October 2006

Grant Results


The Missouri Department of Health and Senior Services (MDHSS) designed, tested and evaluated a method to capture immunization data directly from physician billing and link it to the state's integrated health information system.

Key Conclusions

  • The project demonstrated that extracting immunization information from physician billing data is a viable means to acquire accurate, timely vaccine data for young children. This method may not be viable for other conditions.
  • Based on project results, expanding the number of medical billing clearinghouses that submit immunization data to MDHSS would increase the number of doses of vaccine documented in the statewide registry.

The Robert Wood Johnson Foundation (RWJF) provided a grant of $362,617 to support this solicited project from 2002 to 2004.

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Data on Some Conditions Inadequate for Effective Public Health Surveillance

Public health rests on information. To prevent and control disease, state law or regulations require that physicians report certain diseases and health conditions regularly to state or local health departments. Reportable conditions vary by state, but most include specific communicable diseases, cancer and tests of exposure to toxins (such as lead).

By 2001, it was well known that many physicians in the state of Missouri did not routinely comply with reporting requirements, according to the Missouri Department of Health and Senior Services (MDHSS) in Jefferson City, Mo. Available data for many conditions had become inadequate for effective public health surveillance.

Non-compliance, some Missouri physicians suggested, occurs because physician office staff have no time to report health care data on top of managing patient information and billing.

Immunization Data Used to Test an Easier Way to Transfer Health Care Data

In 2001, a $50,000 "mini-grant" from Connections (a community of practice that assists public health agencies with strategies and planning for integrating information systems essential to improving the health of children) allowed MDHSS to explore the feasibility of extracting health surveillance information from physicians' electronic billing data, using childhood immunizations delivered by private physicians as the test case. Connections grew out of the RWJF-funded national program, All Kids Count: Establishing Immunization Monitoring and Follow-up Systems.

Missouri's integrated health information system includes a voluntary immunization registry. The registry enables MDHSS to assess vaccination coverage rates. It also allows health care providers to track the immunization of specific patients and send out notices when shots are due.

In 2001, Missouri's immunization registry held data on 59 percent of 2-year-olds in the state. Existing records came mostly from publicly funded sources, a few health maintenance organizations (HMOs) and some private practices. Missing information stemmed from children seen in private physician offices, primarily in urban areas.

Clearinghouses Gather Billing Data from Many Private Practices

Most physicians submit billing data to a clearinghouse, which in turn sorts and transfers records to the appropriate payer. The clearinghouse routinely gathers clinical data on communicable disease, outpatient cancer, lead exposure and immunization needed by the MDHSS.

In Missouri, about 50 percent of private physicians sent billing data to Gateway EDI, a clearinghouse in St. Louis.

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RWJF seeks to strengthen the public health system to make it better prepared to promote health and protect all Americans from a wide range of threats — from bioterrorism to emerging infectious diseases to health problems such as obesity, tobacco use and asthma.

This grant followed the work of RWJF's All Kids Count program. Implemented in two phases, 1992–1997 and 1998–2000, All Kids Count sought to bring 16 immunization registry projects based in local, county and state health departments to fully operational status by January 1, 2000, and to develop a long-term policy to ensure registries are implemented and sustained nationwide.

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For this project, MDHSS proposed to design, test and evaluate a method to capture immunization data directly from the Gateway EDI clearinghouse without duplication or error, and link it to the state immunization registry.

To extract data for the immunization registry from physicians' electronic billing records, MDHSS staff:

  • Negotiated a legal agreement with Gateway EDI to obtain billing data on a daily basis. (The nature of reporting requirements eliminates the need for patient consent in Missouri.) For consenting physicians, Gateway would provide:
    • Current and future data on immunization and reportable conditions.
    • Historical immunization and reportable data up to two years old.
    • Non-identifiable records of preventive services.
  • Got signed agreements from more than 200 health care providers who use Gateway to release billing data on reportable conditions from the clearinghouse to the MDHSS.
  • Designed an electronic method to abstract data on immunizations and reportable conditions from the billing data submitted by Gateway.
  • Linked the immunization data from Gateway to each child's master record in Missouri's integrated public health information system using an advanced software package selected by MDHSS staff.
  • Evaluated the quality, quantity and timeliness of the billing data using Updated Guidelines for Evaluating Public Health Surveillance Systems established by the federal Centers for Disease Control and Prevention (CDC).

To obtain physician consent, MDHSS staff wrote a confidentiality brochure explaining that the Health Insurance Portability and Accountability Act of 1996 (HIPAA) allows providers to share client health information with public health authorities for surveillance and related activities required by state and federal law.

To target physicians for future participation, MDHSS staff surveyed providers who receive free vaccines through the CDC's Vaccines for Children (VFC) program to identify the clearinghouses they use.

Project staff presented a final overview of the project to Connections members, and separately to the office managers of participating health care providers. They did not publish or post materials online as part of this grant.

Evaluating Data Quality

Project staff performed several tests to evaluate the quality of billing data for surveillance.

  • To evaluate the timeliness of physician billing data, project staff stored a batch of billing data from Gateway and measured the time it took for health care providers to enter vaccine data into the immunization registry manually.
  • MDHSS staff also compared the timeliness of Gateway data to submissions from the Medicaid billing system.

To evaluate completeness, a public health nurse manually reviewed a sample of patient charts in the offices of selected participating physicians to compare the vaccinations in the charts against the vaccinations entered in the billing data. The nurse entered the patient's demographic and vaccine data into the CDC immunization assessment tool, Comprehensive Clinical Assessment Software Application (CoCASA).

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The project accomplished the following:

  • Through June 2004, the MDHSS received vaccine data from physicians' billing for 28,396 children living in Missouri, of whom 3,203 (11 percent) were not previously documented in the immunization registry. Since the registry includes all children born in Missouri since January 1, 1994, the number of children not registered may include some born elsewhere.
  • Participating providers billed some 98,511 doses of vaccine from July 15, 2003, through May 2004, of which 75,890 doses (77 percent) were not previously documented in the immunization registry. The remaining 22,621 doses had been documented from other sources, and were not re-entered.
  • The immunization records for 1,987 children were updated in the period from October 2003 to April 2004.
  • This project improved MDHSS's ability to link electronic records with their health information system, the project director reported.

Findings from Evaluating the Quality of Billing Data

  • Of the 338 vaccine doses examined, 273 would have been registered with billing data from Gateway before health care providers could have entered them manually. The billing data appeared in the registry a median of two months prior to manually entered data.
  • Immunization data from Gateway billing records arrived at the MDHSS a median of 50 days faster than data submitted in Medicaid electronic files.
  • The manual review of patient charts showed that all doses of vaccine documented in the charts were included in the electronic billing files.

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Project staff offered the following conclusions to RWJF.

  • The project demonstrated that extracting immunization information from physician billing data is a viable means to acquire accurate, timely vaccine data for young children. This method may not be viable for other health conditions.
  • Based on project results, expanding the number of medical billing clearinghouses submitting immunization data to MDHSS would increase the number of doses of vaccine documented in the statewide registry.
  • Working through clearinghouses rather than directly with physician offices is an effective way to collect data. People in the field agree that working with physician offices does not work. Other states have tried it and given up on it.

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  1. Allow more time for each step in the process than you think is necessary. Each step took longer than anticipated. For instance, researching and buying the necessary software took an extended period of time, as did getting provider agreements to release data. (Project Director)
  2. Avoid getting data directly from health care providers' offices. Rather than dealing with different vendor software, get data directly from billing clearinghouses. (Project Director)
  3. Find out whether smaller billing vendors submit their files to clearinghouses. MDHSS staff discovered that some billing vendors also submitted their files to Gateway, although their physician clients may not have been aware of this. Engaging these vendors would increase access to data. (Project Director)
  4. Negotiate agreements with large health care provider groups rather than individual physicians. Work with the clearinghouse to identify large practices. The office manager of such groups often will be key to obtaining a written agreement. (Project Director)
  5. With clearinghouses, emphasize that taking the burden off physician offices to submit reportable conditions is a marketing device for them. The clearinghouse can emphasize it as a free service they offer. (Project Director)
  6. Enlist clearinghouses that have home offices in your state. Negotiating in person speeds up the process. The companies may also be more motivated to help their clients comply with state regulations. (Project Director)
  7. Consult legal counsel to make sure physicians in your state can report immunization data without patient consent. (Project Director)

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MDHSS staff planned to continue the project and seek funding to expand the electronically abstracted files to include other reportable conditions.

At the end of 2005, MDHSS had funding for obtaining immunization data from Gateway through a larger CDC Immunization Grant to the State of Missouri. Technicians' need to focus on compliance with HIPAA regulations and lack of additional funding had delayed expansion of this project.

Information from this project influenced the design and implementation of InformationLinks, an RWJF-funded program that provides funds to state and local health departments to support and encourage their participation in regional health information networks.

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Improving the Transmission of Clinical Data to Public Health Databases


State of Missouri Department of Health and Senior Services (Jefferson City,  MO)

  • Amount: $ 362,617
    Dates: February 2002 to May 2004
    ID#:  044377


Nancy Hoffman, R.N., M.S.N.
(573) 751-6272

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Appendix 1


integrated health information system: an electronic system that integrates, to use child health as an example, child immunization records, newborn screening results and information on lead poisoning. It can be a valuable tool to ensure the timely, accurate and complete information necessary for optimal delivery of preventive and therapeutic health services for children.

immunization registry: a computerized information system that collects child vaccination records from multiple health care providers in a geographic area. For public health authorities, an immunization registry is a useful tool to assess vaccination coverage rates and identify pockets of underimmunization where children could be at risk for vaccine-preventable diseases.

Updated Guidelines for Evaluating Public Health Surveillance Systems: A guideline issued by the CDC that includes assessing the usefulness of the of the information system and describing and measuring it from the following perspectives: simplicity, flexibility, data quality, acceptability to those people and organizations necessary to make it work, sensitivity, predictive value, representativeness, timeliness and stability.

HIPAA (Health Insurance Portability and Accountability Act): Passed by Congress in 1996, HIPAA has two major foci: health insurance reform and administrative simplification. Title I, the health insurance reform section, includes provisions designed to lower the chance of losing existing coverage, and make it easier to switch health plans and/or buy coverage if an individual loses coverage under an employer's plan and has no other coverage available. HIPAA does not address the affordability of this coverage.

Title II, the administrative simplification section, requires the U.S. Department of Health and Human Services to establish national standards for electronic health care transactions and national identifiers for providers, health plans and employers. It also addresses the security and privacy of health data.

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Report prepared by: Antonia Sunderland
Reviewed by: Mary B. Geisz
Reviewed by: Molly McKaughan
Program Officer: Pamela Russo