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Childhood Immunization Registries
Gaps Between Knowledge and Action Among Family Practice Physicians and Pediatricians in Washington State, 1998
James A. Gaudino, MD, MS, MPH;
M. Patricia deHart, ScD;
Allen Cheadle, PhD;
Diane P. Martin, PhD;
Danna L. Moore, PhD;
Sheryl J. Schwartz, MPA;
Beryl Schulman, PhD
Arch Pediatr Adolesc Med. 2002;156:978-985.
ABSTRACT
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Objectives To assess the availability and use of Washington State's CHILD (Children's
Health, Immunization, Linkages, and Development) Profile and other computerized
immunization tracking systems, to determine physicians' attitudes about these
systems, and to identify factors associated with using them.
Design Randomized, population-based, cross-sectional survey.
Participants Washington family physician and pediatrician specialty organization
members providing childhood immunizations in 1998 (N = 2472).
Main Outcome Measure Reported CHILD Profile and other computerized systems use.
Results The adjusted response rate was 75% (n = 1331). Overall, 37.7% of respondents
had heard of CHILD Profile, 6.3% used it, and 24.9% used other systems. Groups
significantly more likely not to use computerized systems than referent pediatricians
in areas fully implementing CHILD Profile were family physicians (adjusted
odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.4-4.0), private physicians
(aOR, 8.0; 95% CI, 3.2-20.1), physicians taking fewest opportunities to immunize
(aOR, 2.3; 95% CI, 1.4-3.7), and physicians practicing in local health jurisdiction
areas with CHILD Profile marketing activity (aOR, 2.1; 95% CI, 1.2-3.9) or
in those areas with little or no registry activity (aOR, 2.6; 95% CI, 1.6-4.4).
Those with systems agreed that they save time (71.0%), make status checks
easier (87.1%), and increase immunization coverage (88.6%). Those without
systems agreed that they help practices (90.3%) and increase efficiency (76.5%),
but fewer agreed that they reduce costs (30.2%).
Conclusions Although most physicians agreed that computerized systems are useful,
few had them or used them. Provider-based systems can improve immunization
coverage, but the feasibility and effectiveness of communitywide and statewide
systems remain unexplored. Because these systems depend on participation,
more understanding is needed to help organizations implement them. Interventions
to increase availability and use should address provider and health organization
needs.
INTRODUCTION
BARRIERS TO "on-time" childhood vaccinations remain despite intensive
public health efforts to overcome them.1-5
A major focus of these efforts recently has been the elimination of missed
opportunities to vaccinate, a major contributor to inadequate childhood immunization
coverage.3-4,6-10
To improve provider vaccination practices, a growing number of public health
agencies and private clinical practices in the United States are developing
and using provider-based computerized immunization management systems and
registries.11-14
Evaluations of such systems suggest that they can help providers use computer-assisted
patient reminders and recalls and improve immunization delivery.11-15
In 1993, published standards16 for pediatric
immunization practices recommended that providers use immunization tracking
systems.
In addition, in the past few years, various public health and clinical
experts and agencies, including the National Vaccine Advisory Committee and
the Centers for Disease Control and Prevention, have recommended implementing
communitywide or larger area–wide, population-based computerized immunization
registries throughout the United States.17-20
In many states, such systems are being implemented. Although provider-based
immunization systems are not considered to be population-based immunization
registries, provider-based systems may contribute child patient records to
and share new records from population-based systems.
In Washington State, partner agencies have been developing a communitywide
and statewide registry and health promotion system called CHILD (Children's
Health, Immunization, Linkages, and Development) Profile.21
A major goal of this system is to help ensure that Washington's children from
birth to age 6 years receive needed preventive health services. At the time
of this study (1998), the CHILD Profile immunization tracking system was at
different stages of implementation and provider recruitment in several, but
not all, local health jurisdictions (LHJs) in the state. This system was first
developed and implemented in western Washington by LHJs in Seattle-King and
Snohomish counties. Age-appropriate health promotion materials were mailed
to parents beginning in 1993, and marketing of the tracking system to health
care organizations began between 1994 and 1995.21
At the time of this survey, CHILD Profile did not have the capability to automatically
generate immunization reminders or recalls, but participating providers could
query the system for vaccine status information for their patients and then
use queries for reminders or recall.
Some private practices and managed care organizations (MCOs) in Washington
State have also been implementing provider-based computerized immunization
tracking systems. For example, Washington's largest health maintenance organization
(HMO), Group Health Cooperative, had already implemented a registry among
its staff-model HMO practices at the time of this study but not among its
affiliate private practices.11, 22-23
Several of these provider-based systems were being linked to CHILD Profile
in areas where it was being implemented.
Because approximately 80% of childhood immunizations are given by private
providers in Washington State, communitywide and statewide immunization registries
and provider-based immunization tracking systems depend on the participation
of private providers and health plans. Consequently, in 1998, we surveyed
Washington family practice physicians and pediatricians who provide childhood
immunizations to (1) assess the availability and use of CHILD Profile and
other computerized immunization tracking systems, (2) determine physician
attitudes about the usefulness of such systems in their practice, and (3)
identify factors associated with using such systems.
PARTICIPANTS AND METHODS
SURVEY PROCESS
Approval to conduct the survey using physician member organization lists
was obtained from the human subjects review boards of the Department of Social
and Health Services and the Department of Health, the University of Washington,
and Washington State University. After a pilot survey in late 1997, we attempted,
in early 1998, to contact all 2472 physician members of the Washington chapters
of the American Academy of Pediatrics (n = 791) and the American Academy of
Family Physicians (n = 1681). The membership chapters agreed to participate
in the survey and provided their most current lists. This contact information
was supplemented as needed by telephone directory information, state Medicaid
provider lists, and information from practices or clinics for some physicians
who had changed practices.
We randomly assigned family practice physicians and pediatricians, by
specialty, to initial contact by either telephone first (with a minimum of
10 contact attempts) or US Postal Service 2- to 3-day Priority Mail first.24 The telephone and the mail survey questionnaires
had the same order of questions and other content. Telephone interviewers
were trained to give the same information to physicians reached by telephone
as given in the mail survey. When eligible, consenting physicians who were
reached by telephone were interviewed. If the physician did not have time
for the interview, another telephone interview time was scheduled or, if requested,
a survey was mailed.24 All mail surveys included
stamped return envelopes. Mail surveys included at least 1 follow-up mailing.
However, after approximately 8 weeks, nonrespondents were contacted again
using the alternate method. Initial data collection was discontinued after
roughly 3 months. Approximately 6 months later, with additional funding, a
final Priority Mail follow-up of the remaining nonresponders was conducted.
When contacted, physicians were informed about the purpose of the study
and were asked to consent to participate. Eligible physicians were those who,
at the time of the survey, administered childhood immunizations and practiced
in Washington State. Emergency department and non–English-speaking physicians
were excluded.
SURVEY INSTRUMENT, VARIABLES OF IMPORTANCE, AND DATA ANALYSIS
To assess the availability and use of computerized patient immunization
tracking systems, participating physicians were asked about whether they had
heard of CHILD Profile, whether they used CHILD Profile or some other immunization
computerized tracking systems in their practice, and, if they used a system,
how often they accessed it during child clinic visits. Related to one of our
objectives, respondents were also asked how much they agreed or disagreed
with statements about specific attributes of and their attitudes about immunization
tracking systems.
We considered several variables as potential markers of physician and
health system barriers to the availability and use of computerized patient
immunization systems. These variables included a composite of answers about
immunization practices in a series of questions about how often physicians
would give vaccines during 17 specific scenarios for child patients, with
a range of illnesses, visiting for well-child care, chronic condition care,
or acute care. All of these visit scenarios represented immunization opportunities
in which 1 or more vaccinations would be indicated by the unified immunization
practice guidelines.16, 25-26
We summed answers to the 17 visit scenario questions to calculate the number
of different visit scenarios during which each physician would "often" immunize
and categorized these composite responses into 4 groups. Other immunization
practice questions were modified from questions developed by Szilagyi et al.27 Answers to questions about immunization practices
or immunization tracking systems with Likert-type scaled response options
were grouped together. Practices conducted "always" or "most of the time"
were considered often-conducted practices. Also, several summary measures
or indices on related topics were developed.
The following physician and practice characteristics were also included
in the survey: gender, number of years since medical school graduation, whether
a residency was completed, number of children cared for each week, type of
practice setting (eg, HMO, different private practice settings, public health
department or community clinic, hospital, or other settings), size of the
community in which the practice was located, type of relationship with managed
care organizations (MCOs) (eg, no relationship, contractor, affiliate, or
employee), and whether the practice contracted with a health plan having immunization
guidelines. Because we had no direct measure of the extent of CHILD Profile's
marketing to specific practices, we used practice ZIP codes to assign a classification
for the type of CHILD Profile activity occurring in the LHJ area where the
physician's primary practice was located (eg, whether CHILD Profile was being
implemented, marketed only, or conducted as a "follow-up" health promotion
activity by the LHJ only or whether no registry activity was occurring in
the LHJ area).
We calculated adjusted response rates using the Council of American
Survey Research Organization (CASRO) method, which adjusts for the number
of known ineligible respondents and the number of estimated ineligible nonrespondents
(CASRO Completion Rates Task Force, unpublished data, 1982).28
We used  2 tests to compare percentages of physician and practice
characteristics and survey answers from pediatricians with those from family
physicians. To evaluate the contribution of various factors to the "risk"
of physicians not using computerized immunization systems, relative risks
were estimated using unadjusted odds ratios (ORs), and adjusted ORs (aORs)
were calculated using multiple logistic regression. SAS statistical software
was used for all data analyses.29
RESULTS
RESPONSE RATES AND RESPONDENT CHARACTERISTICS
There were 1331 completed interviews, 88 refusals, and 558 known ineligible
physicians. After the 3-month follow-up, the overall CASRO adjusted response
rate was 63%. The rate increased to 75% after the final 6-month follow-up.
The initial 3-month CASRO response rate for the Priority Mail first group
was 62%, which was higher than the rate of 41% for the telephone first group.
However, after the 6-month follow-up, the final CASRO response rate of 77%
for the Priority Mail first group was only slightly higher than the 73% rate
for the telephone first group.24 These subsequent
response rate gains were primarily made when Priority Mail attempts were used.
Before the 6-month follow-up, CASRO response rates were higher for pediatricians
than for family physicians, but they did not differ by practice location.
Patient care loads and practice settings differed significantly between
family physicians and pediatricians (Table
1). Compared with pediatricians, family physicians cared for fewer
children per week (eg, 16.6% of family physicians cared for  31 children
per week, whereas 76.1% of pediatricians reported caring for that many children).
Compared with pediatricians, more family physicians practiced in public health
settings and community clinics, HMOs, and settings other than hospitals and
private practices (40.6% vs 23.7%), and more were employed by HMOs (15.1%
vs 11.2%). However, regardless of specialty, 81.2% of all physicians stated
they had an affiliate or contract relationship with an MCO.
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Table 1. Respondent Physician Characteristics, Washington State, 1998*
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More family physicians than pediatricians contracted with an MCO plan
that had immunization guidelines (86.6% vs 78.8%) and practiced in nonurban
or rural communities (37.2% vs 29.6%). Compared with pediatricians, family
physicians took fewer opportunities to immunize children in visit scenarios
at which vaccines were indicated (eg, 26.8% of family physicians compared
with 18.5% of pediatricians would vaccinate in  7 of the 17 vaccine-indicated
scenarios). In contrast, family practice physicians were more likely than
pediatricians to practice in LHJ areas with little or no CHILD Profile activity
(17.0% vs 10.7%), whereas more pediatricians (58.6%) than family physicians
(52.2%) practiced in areas implementing CHILD Profile (Table 1).
AVAILABILITY AND USE OF COMPUTERIZED IMMUNIZATION TRACKING SYSTEMS
Significantly more pediatricians (52.3%) than family physicians (31.6%)
had heard of CHILD Profile (Table 2).
Although only 6.3% of all physicians stated that they had used CHILD Profile,
more pediatricians (11.3%) than family physicians (4.2%) had done so. An additional
24.9% of both physician specialists stated that they used some other computerized
immunization tracking system. Overall, 30.4% of physicians stated that they
used CHILD Profile, another computerized tracking system, or a combination
of systems.
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Table 2. Use of Computerized Immunization Tracking Systems, Washington
State, 1998*
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ATTITUDES ABOUT COMPUTERIZED IMMUNIZATION TRACKING SYSTEMS
Pediatrician and family physician attitudes or impressions about computerized
tracking systems differed little (Table
3). Overall, among physicians with CHILD Profile or another computerized
system, 64.1% used the system often to track immunizations, and 63.1% referred
to the system during patient visits. Most of these physicians stated that
they strongly or somewhat agree that computerized tracking systems have some
beneficial features (Table 3).
Of those using systems, 68.6% agreed that computer systems give patient immunization
status information during office visits, and 88.6% agreed that they increase
immunization coverage. Most physicians with systems also agreed that they
reduce unneeded vaccinations (68.8%), save time (71.0%), and make status checks
easier (87.1%).
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Table 3. Attitudes Toward Computerized Immunization Tracking Systems
Among Providers With and Without Systems, Washington State, 1998*
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Among physicians without a computerized tracking system, most (76.5%)
believed that a system would increase their office practice's efficiency,
and almost all (90.3%) believed that a system would be helpful to their office
practice. However, fewer of these physicians (30.2%) said that a system would
reduce office costs.
FACTORS ASSOCIATED WITH NOT USING COMPUTERIZED IMMUNIZATION TRACKING
SYSTEMS
After examining crude ORs, we modeled 5 characteristics for their associations
with physicians' not using CHILD Profile or other computerized immunization
tracking systems in their practices: medical specialty, type of practice,
relationship of practice with MCOs, cumulative number of visit scenarios (of
17 scenarios) in which each physician would often immunize when a vaccination
was indicated, and practice location by category of LHJ involvement in CHILD
Profile (Table 4). We also controlled
for number of years in practice since graduating from medical school, number
of children cared for per week, and the initial survey contact method.
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Table 4. Odds Ratios (ORs) for Not Using CHILD Profile or Another Computerized
Immunization Tracking System, Washington State, 1998*
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Findings from the unadjusted analyses were mostly consistent with those
from the logistic regression analyses (Table 4). After adjusting for other factors, family physicians were
2.4 (95% confidence interval [CI], 1.4-4.0) times more likely than pediatricians
not to use computerized tracking systems. Compared with physicians practicing
in HMOs, those in private practice were 8.0 (95% CI, 3.2-20.1) times more
likely not to use a system. Those in most other practice settings (other than
HMOs, hospitals, or public or community clinics) were significantly more likely
not to use a computerized system. In univariate analyses, 22.5% of HMO affiliates
and MCO contractors stated that they used a system compared with 75.4% of
HMO employees (unadjusted OR, 10.4; 95% CI, 7.1-15.1). After adjusting for
other factors, including survey recruitment method, affiliates of staff-model
HMOs or contractors with MCOs (aOR, 2.5; 95% CI, 1.1-6.0) and physicians having
no MCO relationship (aOR, 3.5; 95% CI, 1.1-11.1) remained significantly more
likely not to use a system than those employed by HMOs. Physicians in practices
in LHJ areas with CHILD Profile marketing only or little or no CHILD Profile
activity were 2.1 (95% CI, 1.2-3.9) and 2.6 (95% CI, 1.6-4.4) times, respectively,
more likely not to use a computerized system than those practicing in areas
where CHILD Profile was being implemented. In univariate analyses, we also
found linearly increasing ORs for physicians not having computerized systems
as fewer CHILD Profile activities were occurring in areas corresponding to
where their practices were located (2 linear test for trends
with P<.001).
Physicians who would take the fewest opportunities to immunize (ie,
who would often immunize children in 7 of the 17 total visit scenarios)
were 2.3 (95% CI, 1.4-3.7) times more likely not to use a system than those
who would take almost all opportunities (ie, who would often vaccinate in
16-17 visit scenarios). Other lower scorers also were less likely than the
highest scorers not to have a system, although the difference was not statistically
significant.
COMMENT
Most physicians surveyed agreed that computerized immunization systems
are or would be useful, but few (30.4%) had them or used them. Although almost
40% of physicians had heard of CHILD Profile, only a small percentage used
it (6.3%). Physicians using other computerized systems may not realize that
these systems may have been linked to the CHILD Profile system. Compared with
the referent group, physicians more likely not to use CHILD Profile or some
other computerized immunization tracking system were family physicians, those
not employed by HMOs, those in practices not having a relationship with an
MCO, those taking the fewest opportunities to immunize, and those practicing
in LHJs in which CHILD Profile was not available or was just being introduced.
These associations remained after controlling for differences between family
physicians and pediatricians in Washington State regarding types of practices
and community settings and child patient loads.
In Washington State, it seems that staff-model HMOs may have been more
successful than other practice settings at implementing computerized immunization
tracking. Although 90% of physicians were employed by or had some relationship
with MCOs, most were HMO affiliates or MCO contractors rather than HMO employees.
Provider and health plan incentives to implement computerized systems may
differ depending on the type of relationship providers have with MCOs. Staff-model
HMOs have organizational structures, such as centralized data and accounting
systems, that would be amenable to more rapid immunization system implementation.
By contrast, MCOs with affiliate and contract practices and practices with
no MCO affiliations might have less capacity or fewer incentives to implement
computerized systems, especially if implementation depends on capital investments
by the provider practice. The association between computerized system use
and self-reported physician practices related to immunization opportunities
suggests that physician awareness of missed opportunities to vaccinate may
be affected by or may affect the use of interventions such as computerized
tracking systems.
This study has several potential limitations. We could not assess the
practices or perspectives of physicians not associated with the American Academy
of Pediatrics or the American Academy of Family Physicians, for example, nonmember
general practice physicians or physicians who recently moved to Washington.
Neither did we attempt to survey other health providers, such as nurse practitioners
or physician assistants, who practice independently from physicians and who
also provide immunizations.
Also, answers provided by respondent physicians may not adequately represent
all eligible physicians because nonrespondents may not have the same opinions
and practices as respondents. In addition, responses by physicians contacted
via Priority Mail first may be different from those of the telephone first
group, although the final response rates between the 2 groups were almost
identical. To account for any potential differences regarding the use of computerized
systems between these latter groups, we adjusted for the survey method used.
Self-reports about immunization practices or use of computerized systems
may differ from actual practices, especially among those contacted by telephone.
Selective recall or the desire to reflect "good" practices may result in more
favorable practice reports, especially because reminder and recall systems
and immunization tracking have been promoted and supported in the literature
for some time.11-20,30-31
It is also possible, especially in large health delivery organizations, that
physicians may not have been fully aware of all office practices or of the
immunization record-keeping systems available or used. This lack of knowledge
might occur if childhood immunizations were primarily given or managed by
nurses or other health professionals in the practice. Also, some physicians
may not be aware that their practice's computerized system may be linked to
the registry. Limited knowledge about system capabilities might have led to
overestimates or underestimates of their availability and use. Because we
asked different questions depending on the use of computerized systems, we
could not explore the effects of physicians' attitudes toward these systems
on whether physicians' did or did not participate in these systems. Finally,
ORs may overestimate the relative risks for not using computerized systems
because the prevalences of not using computerized systems did not ideally
fit the "rare disease" assumption.
Despite these limitations, to our knowledge, this is one of the first
statewide studies to report on factors associated with the use of computerized
immunization registries. Our findings are based on a large, statewide study
of most physicians providing childhood vaccines. Also, the response rate of
75% in our study was high for a survey of physicians. Our use of 2 multimode
recruitment methods with US Postal Service 2- to 3-day Priority Mail contacts
was particularly helpful. In comparison, response rates in 23 recently published
immunization practice or opinion surveys ranged from 38%32
to 90%.33 Indeed, our response rate is much
higher than the 54% mean response rate reported in a systematic review of
mailed surveys of physicians published in major medical journals in 1991.34
The results of this survey provide baseline prevalences of computerized
immunization tracking system use that are useful for monitoring state implementation
of such systems and changes in provider attitudes about these systems. Statewide,
community-specific, and health organization–specific information regarding
tracking system use and attitudes is needed to inform and influence health
care organization management and public health decision making and to track
system marketing and implementation efforts.
Washington physicians' positive attitudes toward immunization tracking
and the availability of other computerized systems seem promising for further
development of provider- or health plan–based systems linkable to community-based
systems, even if such linkages may not be accomplished easily. Because these
systems depend both on practice and provider participation, further work is
needed to understand how to help providers and health care organizations implement
them. As our findings suggest, further information is needed to identify effective
ways that HMOs and other MCOs contracting with private physicians can promote
these systems among their affiliates.
These results also suggest some potential factors influencing provider
and health care organization decisions about computerized immunization tracking,
such as providers' training, practice setting, immunization practices, and
external payer affiliations. Indeed, these factors may be markers for specific
barriers faced by the provider or organization that should be further assessed.
However, the factors influencing decisions about implementing these systems
are complex. Providers' theoretical support for these systems is probably
tempered by perceptions about the utility of the system, which, for example,
has yet to include all child immunization information from every provider
that a patient visits, as suggested in another recent study of perceptions
about CHILD Profile in Seattle-King County35
and in a study using statewide provider focus groups during the design of
a registry in North Carolina.36
Factors that predict registry participation may also relate to the known
and perceived clinical and business utility that such systems might have to
practices or health care organizations. Because of the variability of health
care delivery organizations in the United States, who makes decisions and
how decisions are made differ. Such differences might explain, in part, the
differences noted in this study between medical specialties and among practice
types. Strategies to promote tracking systems need to address the distinct
needs of individual practices and health care organizations.
Physician surveys are necessary but not sufficient tools for gaining
a better understanding of how immunization tracking systems can be implemented
in various practices. Other approaches should include assessing the roles
physicians and other immunization providers play as decision makers or in
influencing decision makers to implement computerized systems. Identifying
specific incentives or barriers faced by physician and nonphysician decision
makers and providers would be particularly important. What the standards of
practice are for immunization delivery and how providers understand them most
likely play a role in these decisions as well. Understanding how these standards
influence providers to use computerized systems would be valuable, particularly
as standards change over time and as new scientific evidence regarding effective
use of computerized systems becomes available.
Moreover, even if complete population-based tracking systems become
available, decision makers may not be interested in participating in them.
For these systems to be used clinically, providers need assurance that these
systems have accurate and complete information about pediatric patients with
multiple immunization providers in their system's area.35-36
Tracking systems should also include features that are effective in increasing
vaccination coverage, such as computerized immunization patient reminder and
recall features,15, 30 and that
meet other clinical objectives or business needs.
As the use of information technology in health care continues to increase,
as practice standards change, and as immunization registry participation increases,
evaluations should assess the value of specific system features, the availability
of these features to health organizations as incentives for participation,
and the purported practice benefits of immunization registries.17, 37
Finally, having computerized immunization systems does not guarantee
that practices will have the capacity or incentives to use computerized immunization
data on an ongoing basis. Better understanding of the factors that encourage
ongoing use is also needed. The feasibility of full implementation and the
effectiveness of communitywide and statewide immunization systems still remain
unknown and should be evaluated over time.
| What This Study Adds
Despite the strong interest in implementing population-based immunization
registries, there is little published research evaluating the implementation
of communitywide and statewide computerized immunization registries and providers'
use of computerized immunization tracking systems linked to registries. Few
studies (1) address whether providers who have computerized immunization systems
use their systems or (2) explore factors associated with computerized system
use that might suggest incentives to increase the use of computerized systems
and registries. This study is also relevant to providers' use of computerized
systems in general and contributes to the growing field of medical informatics.
Specific findings from this study suggest that although most physicians agreed
that computerized systems are useful, few had them or used them. In addition,
staff-model HMOs may have been more successful than other practice settings
in implementing these systems at this stage. Other factors associated with
not using systems included some characteristics of physicians, such as specialty,
practice type, physicians' immunization practices, and the extent of registry
marketing exposure based on practice location. This article includes recommendations
for increasing the adoption and use of computerized immunization systems,
including the need to identify the role of standards of practice and to include
"value-added" incentives. Also, we suggest that additional data monitored
over time from multiple levels, including providers, would help efforts to
increase registry participation.
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AUTHOR INFORMATION
Accepted for publication April 5, 2002.
This study was funded in part by the State of Washington Department
of Health immunization grants from the CDC.
This study was presented in part at the American Public Health Association
127th Annual Meeting, Chicago, Ill, November 1999; the 12th Annual Conference
of the Society for Pediatric Epidemiologic Research, Baltimore, Md, June 1999;
the 33rd National Immunization Conference, Dallas, Tex, June 1999; and the
annual CDC Maternal, Infant, and Child Health Epidemiology Workshop: Data
and Information for Planning, Prevention and Evaluation Conference, Atlanta,
Ga, December 1999.
We thank the staff of the Social and Economic Sciences Research Center,
Washington State University; Hoyt Wilson, PhD, Statistics and Computer Branch,
Division of Reproductive Health, Centers for Disease Control and Prevention;
and the Washington State chapters of the American Academy of Pediatrics and
the American Academy of Family Physicians.
Corresponding author: James A. Gaudino, Jr, MD, MPH, Pregnancy and
Infant Health Branch, Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, Centers for Disease Control
and Prevention, Mailstop K-23, 1600 Clifton Rd, Atlanta, GA 30333.
From the Maternal and Child Health Programs, Community and Family Health,
Department of Health, State of Washington, Olympia (Drs Gaudino and deHart);
the Pregnancy and Infant Health Branch, Division of Reproductive Health, National
Center for Chronic Disease Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Ga (Dr Gaudino); the Department of Health
Services, School of Public Health and Community Medicine, University of Washington,
Seattle (Drs Cheadle, Martin, and Schulman and Ms Schwartz); and the Social
and Economic Sciences Research Center, Washington State University, Pullman
(Dr Moore). Dr Gaudino was affiliated with the Maternal and Child Health Programs
during the study period.
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