Delaware Department of Health and 
Social Services 
Division of Public Health 
Bureau of Communicable Disease 
Immunization Program 

Thomas Collins Building 
540 S. Dupont Highway 
Dover, DE 19901 

Delaware Immunization Program 

ACHIEVING IMMUNIZATION 
PROGRAM PRIORITIES: 
CONSIDERATIONS FOR 
IMMUNIZATION INFORMATION 
SYSTEM IMPROVEMENT 

January 18, 2010 [DRAFT] 

This document was developed with the financial and technical support of the Centers for Disease Control 
and Prevention and technical support from the Public Health Informatics Institute. 


DELAWARE IMMUNIZATION PROGRAM 

ACHIEVING IMMUNIZATION PROGRAM PRIORITIES: CONSIDERATIONS FOR IIS IMPROVEMENT 

TABLE OF CONTENTS 

1. 
INTRODUCTION ......................................................................................................1 


2. 
PURPOSE .............................................................................................................2 


3. 
DELAWARE IMMUNIZATION PROGRAM STRATEGIC PRIORITIES.......................................2 


4. 
REGISTRY FUNCTIONS REQUIRED TO MEET PROGRAM PRIORITIES.................................3 


5. 
EXTENT OF THE GAP BETWEEN CURRENT AND REQUIRED REGISTRY FUNCTIONALITY .......7 


6. 
ASSUMPTIONS AND CONSTRAINTS ............................................................................7 


7. 
OPTIONS FOR IIS IMPROVEMENT ..............................................................................8 


8. 
NEXT STEPS TO CONFIRM DELAWARE’S APPROACH TO REGISTRY IMPROVEMENT ............9 


APPENDIX A: SUMMARY OF CURRENT ISSUES AND CHALLENGES WITH VACATTACK .......10 


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DELAWARE IMMUNIZATION PROGRAM 

ACHIEVING IMMUNIZATION PROGRAM PRIORITIES: CONSIDERATIONS FOR IIS IMPROVEMENT 

1. 
INTRODUCTION 
The Delaware Immunization Program, with the leadership and support of the 
Delaware Department of Health and Social Services (DHSS), operates a 
statewide immunization information system (IIS). IISs are arguably the most 
powerful tool available to increase immunization coverage rates, decrease the 
incidence of vaccine-preventable diseases, and improve the quality of 
immunization practice in private and public settings. The Delaware IIS, known as 
VACAttack, is intended to serve as the data backbone of the Immunization 
Program and is relied upon as a resource to store and recall individual 
immunization information and support overall Program needs. VACAttack was 
developed in 1995 and, now aging, fails to meet current demands. As such, the 
Immunization Program has pursued additional federal stimulus funding to 
improve registry functionality. As a condition for funding, the Centers for Disease 
Control and Prevention requested that the Immunization Program clarify its 
registry development plans. To that end, a joint planning session was conducted 
on January 6, 2010 to achieve the following objectives: 

1. 
To gain clarity on Immunization Program priorities for a 5-year planning 
horizon. 
2. 
To reach agreement on a proposed approach and schedule to improve the 
Delaware immunization registry while addressing known or expected 
constraints. 
Participants in the joint planning session included representatives from the 
Immunization Program, the Immunization Registry, CDC, and Public Health 
Informatics Institute (PHII), a CDC technical assistance partner: 

DHSS • 
Martin Luta, MD, Chief, DHSS Bureau of Communicable 
Disease 

• 
Fred Bailey, DHSS Health Program Coordinator 
• 
Tim Egan, CDC Public Health Advisor, Acting Program 
Manager, Delaware Immunization Program 
• 
Kendall Patterson, Information System Support Specialist, 
DHSS, Division of Public Health 
CDC/NCIRD 
• 
Bobby Rasulnia, LT USPHS, PhD, MPA, MPH, CHES 
Senior Research Scientist, NCIRD/ISD/IISSB 

PHII • 
Laura Ripp, RN, MPH, MBA, PMP, Senior Public Health Advisor 

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Achieving 
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Immunization 
Program 
Priorities: 
Considerations 
for 
IIS 
Improvement 


2. 
PURPOSE 
The Immunization Program views registry improvement efforts as an imperative 
to enable achievement of strategic programmatic priorities in pursuit of its 
mission to “prevent and control the transmission of vaccine preventable 
diseases through the support and implementation of interventions aimed at 
increasing immunization rates.” This report summarizes Program priorities, 
describes immunization registry functionality required to support these priorities, 
and establishes the basis for a rational approach to registry improvement. 

3. 
DELAWARE IMMUNIZATION PROGRAM STRATEGIC PRIORITIES 
Using a five-year horizon, seven major areas were identified as strategic priorities 
for the Immunization Program that must be supported to enable achievement of 
mission-critical activities. Table 1 summarizes responses by Program and Registry 
personnel to indicate whether VACAttack currently satisfies the registry 
requirements for each Program priority. A “No” response indicates that VACAttack 
does not currently satisfy Program needs. In cases where the response is “Partial” 
and the registry mostly meets Program needs, the Partial response is noted to be 
“high” (PH); if the registry offers minimal capability, the Partial response is noted to 
be “low” (PL). There were no “Yes” responses; a finding consistent with the 
recognition that Delaware’s IIS is in critical need of improvement. 

Table 1. Immunization Program Priorities and Current Registry Capabilities 

DE Immunization Program Priorities 
[5-year horizon] 
1. Perform/support ad hoc surveillance and response projects 
2. Identify gaps in immunization coverage 
3. Support provider need for accurate, complete imm’n information 
4. Support stakeholder engagement and retention 
5. Support daily operations 
5.1. Vaccine-preventable disease follow-up/case management 
5.2. Vaccine accountability, management and inventory 
5.3. Training for registry users (initial and ongoing) 
5.4. Maintain linkages to key data sources 
5.5. Support focused, timely communication (internal/external) 
5.6. Reporting (CDC, ARRA, other) 
5.7. Respond to queries; policy support for DPH, legislators, CDC, public at 
large, etc. 
6. Support for nontraditional registry functions, e.g., BMI, newborn screening, 
lead cases, etc. 
7. Monitor provider activity/use of the registry 

Can VACAttack 
currently satisfy 
Program needs? 
No / Partial / Yes 
N 
N 
P 
P 
<See 5.1-5.7> 
P 
N 
N 
PH 
PL 
PL 
N 
N 
N 

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4. 
REGISTRY FUNCTIONS REQUIRED TO MEET PROGRAM PRIORITIES 
Table 2 describes the specific immunization registry functionality that Program and Registry personnel indicate would be 
required to satisfy the Delaware Immunization Program priorities as defined for the next five years. 

Table 2. Immunization Program Priorities and Required Registry Capabilities 

DE Immunization Program Priorities 
[5-year horizon] 
Required Immunization Registry Functions 
1. Perform/support ad hoc surveillance and response projects 
• 
Capability to generate form-based surveys and dynamically 
assign data elements to events. 
• 
Capability to store event-/project-specific data 
• 
Capability to perform data extraction 
• 
Capability to support statistical analyses 
• 
Capability to perform ad hoc (non-standard) reporting 
• 
Capability to support user-managed survey creation, data 
analysis and reporting for special projects as they are defined 
2. Identify gaps in immunization coverage 
• 
Capability to capture immunization and related data 
• 
Capability to store complete data sets 
• 
Capability to perform complex queries to support data 
stratification 
• 
Capability to support statistical analyses 
• 
Capability to support geographic mapping functions, 
geocoding, etc. 
• 
Capability to perform data representation, graphing functions 
3. Support provider need for accurate, complete imm’n information • 
Capability to perform deduplication of records • 
Capability to support data quality assurance functions 
(scrubbing) to migrate reliable information to the registry from 
external systems 
• 
Capability to capture and store immunization information from 
numerous external sources and make it available to providers 
in a timely manner 

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Achieving 
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DE Immunization Program Priorities 
[5-year horizon] 
Required Immunization Registry Functions 
4. Support stakeholder engagement and retention 
• 
Capability to capture stakeholder identification and 
characteristics, i.e., for health plans, providers, etc. 
• 
Capability to receive data from external systems in multiple 
formats, including, but not limited to, HL7 
• 
Capability to perform data validation 
• 
Capability to perform stakeholder-specific analyses to support 
value-added services, e.g, HEDIS reporting, reminder/recall 
notifications, etc. 
• 
Capability to support stakeholder-specific report formats and 
generate reports 
• 
Capability to support automatic, periodic transmission of 
stakeholder reports to named recipients 
5. Support daily operations [Functions described in 5.1 – 5.7] 
5.1. Vaccine-preventable disease follow-up/case management 
• 
Capability to perform complex queries to support data 
stratification 
• 
Capability to analyze sub-population and full population data 
• 
Capability to support search for specific cases 
• 
Capability to support VPD case-specific templates 
• 
Capability to display results 
• 
Capability to generate structured reports 
• 
Capability to generate ad hoc reports 
• 
Capability to record specific case observations using forms-
based tools 

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Achieving 
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IIS 
Improvement 


DE Immunization Program Priorities 
[5-year horizon] 
Required Immunization Registry Functions 
5.2. Vaccine accountability, management and inventory 
• 
Capability to interface with an external system (McKesson) to 
capture vaccine distribution data 
• 
Capability to support communication from provider systems 
(e.g., vaccine inventory data) to the registry 
• 
Capability to perform reconciliation between amounts 
distributed to and amounts reported by providers 
• 
Capability to perform decision support functions regarding 
vaccine order quantities 
5.3. Training for registry users (initial and ongoing) 
• 
Capability to support training videos 
• 
Capability to provide contextual “help” functions within the 
registry application 
• 
Capability to support audio/video enabled “help” functions 
within the registry application 
• 
Capability to provide access to printable registry reference 
and “how to” guides 
• 
Vendor-assisted Help Desk (direct technical) support 
5.4. Maintain linkages to key data sources 
• 
Capability to support bidirectional connectivity to target 
databases 
• 
Capability to provide “intelligent” interfaces to support specific 
data calls 
• 
Capability to support numerous small, custom interfaces 
• 
Capability to monitor changes in status of connections 

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Achieving 
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Considerations 
for 
IIS 
Improvement 


DE Immunization Program Priorities 
[5-year horizon] 
Required Immunization Registry Functions 
5.5. Support focused, timely communication (internal/external) 
• 
Capability to support a resource email account, i.e., a general 
mailbox 
• 
Capability to generate and submit communication content 
• 
Capability to enable/disable specific bidirectional 
communication channels 
• 
Capability to set time (and other) parameters for 
communication content 
• 
Capability to enable decision points/action steps within 
communication content to achieve specific outcomes, e.g., 
acknowledgement of receipt, feedback, etc. 
5.6. Reporting (CDC, ARRA, other) 
• 
Capability to develop standard reports for timely, periodic use 
• 
See functions in 5.7 
5.7. Respond to queries; policy support for DPH, legislators, CDC, public at 
large, etc. 
• 
Capability to perform complex queries to support data 
stratification 
• 
Capability to support ad hoc report design and generation 
• 
Capability to support complex reporting, e.g., interface with 
3rd party report tools such as Crystal Reports. 
6. Support for nontraditional registry functions, e.g., BMI, newborn screening, 
lead cases, etc. 
• 
Capability to capture and store additional data 
• 
Capability to view additional data 
• 
Capability to perform complex queries 
• 
Capability to support reports using integrated data sets 
• 
Capability to support role-based permissions, access controls 
and other user-related confidentiality safeguards 
7. Monitor provider activity/use of the registry 
• 
Capability to support and maintain a statewide provider 
directory 
• 
Capability to support user activity logs and audit capability 
• 
Capability to support user query logs 
• 
Capability to support options in presentation layer, e.g., user-
defined look and feel 
• 
Capability to support provider communication (see 5.5) 

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Achieving 
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Considerations 
for 
IIS 
Improvement 


5. 
EXTENT OF THE GAP BETWEEN CURRENT AND REQUIRED REGISTRY FUNCTIONALITY 
Table 3 is intended to represent the general level of technical effort required to 
close the gap between the current functionality of VACAttack and what 
Immunization Program and Registry personnel identify as the registry 
functionality required to support Program priorities. Information from Table 1 is 
also incorporated here as a reference to current registry capabilities relative to 
Program needs and a list of key issues and challenges with VACAttack as 
described by the Delaware team is provided as Appendix A. It should be noted 
that among 8 of 13 distinct Program priority areas, the technical effort to 
implement the required functionality in the current registry is felt to be “large”. 

Table 3. Extent of the Gap Between Current and Required Registry Capabilities 

DE Immunization Program Priorities 
[5-year horizon] 
Can 
VACAttack 
satisfyProgram 
priorities?*
Extent of Gap 
Between Current 
and Required 
Registry 
Functionality 
Sm / Med / Lg 
1. Perform/support ad hoc surveillance and response projects N L 
2. Identify gaps in immunization coverage N L 
3. Support provider need for accurate, complete imm’n information P L 
4. Support stakeholder engagement and retention P S 
5. Support daily operations <5.1-5.7> 
5.1. Vaccine-preventable disease follow-up/case management P L 
5.2. Vaccine accountability, management and inventory N M 
5.3. Training for registry users (initial and ongoing) N L 
5.4. Maintain linkages to key data sources PH S 
5.5. Support focused, timely communication (internal/external) PL M 
5.6. Reporting (CDC, ARRA, other) PL M L 
5.7. Respond to queries; policy support for DPH, legislators, CDC, public 
at large, etc. N L 
6. Support for nontraditional registry functions, e.g., BMI, newborn screening, 
lead cases, etc. N L 
7. Monitor provider activity/use of the registry N L 

* As per Table 1, N = No, VACAttack does not satisfy Program needs; P = Partially satisfied; Y = Yes, fully satisfied 
6. 
ASSUMPTIONS AND CONSTRAINTS 
Program and Registry personnel reviewed assumptions and discussed actual 
and potential constraints that must be factored into a decision to pursue a custom 
coded solution (“build”) or a commercially available solution (“buy”) to implement 
registry improvements. Relevant assumptions and constraints include: 

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A. 
Cost. The approach to implement registry improvements cannot exceed 
$385,444 in federal stimulus funding to be made available to Delaware by 
CDC. The funding application is a Financial Assistance (FA) request. 
B. 
Schedule. Rapid deployment is required. Project funding must be 
encumbered by the end of the 18 month period (approximately March 2011) 
as stipulated in the ARRA Program Requirements. 
C. Customization. Complex functionality such as forecasting, reminder/recall, 
immunization coverage reporting and deduplication do not exist in the current 
solution. Therefore, improvements in the registry as required to meet 
Immunization Program goals could require some degree of customization 
which should be factored into the total cost of solution development and 
maintenance. 
D. 
Sustainability. The chosen registry solution must be financially and 
technically sustainable, i.e., the solution should include consideration of 
defined mechanisms to ensure long-term availability and productive use. 
i. 
Ongoing maintenance and support. The ongoing cost of registry 
maintenance and support must not exceed the amount of federal grant 
funding allocated to the registry (Section 317 program funds). 
ii. 
Access to required skills. Human resource factors must be considered in 
the operating plan for the registry. The skills and knowledge required to 
support the registry must be readily accessible. 
E. 
Procurement. Possible registry solutions must be acquired through accepted 
procurement and contracting mechanisms. This may include purchasing from 
the State’s pre-approved vendor list or solicitation of offerings through 
issuance of a Request for Proposals. 
F. 
Project Approval. The project schedule should anticipate requirements for 
State and federal approvals. 
7. 
OPTIONS FOR IIS IMPROVEMENT 
Five options were initially identified as potential approaches to improve 
immunization registry functionality in order to satisfy the needs and priorities of 
the Delaware Immunization Program. After discussion, the “maintain status quo” 
and “outsource registry” options were eliminated. Three options for IIS 
improvement will be further evaluated. These include: 

A. 
Adopt a registry product currently in use by another state. 
B. 
Procure a commercial off-the-shelf (COTS) registry solution. 
C. 
Develop a “pseudo-custom” solution by building or buying a new presentation 
layer with the required logic and integrating it with the existing registry 
database. 
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Achieving 
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Priorities: 
Considerations 
for 
IIS 
Improvement 


8. 
NEXT STEPS TO CONFIRM DELAWARE’S APPROACH TO REGISTRY IMPROVEMENT 
The following near term actions will be taken to gather additional information 
regarding each of the potential options for registry improvement: 

• 
By January 31, 2010, CDC will assist in scheduling at least four remote live 
demonstrations of registry solutions currently in use. The solutions previewed 
will range from COTS products to state-developed registries. Information on 
contract terms/scope of work, cost, and other factors will also be requested. 
• 
By January 20, 2010, Delaware (Registry Manager) will define the state 
procurement process applicable to each of the three options. The process 
description should minimally include: a) the estimated timeline; b) specific 
action steps; and c) special considerations for ARRA funds. 
• 
By January 20, 2010, Delaware (Registry Manager) will describe the plan 
required to pursue the “pseudo-custom” solution option. 
• 
By January 31, 2010, the Delaware team will reconvene by teleconference to 
discuss findings, impressions and any remaining next steps required to 
confirm a decision on the preferred approach to registry improvement. 
• 
By February 12, 2010, the Delaware team will confirm a decision on the 
preferred approach to registry improvement. 
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Considerations 
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IIS 
Improvement 


APPENDIX A: SUMMARY OF CURRENT ISSUES AND CHALLENGES WITH VACATTACK 

VACAttack, the current immunization registry in use by the Delaware Immunization 
Program, is a significant target for improvement as it does not currently meet 
programmatic needs and is generally deficient in functional capabilities as compared 
with the CDC-endorsed functional standards for immunization registries. The Delaware 
team (as listed on Page 1 of this report) described and demonstrated key issues and 
challenges with VACAttack. A summary of those issues is presented here. 

1. The current registry lacks the capability to support core functionality including: 
a. 
Support for reminder/recall notification 
b. 
Immunization coverage reporting 
c. 
Vaccine inventory management 
d. 
Vaccine forecasting to determine routine immunizations needed 
e. 
Exchange records using HL7 standards 
2. 
The registry cannot currently support the requirements for pandemic influenza 
management. 
3. 
The Master Client Index (MCI) for the registry is controlled at the Department 
level (DHSS) and must be reconciled with numerous demographic databases. 
4. 
Deduplication of records and discrete immunizations is a fully manual, highly 
time-consuming process currently being addressed by the Registry Manager. 
5. 
The registry is a highly customized proprietary solution with several components 
that have been rendered inoperable due to unresolved software coding conflicts. 
Performance issues are common. 
6. 
There are no direct feeds of electronic birth certificate data to the registry. The 
vital records system is housed in a non-state database which is problematic for 
timely receipt of this essential information. There are currently no connections 
from birthing hospitals to the registry. 
7. 
Value received by providers using the registry is minimal. Participating providers 
may access a read only, web-based interface to view immunization histories. 
8. 
Immunization data is captured by entry of paper-based immunization records as 
well as some electronic file transfer from participating stakeholders. Timeliness 
of data availability must be improved. 
9. 
Reporting is accomplished using custom scripts and data extraction to support 
analyses is not generally able to be performed by program staff. 
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