nd National Immunization
Conference, 1965
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)
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
Potential Problemas Administrative
System vs. Nominal Imm. Registry
 Administrative
– Errors(non-intentional and
intentional) in dose
– 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
– 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. 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.
 Data entry
– For other interventions, evidence that improves data quality
and time
– May reduce number of records completed at time of
 Recall-reminder systems for immunization
– Proven to work in developed countries
– For other interventions, evidence that sending SMS reduces
missed appointments
Mobile Use Distribution1998-2018
Global Penetration
3G+ penetration
Up to 2 Mbps
Up to 1 Gbps
Dispositive cost
2 hours
2.5 hours
24 hours
Battery life time avg.
Mobile Services Evolution 2008-2018, Chetan Sharma, June 2008
Health post/ health care worker
Health facility
District / Department
Slide by Heather Zortnetzer, SSI
National Level
Access to Data
1. Web application
3. Paper flow
Slide by Jan Grevendonk, PATH
2. Mobile application
Mobile use for Recall-Reminders
Engine (YAWL) Mobile ap(openXdata)
Info on people
Slide by Jan Grevendonk, PATH
management by
mHealth+immunization: examples
mVAC consorcio
• 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
• 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
Slide by Heather Zortnetzer, SSI
• $ = Gates Foundation
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
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
 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
Visit PAHO’s Immunization Newsletter:
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.
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)
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
 2008: PAHO RESOLUTION CD48.R6 – Regional Plan of Action for
Strengthening of Vital and Health Statistics
 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

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