Vaccination Programs: Immunization Information Systems

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends immunization information systems (IIS) to increase vaccination rates.

The full CPSTF Finding and Rationale Statement and supporting documents for Vaccination Programs: Immunization Information Systems are available in The Community Guide Collection on CDC Stacks.

Intervention

Immunization information systems (IIS) are confidential, population-based, computerized databases that record all immunization doses given by participating providers to people within a geopolitical area.

IIS are set up to:

  • Create or support effective interventions (client reminder and recall systems, provider assessment and feedback, provider reminders)
  • Determine client vaccination status to aid decisions by clinicians, health departments, and schools
  • Guide public health responses to outbreaks
  • Inform assessments of vaccination coverage, missed opportunities, invalid dose administration, and disparities
  • Facilitate vaccine management and accountability

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 240 studies (108 published studies and 132 conference abstracts; search period January 1994-April 2011). Included studies represented IIS-supported interventions (e.g., client reminder and recall systems) and described IIS program activities and experiences.

Study Characteristics

Studies evaluated systems in United States (209 studies), Australia (2), and other countries (5)

  • Of U.S. studies, 108 described IIS Sentinel Site program
  • Most U.S. studies considered children and childhood series vaccinations
  • 33 studies (20%) described IIS use for adolescents; 12 (7%) for adults, mostly influenza
  • 47 studies evaluated IIS-supported interventions: client reminder and recall, provider assessment and feedback, provider reminders
  • Studies evaluated IIS used in various settings for different reasons:
    • U.S. studies evaluated or described use of IIS by vaccination providers, schools and day cares, or health care systems (14 studies).
    • U.S. studies described IIS interactions with schools and day cares (10 studies).
    • U.S. studies evaluated or described use of IIS in responses to outbreaks of vaccine-preventable disease or other public health emergencies (18 studies).
    • Studies described use of a state IIS by a health care system (4 studies).
    • Studies described IIS use to facilitate vaccine ordering, inventory monitoring, and vaccine-related accountability (14 studies).
    • Studies (12 from the U.S.) described IIS use to assess or respond to vaccine safety issues or to evaluate vaccine effectiveness (17 studies).

Summary of Results

240 studies were included and assigned to nine categories.

  1. Overall evidence on effectiveness
    • A published study from Australia reported an increase in vaccination rates following adoption of a national IIS. This change, however, was likely due to an increase in participation rates associated with incentive payments offered to families and vaccination providers.
    • A cross-sectional study from the United States reported that medical practices using IIS did not have significantly higher vaccination rates than did practices not using IIS.
  2. IIS-supported interventions to increase vaccination rates
    • Client reminder and recall systems
      • Vaccination rates: median increase of 6 percentage points(13 studies with 16 study arms)
      • Additional descriptive studies reported client reminder and recall activities (17 studies).
    • Provider assessment and feedback
      • Vaccination rates: median increase of 9 percentage points (5 studies)
      • Additional descriptive studies reported the use of IIS to support the conduct of these interventions (10 studies).
    • Provider reminders (also referred to as clinical decision support for immunizations, or CDSi)
      • Vaccination rates: increase of 14 percentage points (1 study)
      • Many IIS in the United States have built-in reminders that prompt vaccination providers when a client record is consulted.
  1. IIS use in vaccination-related decisions by clinicians, schools, and health care systems
    • No studies evaluated the use of IIS by vaccination providers at the clinic level.
    • Studies described use of IIS in school settings (10 studies).
    • Studies described use of a state IIS by a health care system (4 studies). Of these studies, three described using IIS data for quality measurements, including HEDIS (Healthcare Effectiveness Data and Information Set).
  2. IIS use in public health response
    • Studies described use of IIS to respond to outbreaks of vaccine-preventable disease (18 studies), including:
      • Targeted recalls of unvaccinated patients
      • Retrospective review of vaccine uptake to monitor provider adoption of revised vaccination recommendations
      • Guiding decisions around 2009 H1N1 influenza vaccine distribution and client management
    • Studies described use of IIS to respond to a public health emergency situation (3 studies). Of these, two detailed the use of IIS to avoid administering unneeded vaccines to people displaced by Hurricane Katrina.
  3. IIS to support vaccine management
    • Studies described the use of IIS in the process of vaccine supply management, distribution, and accountability (14 studies). Of these, 10 involved doses distributed as part of the S. Vaccines for Children Program.
  4. IIS to assess vaccine safety and effectiveness
    • Studies described use of IIS in assessment of, or response to, vaccine safety issues or in evaluation of vaccine effectiveness (17 studies).
  5. IIS as a tool for public health decision support
    • Included studies described a range of IIS surveillance capabilities:
      • Coverage assessments for specific vaccines (51 studies)
      • Investigations of vaccination rates among high risk subsets of the population (32 studies)
      • Ability to monitor uptake of new vaccines (16 studies)
  1. IIS integrated with other child health information systems
    • Studies discussed integration of additional child health data (e.g. blood-lead levels, early hearing detection) into existing IIS (8 studies).
  2. IIS contributing to change in documentation
    • Studies compared the completeness of individual IIS vaccination records with some other immunization data source (e.g. medical records, parental report; 24 studies).

Summary of Economic Evidence

Included studies evaluated the cost of IIS (9 studies; 7 assessed system costs, and 2 assessed the cost of exchanging immunization data), benefits of IIS (9 studies), and cost-benefit ratios (4 studies). All monetary values in 2013 U.S. dollars.

  • Benefits evaluated in the included studies were mostly specific to savings associated with administrative efficiency and decreased over-vaccination.
  • All studies provided information about IIS implemented in the United States and focused on pediatric immunizations.
  • Variability in costs might be attributable to the scale of the IIS and the target population size.

Program Costs

  • Estimated total costs: $205,077 to $108 million
  • Estimated annual cost per child: $5.40 to $60.82
  • Estimated cost per vaccination record: $0.11 to $12.88

Cost-Benefit

  • Nationwide IIS model: benefit-cost ratio of 3.5:1 ($3.50 in savings per dollar invested; 1 study)
  • State-level model: benefit-cost ratio of 1.59:1 (1 study)
  • City level: net savings of $36,815 in single year (1 study)
  • Managed care organization: return of $8 for every $1 spent (1 study)

Applicability

Results broadly applicable to IIS implemented in the United States for childhood vaccination series, especially as systems achieve levels of provider and client participation demonstrated by IIS Operational Best Practices.

Evidence Gaps

  • What is the overall impact of IIS (or IIS activities) on vaccination rates in the general U.S. population or among target populations that have gaps in coverage?
  • How useful is IIS for vaccination providers in clinical settings?
  • How do participation rates and records capture vary based on demographic characteristics, such as race and ethnicity, household income, and insurance status?
  • What is the frequency and reach of various IIS activities within the population?
  • What are the costs of implementing present-day IIS, either with systems developed in-house or with systems supported by vendors?
  • What are the economic returns associated with additional benefits (improved efficiencies and decreased time associated with conducting provider reminder/recall functions, provider assessment and feedback efforts, improved vaccine supply and management, and reduced morbidity and mortality)?
  • What is the cost to connect between providers’ Electronic Health Records (EHRs) and central IIS?

Implementation Considerations and Resources

Many systems rely on voluntary participation of vaccination providers. Completeness and utility of data depend on extent and timeliness of provider reporting.

Client participation and confidentiality requirements may limit ways IIS data can be entered, retrieved, or used for clinical and public health purposes.

Vaccination providers have expressed concerns over technological constraints and time and staffing required to enter complete and timely reports.

Crosswalks