COVID-19 and the hope for a solution—a vaccine—have shined a light on yet another long-standing problem in healthcare that is likely to get worse: patient identification.
The coronavirus crisis, responsible for more than 200,000 deaths in the U.S., has brought renewed focus on patient matching, a subtle but still crucial patient safety and operational challenge hospitals have been grappling with for decades.
Without a way to accurately identify patient immunization records across care settings, providers won’t be able to track who has received a COVID vaccine—a priority for returning to a so-called new normal.
Effectively distributing and administering a vaccine requires knowledge of who has received it and who hasn’t, said Ben Moscovitch, project director for health information technology at the Pew Charitable Trusts. The process, which largely relies on providers looking up patient records in state immunization registries, “is a patient-matching issue,” he said.
Patient matching, or matching patients with their medical records, sounds like a simple concept. But while organizations have made strides in accurately matching patients to records within their own system, it’s challenging to link records with outside organizations, making it difficult for providers to get a comprehensive view of a patient’s medical history. That’s particularly true for immunizations, which can be doled out at hospitals, clinics and pharmacies across a patient’s life—and thus held in numerous systems.
The yet-to-arrive COVID vaccine puts a spotlight on those challenges, as long-standing problems will be compounded by the expected volume of patient demand and its likely status as a multidose vaccine.
“It’s the same story,” said Julie Pursley, director of health information thought leadership at the American Health Information Management Association, “just on a larger scale.”
And the COVID vaccine isn’t the only immunization challenge facing providers during the pandemic. Providers will also have to stay attuned to immunizations for the thousands of patients who delayed routine care in the spring, forgoing childhood immunizations and adult booster shots.
The Trump administration this month unveiled a national COVID vaccine distribution strategy, which includes an emphasis on using IT systems to “identify when a person needs a potential second dose, to monitor outcomes and adverse events, and to account for products the U.S. government is spending billions of dollars to research, develop, and produce,” according to a strategy report from HHS’ Operation Warp Speed. Immunization registries will be “central to this IT infrastructure,” the report reads, with Operation Warp Speed creating new IT tools to fill existing gaps.
Under the administration’s strategy, COVID vaccination data that would typically be documented in immunization registries, providers’ electronic health records and pharmacies’ dispensing record systems will be subsequently reported into a “common IT infrastructure” developed by HHS.
HHS and the Centers for Disease Control and Prevention did not return a request for comment on the system.
Immunizations are just one part of a patient’s medical history. But tracking vaccinations—from childhood into adulthood—comes with its own set of unique challenges.
Already, it’s pretty common for patients to be unsure of their own immunization history, said Dr. Corey Lyon, a family physician at UCHealth’s A.F. Williams Family Medicine Clinic in Denver. There’s a slew of vaccinations that patients are expected to receive, some of which take place during childhood with boosters every five or even 10 years in adulthood.
“A lot of times the patient will say, ‘I think so,’ or ‘I don’t know’ ” when asked about a vaccine, Lyon said. “It’s a pretty common exercise we have in trying to validate and see when patients are potentially due for an immunization.”
That problem could intensify in the wake of COVID, as fewer children received vaccinations when families delayed non-emergency care in the spring. In mid-April, at the height of the COVID pandemic, childhood vaccinations dropped by roughly 60% compared with the year prior, according to an analysis of claims data from the Health Care Cost Institute. Measles vaccinations dropped roughly 73% in April and were down 37% at the end of June, suggesting families aren’t rushing to reschedule deferred care.
It’s a trend that could have long-term effects on patients, if providers aren’t able to flag who hasn’t received expected vaccinations and offer them at future appointments.
Generally, if a patient has received all their immunizations at one organization, it’s pretty seamless to look up their history in the EHR, experts say. It gets more complicated if the patient is new to the practice or has received vaccines at other locations. Then a clinic will have to request their records from a previous provider or, if the patient’s previous provider is in the same state, can check with the state’s immunization registry.
It’s “kind of a hodgepodge,” said Dr. Lane Tassin, Western region chief medical officer at FastMed Urgent Care, a company that operates urgent-care and family medicine clinics in Arizona, North Carolina and Texas. “There’s no distinct, definite way to know if any one particular individual has received any one particular vaccination.”
Not all patients and providers participate in registries, so they’re not “an absolute guarantee,” Tassin said. States vary in making reporting to immunization registries voluntary or mandatory, as well as what particular vaccines providers are required to report.
Immunization registries, also called immunization information systems, are typically managed by state public health departments as a way to gather and consolidate patients’ vaccination data across organizations. Providers in the state can log into the registry to search for and input a patient’s immunizations, providing a record of patient vaccinations over time.
“Whether you get your hep B (vaccine) as an infant or whether you get your shingles shot at the pharmacy when you turn 50, all of those would be tracked in an immunization information system,” said Mary Beth Kurilo, senior director of health informatics at the American Immunization Registry Association.
Providers urged to use registries
The CDC has stressed that it’s critical for public health entities to onboard providers who will be administering COVID-19 vaccines into the local immunization registry.
Immunization registries play a critical role in centralizing patients’ vaccination histories in the same state, but they face many of the same patient-matching challenges seen elsewhere in healthcare.
To identify patient records in an immunization registry, the systems tend to rely on demographic data like names, dates of birth and addresses.
The Colorado Immunization Information System, which is used by the A.F. Williams clinic, asks providers to search patients by a system-generated patient ID, medical record number or Medicaid ID number; alternatively, they can search by date of birth and the first two letters of a patient’s first and last name. The system is integrated with the A.F. Williams clinic’s EHR, so clinicians can bring outside immunization data into patient records, as well as push that data to the state system. Medical assistants confirm with patients that the immunization records flowing in from the state system are accurate before they’re added to the patient’s record, Lyon said.
But linking a patient’s records using demographics is a fallible process. A few seemingly small, but consequential, problems arise if a name or date of birth is entered with a typo, if a patient has recently moved to a new address, if there are inconsistencies in the way addresses are written, or if patients with similar information are confused with one another.
“It’s going to be really important that we’re tracking this carefully, so we don’t have patients come in that are showing that they’ve been vaccinated with the COVID vaccine, when in reality, they haven’t been,” said Ryan Smith, vice president and chief information officer at Intermountain Healthcare.
Another key challenge for tracking immunizations is that they span multiple types of healthcare organizations—hospitals, clinics and pharmacies all dole out vaccines—leaving room for information systems to inaccurately link records. Salt Lake City-based Intermountain, like many systems, has an interface embedded within its EHR to its state immunization registry. If just one organization omits data or mismatches a patient, it can inaccurately inform care.
“You’re at the mercy of the weakest link in that chain,” Smith said.
Match rates tend to be pretty high when matching patients within the same facility, experts say. But they can be as low as 50% to 60% when matching patient records between organizations, in part because organizations vary in what demographic data they collect and in what format.
The American Immunization Registry Association, for example, in 2017 released what it calls an “address cleansing service.” It’s a tool that immunization registries implement, which validates addresses and standardizes them to the format used by the U.S. Postal Service.
Hospitals aren’t required to use a specific format when collecting patient addresses, although many healthcare stakeholders submitted public comments last year requesting HHS’ Office of the National Coordinator for Health Information Technology make it easier for organizations to use the Postal Service standard as part of the agency’s interoperability rule, noting studies have suggested it’s proved helpful for improving matching sensitivity.
Two senators last month introduced a bill to make the Postal Service address-formatting tool used by online retailers available to healthcare providers.
No national strategy
While the federal government has taken steps to encourage healthcare providers to link EHRs with immunization registries—chiefly by setting data standards that make it easier for systems to share data—agencies haven’t mandated a strategy for how to identify patients within them.
That’s because the U.S. doesn’t have a national patient-matching strategy. Patient identification is done at the facility or system level, said Chuck Christian, vice president of technology and chief technology officer at Franciscan Health in Indiana.
To tackle healthcare’s patient-matching problem, Congress last year directed ONC to create a report evaluating patient identification practices and offer recommendations. That report won’t come in time for a COVID-19 vaccine, though.
And several potential vaccines, like ones developed by Moderna and Pfizer, require two doses to be most effective—making complete patient records critical for managing immunizations.
It’s likely patients will be receiving each dose of the vaccine at the same location. However hospitals will have to prepare to track which patients have received which company’s vaccine, so they can accurately administer and remind patients to return for the appropriate second dose.
Rates of completion for multi-dose immunizations can be as low as 27%, according to one review of more than 6,000 studies on adolescent adherence to vaccine schedules.
That could be particularly problematic for a COVID vaccine, since organizations may have a limited supply—so a patient who fails to get a second dose at the right time or is provided the wrong dosage at a following appointment could squander part of a critical supply.
Dr. Christopher Alban, vice president of clinical informatics at Epic Systems Corp., a major developer of EHR systems, said he’s “optimistic” the company is well-prepared to track a COVID vaccine.
It’ll be important for providers to bring patients’ COVID immunization histories into medical records, even if the patient receives the vaccine at a different organization.
“Technology and patient education are going to be key with a multidose vaccine,” said Azra Behlim, senior director of pharmacy sourcing and program services for Vizient. Having a central repository to document vaccination information, providing patients with vaccination cards and emphasizing returning to the same location for second doses, when possible, will help to manage COVID immunizations, Behlim added.