Overview of activity
The Alabama Department of Public Health (ADPH) partnered with the Alabama State Department of Education (ALSDE) to give public schools the ability to print valid Certificates of Immunization for their students directly from the state immunization information system (IIS).
This activity currently covers public school students in grades K-12.
Background/impetus for the activity
Alabama state law requires that every student have on file at his/her school a valid Certificate of Immunization (COI) documenting receipt of vaccines required for school entry (or an exemption form). Schools submit an annual School Entry Survey every fall in which they record for each grade K-12 the number of students with valid, invalid, and missing COIs, as well as exemptions. Based on data from the 2015-2016 School Entry survey, about 5% of all students (in public and private schools) had expired or missing COIs, with a wide range across individual schools. In January 2016, ADPH and ALSDE announced measures to help increase the number of children with valid COIs on file and improve the efficiency of the COI and reporting processes for schools.
Description of activity
ADPH is giving schools more access to the statewide IIS (i.e., Immunization Patients Resources with Integrated Technology, or ImmPRINT) to facilitate these improvements. Changes that ADPH has made include:
- A COI printed directly from ImmPRINT is the only department approved COI form. The COI was typically a paper form that parents submitted to their child’s school. Screenshots or lookalike forms printed from electronic health records (EHRs) had been accepted previously, but are no longer allowable. Provider EHRs must use ImmPRINT, COI web service, or have an HL7 bidirectional interface with ImmPRINT.
- The COI form previously had to be printed on state-supplied, watermarked blue paper. The blue paper requirement is being phased out as inventory is depleted; the forms can now be printed on any regular paper.
- A school nurse access level was already available in ImmPRINT. To use ImmPRINT for generating COIs, a field was added to record a child’s grade level. The COI template was added, with an expiration date that auto-populates with the date of the next required vaccine dose. In addition, a “Not Up to Date” report was added that school nurses can print.
- Nurses at public schools with existing access to ImmPRINT can print COIs directly from ImmPRINT for children who are up to date on their vaccines. School nurses can also print the Vaccine Forecaster and a Patient/Parent Card for students to take home for parent review. They also have the option of entering historical data and were given the ability to report duplicate patients.
- For the annual School Entry Survey that schools must submit every fall, ADPH is planning to transition away from collecting these data via an online survey to using data already available in ImmPRINT. For schools to take advantage of this, school nurses must log in to ImmPRINT to enter the school assignment for all of their students, and enter exemption information and historical data if known. This also would reduce double entry with ALSDE’s own system for collecting immunization information; they have agreed to use ImmPRINT as the source of immunization data.
Role of Immunization Program and other agencies/groups involved
The ADPH Immunization Program meets regularly with ALSDE’s State Nurse Administrator and two Nurse Managers to discuss and disseminate these changes. ADPH was responsible for making the necessary changes to ImmPRINT. ADPH field staff were trained to train lead school nurses (who are at the school system, city, or county level) on using ImmPRINT, who then are responsible for training individual schools’ nurses.
Both the ADPH and ALSDE communicated these changes to city and county superintendents of education. The Immunization Program regularly communicates with ALSDE’s nursing administrators, and they communicate with their local nurses. ADPH has spoken at the annual school nurse conference. ADPH regional field staff lead training for school nurses on using ImmPRINT.
Intersection with other program activities
Concurrent with this activity, ADPH worked to communicate with stakeholders that HIPAA allows the exchange of patient information for public health activities, including via ImmPRINT. Also, this work overlaps with ADPH’s efforts to encourage healthcare providers with EHRs to report via an HL7 bidirectional interface.
The work done by the Immunization Program, including changes to their IIS, have been funded through the standard cooperative agreement with CDC.
The Immunization Program Manager, Registry Branch Manager, and Data Quality and Surveillance Branch Manager interact with the ALSDE nurse administrators. The ADPH’s 25 field staff, who also do VFC and AFIX visits, train local nurses on using ImmPRINT.
These changes are a work in progress for public schools. Future expansions are planned to cover K-12 students in private schools, children attending licensed day care facilities, and college-enrolled students.
- A selling point for school nurses is that they no longer need to communicate repeatedly with parents about bringing in a piece of paper.
- Once fully established, fulfilling annual immunization reporting to ADPH should be much easier for schools.
- The data that school nurses have should more accurately reflect the immunization status of their students, though it is too early to determine the impact on data quality.
- The switch from paper forms to ImmPRINT should provide an easier way for schools to track compliance with new or existing school immunization requirements. For example, middle school students are required to have a Tdap vaccine (6th grade) and a second varicella dose (if older than 13 years). The 2015-2016 School Entry Survey requested that schools record the number of students up to date on tetanus, diphtheria, and pertussis vaccines, which at the time meant reviewing this information on each individual COI.
- Communication with ALDSE’s nurse administrators can be challenging. They travel frequently so it can be difficult to maintain regular communication. Also, at times ALDSE may change things based on feedback from nurses in the field without first communicating the issues to ADPH. To improve this process, ADPH feels it should better document their meetings and decisions made (e.g., circulate meeting notes and relevant action items for approval).
- To be able to use ImmPRINT data for the annual School Entry Survey, schools must first set up some things in ImmPRINT (e.g., assign all of their students to the school, enter exemption status and grade), which can be burdensome particularly for larger schools. To reduce the burden, the state can help with ImmPRINT school assignments; schools can give an electronic list of students to ADPH with a few other fields and the state can make assignments electronically for those kids that match on those fields. In recent attempts, ADPH has gotten ~75% match, so those schools have to do manual assignments for only 25% of their students.
- Going forward, a challenge related to private schools is determining who should have ImmPRINT access if they have no medical staff. APDH will likely restrict access to view and print only (no entering of historical data) if they do not have medical staff.
Other lessons learned/Advice to other programs
- Public schools already had view access to ImmPRINT, so they were already enrolled and familiar with it. Replicating this activity would be more work for immunization programs that first need to bring schools on board with their IIS.
- Starting the discussion at the top – i.e., working with school nurse administrators at the state level – is necessary for these changes to be widely adopted.
For more information
Contact Cindy Lesinger, Immunization Division Director, ADPH, at (334) 206-2018 or cindy. firstname.lastname@example.org. Al.us