Episode 7: AIMing to Inform Guests Molly Howell and Kristy Westfall

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Learn how immunization managers best leverage their immunization information systems (IIS) to improve vaccination rates. In this episode, North Dakota Department of Health and Human Services Immunization Director and Assistant Section Chief of Disease Control Molly Howell and AIM Data Project Manager Kristy Westfall share insight into their successes with IIS. Using IIS data is one of the best ways to streamline program operations, pinpoint vaccine deserts, and guide real-time decisions for all vaccines and age groups. Tune in for resourceful ideas on how to use your state’s IIS.

WEBSITE: https://www.health.nd.gov

WORK TWITTER: @hhsndgov

Speaker Bio: Molly Howell

Molly Howell is currently the Immunization Director and Assistant Section Chief of Disease Control at the North Dakota Department of Health and Human Services (NDDoH). Molly has worked in the field of immunization for the past 19 years. As Immunization Director, she oversees the implementation of immunization policies and activities in North Dakota, including evidence-based activities to increase immunization coverage rates, healthcare provider education, surveillance, and implementation of the North Dakota Immunization Information System (NDIIS). Molly has a Bachelor of Science degree in biology from the University of Nebraska – Lincoln and a Master of Public Health degree from the University of Massachusetts – Amherst.

Molly is an active member of the Association of Immunization Managers (AIM) and previously served as Chair of the organization. She is currently a member of the executive committee and AIM’s liaison to the Advisory Committee on Immunization Practices. In January 2020, Molly was appointed to the National Vaccine Advisory Committee.

She has previously published immunization and infectious disease-related articles in Public Health Reports, the American Journal of Preventive Medicine, Travel Medicine and Infectious Disease, Morbidity and Mortality Weekly Report, and the New England Journal of Medicine.

Speaker Bio: Kristy Westfall

As Data Project Manager, Kristy supports AIM members in immunization information systems and data exchange. Before joining AIM, she worked with the Wyoming Department of Health Immunization Unit for eight years in various roles, including as the VFC Coordinator and the IIS Manager. Kristy is a Certified Public Manager and earned associate degrees in Computer Networking Systems and Business Administration. She has worked in public health for over 13 years.


Brent Ewig 0:37

Welcome back to Aiming To Inform. I’m your host, Brent Ewig, and thrilled to be joined today with Molly Howell, Immunization Program Manager from North Dakota, and AIM’s own Kristy Westfall, our AIM Data Project Manager. Welcome, Molly and Kristy.

Molly Howell 1:27

Thanks for having us.

Brent Ewig 1:30

Glad to have you. So we’re gonna be talking a lot of things today, workforce immunization information systems and data and resources. So let’s just jump right in. And first, let me ask you first, do you know what a baby computer calls its? Father?

That’d be deta.

Kristy Westfall 1:46

Oh, Brent.

Brent Ewig 1:47

Yeah. And with that, we’re off and running.

So, Molly, it’s wonderful to have you on and the, your dedication to immunization programs is well known. And your, your leadership on IIS is extraordinary and all of this was recently recognized with one of AIM’s highest awards for immunization program. So congratulations on your recent major award win, and can you just kind of jump and tell us a little briefly about your career and what brought you to your current role?

Molly Howell 2:14

Sure. So I grew up in North Dakota and I went to the University of Nebraska Lincoln for my undergraduate degree and, and I was going to be a physician assistant. And so while I was in college, I did an internship at the Lincoln, Lancaster County Public Health Department. And just kind of fell in love with public health and infectious disease and have been in public health ever since then.

Um, I started with the North Dakota Department of Health in 2006, and the immunization program, I was the immunization surveillance coordinator. And at that time, our program only had two people in it, the program manager and the immunization surveillance coordinator. And so I was responsible for vaccine-preventable disease surveillance, but also perinatal hepatitis B.

Immunization information systems, and kind of other duties as assigned, I guess. And so that was in 2003, and then in 2006 I became the immunization program manager and have been here ever since.

Brent Ewig 3:21

And I know, so that’s covering the, the professional. I know on the personal side that one of the things you mentioned is your interest in international travel, and particularly to Paris, France, which reminds me of that question. Do you know the difference between a tick and the Eiffel Tower?

Molly Howell 3:38

I don’t, but are you gonna tell me

Brent Ewig 3:40

Yes, they are both Paris sites

Molly Howell 3:44


Brent Ewig 3:45


Molly Howell 3:46

Thank you. That’s a that’s a good one.

Brent Ewig 3:48

Yeah. So that’s kind of your path to your role. Can you tell us a little bit about what motivates you to do this work?

Molly Howell 3:57

Well, I, I think all of us get into immunizations in public health because we really care about the public’s health and about people being well and being healthy, and we don’t want people to die or be disabled due to vaccine-preventable diseases. But I think beyond that, there’s a great team here at the North Dakota Department of Health, which recently became the North Dakota Department of Health and Human Services.

And so I think that’s motivating when you get to work with a lot of great people. I also think I like to be busy, and if you like to be busy, then take a job in the field of immunization.

Brent Ewig 4:35

So true, So true. And you had mentioned this with starting with just two staff and I’d heard it called the North Dakota as a lean, mean machine. Can you tell us a little bit about your program? How have you dealt with limited staff? What’s been the change, and what’s your secret to making that work?

Molly Howell 4:51

Well, we have more than two staff now, so that helps out quite a bit. I think during COVID we were able to add seven additional staff. And so we’re up to 16 people in the immunization program in North Dakota. And I, I think the way we’re able to make that work is we have a lot of dedicated individuals a lot who have been here for some time, and so we work well together, know each other quite well. But on top of that, I think we’re split up into different teams. So we have a VSC I Quip team. We have our IIS team, our surveillance team, and now our COVID team has transitioned into our adult team. And we’re hoping to move that in the future towards adult immunizations more I think one of the reasons we’ve been able to be successful is the use of our immunization information system uh, the NDIS as helping us really streamline a lot of our activities, automate a lot of our activities and it really touches every single program within the immunization division.

Brent Ewig 5:55

Great. And we do wanna come back and, and delve in a little more in-depth. In IIS in a moment. But I wanted to ask a little bit about how you manage that team with your financial resources. And I imagine, you know, COVID obviously has scrambled the outlook but, but prior to COVID, how, how did you make the most of that limited budget?

And then if you could kind of talk about where we are now with the expansion with emergency funds and and what you see coming ahead with that outlook.

Molly Howell 6:21

Well, my program is a hundred percent federally funding. We don’t fund it. We don’t receive any state funding. And so really it is solely dependent on the cooperative agreement that we receive from the CDC. And then that kind of drives what activities we’re working on. Whenever possible I write. So if there’s any competitive grants coming from CDC, whether it’s through the immunization division or even through the Epi and Lab Capacity grants um, we write a lot of those competitive grants to help fund staff and, and get new staffing.

We’re also limited in FTEs or like full, full-time positions that are available. Mm-hmm. . And so if needed, we work with a lot of contractors to try and get certain things done. We have a close relationship with. North Dakota State University Center for Immunization Research and Education. And I know we’re gonna talk about the IAS, but our IAS really, we’ve tried to keep costs as low as possible.

We did previously for interoperability receive Medicaid match dollars, which really helped fund a lot of our connections to electronic medical records throughout the state. And then our vendor, Blue Cross Blue Shield of North Dakota, does have some cost sharing with us where they help with some of the costs of our IAS, which has really helped our small program that has limited funding.

I think, with the COVID grants, that kind of just really changed everything, and we were able to do a lot more than we’ve ever done before. Focusing on adult immunizations, which we haven’t done. Modernizing our IAS and, and really focusing on health disparities and increasing immunization rates in areas where needed and funding a lot of our partners.

Brent Ewig 8:07

Yeah. And and I know you like many other states have really built up a lot of your infrastructure with that emergency funding. So just sharing with our listeners, you know, we’re, we’re well aware of that upcoming cliff when that emergency funding runs out in 2024. The good news is we have time to think about solutions now and to, to raise awareness. But I know that’s on a lot of people’s minds. Of all the achievements we’ve been able to make with emergency COVID funding, particularly in building out adult vaccine infrastructure, something we need to really be thinking about how we sustain most efficiently.

And while we’re thinking of that, can you just kind of talk a little bit about some overall your biggest challenges and opportunities in North Dakota?

Molly Howell 8:47

Well, I think, like all awardees, some of our challenges have been the decline in immunization rates during the pandemic, and that really applied to all age groups. And so we have make made some headway there and really work to increase a lot of our routine immunization rates. But still my, probably my biggest concern right now is pediatric influenza vaccination rates, which really ha, probably declined the most out of any of our vaccination rates, and we haven’t really seen that pickup yet. And so hoping this fall that we’ll be able to get those rates back up and really communicate why it’s so important children receive their influenza vaccine annually.

I think obviously there’s been a lot of legislation out there addressing vaccines and so just wanting to make sure that we’re in a good spot and and that there isn’t any legislation that’s passed that may hinder or prevent people from accessing immunizations or, or being aware of what immunizations they need has been a core focus of the program.

And then of COVID vaccination rates. We have a lot of work to do there in really informing the public about why COVID vaccine is so important. And now, with the bivalent boosters addressing why the public needs a Bivalent booster, I think there’s a lot of confusion out there about who needs it, why, and when to get it.

And so just need to increase some of that messaging and, and reduce some of the confusion around the COVID vaccine.

Brent Ewig 10:18

Great. So let, let’s turn to some specifics on is, and we’re gonna pull Kristy here in, in just a moment, but I wanted to ask you, my understanding is North Dakota has developed its own homegrown system to collect, analyze, and use data to improve vaccination rates. Keep, kind of tell us a little bit about what that process was like and what you’re most proud of

Molly Howell 10:39

Yeah. So the North Dakota Immunization Information System, the NDIS was developed in 1988, so I have been around a long time, but I’ve not been around since 1988, so I cannot take credit for the NDIS. But it was modernized and upgraded in 1996. But Blue Cross Blue Shield of North Dakota to this day, who originally developed the system, continues to maintain and upgrade our IAS, and we have an excellent relationship with Blue Cross Blue Shield of North Dakota.

We really look to programmatically what the needs are. So what we need for our program to function and be more automated and streamlined, whether that’s vaccine ordering or certain reports or data that we need. And then also really focus on what provider needs are and listening to providers as to what they would like to see in terms of functionality and needs.

Right now, with our COVID funding, we’ve been able to do a large modernization project, and so, really focused on ensuring security moving into the future, moving into the cloud, increasing a lot of the data visualizations that we have inside the system so providers can do more real-time decision making.

And then just how data is accessed. We wanna make sure you know, during COVID we were able to provide daily updates on a dashboard, and we kind of set that expectation now for the public that they’re gonna be able to readily access data. And we wanna meet, maybe not a daily expectation in the future, but we do wanna make sure we’re providing up-to-date data to the public and healthcare providers and decision-makers regarding immunization rates for all vaccines and all age groups.

And to do that, you have to have your data accessible but yet still secure and in certain formats. And you sometimes even have to. Merge your data with other data and make sure that you have the cleanest data possible by regularly monitoring data quality and addressing data quality issues.

Brent Ewig 12:43

Great. And you kind of touched on this, but can you tell us a little bit about future directions that you’re exploring for that system?

Molly Howell 12:49

Yeah. Right now, it’s really focused on moving to the cloud. We’re still a server-based system, which actually, during COVID, even worked well. Our system was never really down. The system to worked well for providers, and we were able to give people data when they needed it.

But just looking to the future, we wanna make sure that it’s in the cloud and it’s secure, and then really changing how we access data and making it more readily available and easier to analyze. And then visualization and different functionality, including different reports. I mean, my dream is that a provider will open the NDIS, and right there, we’ll know real time what their immunization rates are, what vaccine is coming close to being expired, a list of children who are not up to date that they could call if they have time. Um, Just everything a provider would need to make sure they have the best immunization program.

Brent Ewig 13:43

That’s a great vision. Thanks for sharing that. Let’s pull Kristy into the conversation. So Kristy, I just can’t tell you how excited we are to have you as a colleague at AIM, somebody with your experience and your smarts. Clearly, you know, working with data, you have to be good in math. And that reminds me, you know, there’s three kinds of people in this world. Those who are good in math and those who aren’t. And I just demonstrated where I fall on that continuum. But can you tell us a little bit about your path into public health and how you came to AIM?

Kristy Westfall 14:11

Yeah. Well, thank you and Molly, that was so great to hear all about North Dakota and program perspective. So I started with the Wyoming Department of Health Immunization Unit about nine years ago now. And for me, it wasn’t, uh, you know, a career path that I had thought of. It was a job like it.

State government job with great benefits. And I say that then I, I’ve been hooked ever since, pretty much in public health and especially immunizations. And like Molly, you know, I came from a very small state, very small program. So I got to have my hands on a lot of different things. And it’s just always been so incredible.

I never wanted to go into state government, though, so there was an opportunity at AIM to continue doing exactly what I love, which is supporting the programs, you know, supporting the people who do the everyday work. And now I get to do that. More at the national and federal level. And that’s really great um because I get to work very closely with folks like Molly and her staff, as well as all of the other awardees too. So that’s how I got here.

Brent Ewig 15:17

Great. And so, thinking about North Dakota and what we heard from Molly, can you kind of give your perspective on, on what you see them that they do a little differently than other states?

Kristy Westfall 15:26

Yeah, and I think it’s something that they do really different. They have a lot of staff who have been around for a long time, like Molly said, and having a a homegrown system in and of itself is a lot of work and takes a lot of resources and a lot of very smart people, as you say, who know math very well.

But she’s got an amazing team that they can do so much with so little you know, having 16 people and that’s, you know, a lot for the North Dakota program. And again, being able to have their system in-house and get data from their system that’s been around for decades, as we just learned as well.

That’s not something that you see in a lot of states. Most jurisdictions and I’d say most, as in about two-thirds use, uh, vendor-based products. They don’t have, you know, their internal teams that are uh, the ones building these systems and working on them and all of that. And so the partnerships that Molly has talked about with Blue Cross Blue Shield being since day one and even working with universities and things like that, it’s, it’s the creativity and really.

That motivation and drive to continue doing more and more without maybe, you know, taking on more staff and really just building the expertise and the strength that they have. So not saying that other states don’t have great teams, but having a small team like that that’s been around for a while is one of the strongest assets that you can have in, in the immunization game right now.

Brent Ewig 16:59

So what do you think other programs can learn from that North Dakota model?

Kristy Westfall 17:02

I think that other teams can learn a lot from the North Dakota model on really doing everything that they can with the resources that they have right now. And that’s kind of been a mantra lately of do what you can with what you have. And their team has amazing resources on staff. And again, having the longevity and just that historical knowledge in a program is incredibly valuable. From the IIS perspective, I would say even just having the ability, like Molly said, access to the system and being able to get data right now what you need and not having to rely on whether it’s your vendor or other programs within your Department of Health.

The more you’re able to really have access to your data, the more you can do with it to get it out to the public, to really show areas and pockets of need. What they’re able to do with the information that they have because they have that all right there at their fingertips is something that I think a lot of programs can learn from especially moving forward.

Again, data is one of the big things right now. Everybody wants it. Everybody wants it to be perfect and without having, you know, the staff and the ability to have access to that data, it really limits your abilities to to really get real-time and usable information that you can then get out quickly.

Brent Ewig 18:30

So we, we talked about some of those challenges with data and and people understanding data. I just recently read that four out of three people are bad at fractions. Yeah.

Kristy Westfall 18:42

Apparently, you are the fourth.

Brent Ewig 18:45

I also read that 67.4% of statistics are made up right on the spot. So dunno how much we can trust that. With that, there are three questions that we ask all of our guests at the end of the episode. And so we’re just gonna kind of shoot these in rapid fire. Are you guys ready? All right. We’ll start with you, Molly.

What is one thing you wish you could tell your younger professional self?

Molly Howell 19:08

Work in chronic disease.

Brent Ewig 19:18

Yeah, that’s a good one.

And did you wanna expand on that, or?

Molly Howell 19:25

No, I’m kidding, of course. No. I think my younger professional self, I think you do really need a work-life balance, and coming up with a way to do that early on and prioritizing, not just prioritizing work, but figuring out a way to get that work-life balance, I think is probably the most important thing in terms of maintaining some sort of longevity in a career.

Brent Ewig 19:50

Very on target. Christie, how about you, your younger professional?

Kristy Westfall 19:54

My younger professional self, I would pretty much go with the, don’t worry about tomorrow. Tomorrow will have enough worries of its own. Don’t always, you know, run towards the next big thing. Stop and enjoy the moment. And you can plan for the future, but worrying about it isn’t gonna get you anywhere because all of a sudden, one day, it’s gonna be a pandemic and lockdown.

So yeah, don’t, don’t worry too much. Just have fun, enjoy it and it’ll all work out.

Brent Ewig 20:22

Very wise. Second question. What are you looking forward to professionally in the next year? Molly, you want to take that one?

Molly Howell 20:29

Yeah, I think. Really think we can get our routine vaccination rates up to where they were pre-pandemic. I think we’re on the way there, and I, I think we can do it and we’re up for the challenge. And so I’m looking forward to, you know, by this time next year, hopefully being able to say that we’re at or above what our vaccination rates were prior to the COVID pandemic.

Brent Ewig 20:54

Super, Kristy, how about you?

Kristy Westfall 20:57

I would say that I am looking forward to continuing to be able to see people in person and continue to network and learn and grow. We just recently had our big AIM conference and I learned so much from the amazing people who are the AIM community. And because of the great work that they’ve all done, we can now finally be back in person for the most part.

So, I, I’m very, very looking forward to more learning and growing from our community.

Brent Ewig 21:27

Well, that’s a, a perfect transition to the last one. I, I appreciate the way you framed that, Kristy. So besides the, the Great Annual Conference, what’s the greatest value you get from the AIM community? Kristy, you wanna just keep going on that?

Kristy Westfall 21:38

Yeah, yeah, absolutely. So when I was with the program in Wyoming, I always, you know, knew AIM was the ones with the communication, and they could get it to you concise and whatnot. And now I’m within the AIM family uh, but get to continue with the AIM community. And it truly is exactly those two things.

It’s a family and a community and I just love how everybody supports each other. Flawlessly. Like there’s always somebody there to lean on or understand what you’re going through because it’s a very isolating thing to be on this side of a pandemic. And so it’s just, it truly is a community and a family, and I just, I love the networking, the mentorship, and the relationships that I’ve gotten through AIM.

Brent Ewig 22:28

How about you, Molly? Greatest value from the AIM community.

Molly Howell 22:32

The greatest value that AIM brings is really being able to learn from each other. And when someone does something, well, I’m not opposed to copying them. And so I think the biggest thing is just being able to learn whether it’s lessons learned or best practices and trying them in your own program and, and getting to see those results.

I think that’s probably the best thing about AIM.

Brent Ewig 22:58

Wonderful. Well, we’re coming to the end. And unfortunately, I’ve exhausted all of my math or data-related dad jokes, but I’ll leave you with one. I really love this if you have any little kids around to ask them, what do you call a fish wearing a bow tie? So Phish, Decayed.

Kristy Westfall 23:15


Brent Ewig 23:16

Fished. Yes. Yes. And with that, I wanna thank you, Kristy McNichol Westall, and Molly Howell from North Dakota.

It’s been wonderful talking with you today, and we’ll look forward to seeing more of your great work in the future. Thanks so much for being here.

Kristy Westfall 23:30

Thank you so much.

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