Immunization Information Systems

Immunization (IZ) information systems (IISs) are confidential, population-based, computerized databases for maintaining information regarding an individual’s vaccination history.¹  IISs, also known as “IZ registries,” have made patients’ health information available to IZ providers for almost 25 years.² 

The urgency to develop these registries became apparent, in part, after the United States experienced a nationwide measles epidemic from 1989 to 1991, which resulted in more than 55 000 cases, 123 deaths, and 11 000 hospitalizations.³  One of the main drivers of this epidemic was the incomplete IZ of preschool-aged children. At the time, less than 65% of children younger than 5 years were fully vaccinated.² 

The idea for a universal computerized system to collect, track, and exchange IZ information has existed since the 1960s, when the Centers for Disease Control and Prevention (CDC) posited that automated and accessible IZ records could facilitate “national follow-up of births for maintenance of IZ levels.”⁴  In late 1991, the Robert Wood Johnson Foundation provided initial grant funding to develop the first computerized systems for tracking vaccines.⁵  In April 1993, President Clinton submitted the Comprehensive Child IZ Act to Congress, which established the first, state-based IZ information and tracking system.⁶ 

To date, the CDC has funded 64 grantees to develop IZ registries. These include all 50 states, the District of Columbia, 5 major cities (Chicago, Houston, New York, Philadelphia, and San Antonio), and 8 territories.⁷  Regulations mandating reporting to IISs have been widely established, although there is variability among IISs regarding these regulations.^8–10  IISs remain a critical tool in reducing the under- and over-IZ of children, as well as overcoming barriers to effective IZ delivery.¹¹  For a general introduction to IISs and their goals and implementation, the Public Health Informatics Institute has a learning module located at https://phii.org/welcome-to-iis.

Beginning in 1992, the development of IISs was supported by a number of different streams of funding, including time-limited grants and public funds. Although beyond the scope of this policy, a more detailed history of this development is available.^1,12–14  Today, most IISs use some combination of federal, state, and local funds to support activities, including funds administered through 317 grants through the CDC.¹⁵ 

IISs were developed to consolidate IZ histories for clinical use. They have since evolved, in some instances, to serve essential functions beyond individual record-keeping, clinical decision support, and forecasting, including improved practice management of vaccine supplies, vaccine recall,¹⁶  quality improvement, vaccine distribution, and data exchange for public health purposes. These functions also may include meeting and documenting school IZ requirements, infection control and disease outbreak management, and quality assurance programs, as well as serving as an adjunct tool for management of public health emergencies, including bioterrorism.

IISs have helped to identify coverage gaps and improve IZ rates, especially in highly mobile or medically underserved populations.¹⁷  They have been a valuable tool for public health efforts in infection control and prevention during disease outbreaks (eg, measles outbreaks, hepatitis A outbreaks) and natural disasters.^18–22  The Louisiana IZ Network for Kids Statewide (LINKS), established in 2001, contained IZ records for ∼1.5 million children and adults when Hurricane Katrina occurred in August 2005. Because a backup system was located in Baton Rouge, LINKS remained online and operational in the aftermath of the hurricane. A total of 21 295 successful external patient IZ queries were made to LINKS from August 29 to October 11, 2005, by IISs in 44 states, 5 cities, and Washington, District of Columbia. Had these vaccination histories not been available (eg, because of flooding or other damage), complete revaccination of the 21 295 children and adolescents displaced by Hurricane Katrina would have cost $13 617 727 ($9 831 476 for vaccine and an estimated $3 786 251 for vaccine administration costs).²³  As part of a mass vaccination campaign for the 2009 H1N1 influenza pandemic, the US federal government, via the CDC and the National IZ Program, distributed more than 124 million doses of the 2009 H1N1 influenza vaccine in the United States by the end of January 2010.²⁴  Most IZ program grantees required IZ providers to enroll in an IIS to receive the vaccine for purposes of tracking distribution and administration, with a resulting increase in enrolled provider sites from 40 075 in 2006 to 88 601 in 2010.

The rollout of the vaccines against severe acute respiratory syndrome coronavirus 2 includes a federal requirement that all administered doses be entered promptly in state IISs, with each jurisdiction responsible for implementation.²⁵  This process requirement will ideally demonstrate the utility of IISs as a real-time repository of IZ data, providing current information on the process of immunizing an entire nation in a short time period.

In June of 2014, after reviewing 108 published papers and 132 conference abstracts, the Community Preventive Services Task Force of the US Department of Health and Human Services concluded that there is strong evidence that IISs are effective in increasing vaccination rates and reducing vaccine-preventable disease. The task force recommendation highlighted the capabilities of IISs to:

1. create or support effective interventions, such as client reminder and recall systems, provider assessment and feedback, and provider reminders;

2. generate and evaluate public health responses to outbreaks of vaccine-preventable disease;

3. facilitate vaccine management and accountability;

4. determine client vaccination status for decisions made by clinicians, health departments, and schools; and

5. aid surveillance and investigations on vaccination rates, missed vaccination opportunities, invalid dose administration, and disparities in vaccination coverage.

The task force noted that net cost savings would be obtained despite the startup costs of building IISs. It further identified a lack of information regarding the daily use by and utility of IIS to vaccination providers, especially in clinical settings, recommending further study to both quantify this utilization and investigate the effective practices and requirements involved in the incorporation of IISs into clinical practice.²⁶ 

Although children may receive IZ services in a number of different health care settings, the pediatric medical home is both a major contributor to and major beneficiary of IIS participation. Pediatric practices have large amounts of historical IZ data that, ideally, would be used to populate an individual’s lifetime IZ record in the IIS, while ongoing IZ delivery provides new data to the IIS. The amount and completeness of documentation of a person’s IZ history in an IIS is dependent on multiple factors, however, including how strongly health care practitioners in all settings are encouraged to submit data. To help achieve maximum compliance, strategies such as implementation and enforcement of mandatory reporting laws are necessary at the state level.

The presence of fully functional and interoperable IISs could help pediatricians manage their IZ efforts and improve patient care. IISs can maintain vaccine inventories and provide an assortment of clinical reports, including usage, coverage, population health and completeness, and ordering reminders. These can help avoid wasting vaccines because of inefficient or poor management of stock or expiring vaccines, and can help reduce supply issues and associated costs attributable to missed IZ opportunities. IISs can be used to enhance patient recall efforts and help ensure full compliance with the recommended IZ schedule. Because completion of the IZ series is a Healthcare Effectiveness Data and Information Set measure, increased compliance will improve a practice’s Healthcare Effectiveness Data and Information Set scores and can lead to benefits from any applicable pay-for-performance programs, thus providing a financial benefit to many practices.

The elimination of duplicated or invalid doses of vaccines also serves to reduce financial waste in a practice by verifying that every administered dose is necessary. The robust vaccine logic in an IIS may be more accurate than that in an electronic health record (EHR) and may provide a more valid indication of required doses, allowing a provider a greater degree of certainty when administering vaccines. The IIS may generally be the compendium of a person’s IZ history, which is relied on by schools and other entities to determine the completeness of a person’s vaccine history, and thus can serve as a resource for providers, reducing potential confusion arising from sources with different vaccine prediction logic algorithms.

The ability to obtain an IZ history from an IIS for review and entering into an EHR could be a tremendous time-saver, reducing clerical costs associated with manually entering historical data any time a patient moves to a new practice, as well as providing for a core part of a patient’s history to be truly portable. Fully automated, bidirectional data exchange, with data reconciliation before incorporation into the EHR, where IZ histories may be shared from IIS to health care practitioner in electronic format via direct population of the EHR vaccine record, in addition to uploading data from provider to IIS, would greatly simplify the logistics of ensuring that the most complete IZ record is available for all practitioners at all times. As the Community Preventive Services Task Force noted in 2014, however, data are limited regarding the impact of daily use of IISs on health care practitioners in clinical settings, and such data are critical for evaluating the cost/benefit ratio of IIS implementation and upgrading.²⁶ 

Use of an IIS in a pediatric practice is not without its challenges. The implementation of any technology in practice is associated with a user learning curve. Communication between the office and the IIS must be developed, tested, implemented, and maintained. Practices must be onboarded promptly by the IIS, which requires the IIS to test and implement the communication tools developed by the EHR developers. The proliferation of different EHR and practice management system platforms requires individualization of these communication interfaces. Individual registries still maintain their own specific requirements, however, despite the robustness of the current standard format, and further standardization of the required data points for entry into an IIS will be needed to facilitate complete and error-free data exchange. However, “meaningful use” criteria require the ability to communicate with an IIS in a standard current format (currently HL7 2.5.1), and this will eventually lead to standardized interfaces. Lack of interoperability—the ability of different IIS systems to exchange data across differing data/information technology architectures and configurations—between the 58 independent IISs in the United States greatly reduces the utility of any one IIS, because providers in one jurisdiction generally are not able to query an IIS in a different area without registering for each IIS they would want to query. In addition, state regulations governing individual IISs may add barriers to those out of the jurisdiction from accessing vaccination records directly at all. The completeness of an individual’s IZ record depends on full participation in the IIS by all entities that provide IZs; failure of even one part of the health care system to enter appropriate data will lead to incomplete records and will negate many of the benefits IISs could provide.

The costs of initial implementation and ongoing use of an interface between an EHR and IIS and costs associated with algorithm and IZ schedule updates in an EHR can be a significant burden, especially to the small, independent pediatric practice. Although these costs are accounted for in the relative value units (RVUs) value of the Current Procedural Terminology codes for vaccine administration, this value has recently been significantly reduced. In addition, Medicaid does not recognize, nor does it pay for, individual vaccine component counseling and administration, which, coupled with historically low Medicaid payments in general, can create financial hardships for practices that serve large populations of Medicaid-eligible children.

Many technical issues can impair communication among health care practitioners, EHRs, and IISs, as well as between various geographically distinct IISs that affect the free flow of accurate data among stakeholders. These issues include the fact that some IISs store data, in both their inventory and registry functions, in formats that differ from the format in which the information is received from the provider, and when that data are returned to the provider during a search, it may appear that the IIS is sending information on a different vaccine. This inaccuracy may lead to duplicate or incorrect entries in the EHR and suggests that automated downloading of data from the IIS to at least some EHRs is not ready to be used without manual supervision and verification. In addition, because the EHR is usually the actual submitter of IZ information, IISs may not communicate directly with the provider, leading to inaccuracy of communication, as well as difficulty onboarding health care practitioners and EHRs to the IIS. Pediatricians are encouraged to work with their state IIS administrators to assist in resolving any barriers to robust and seamless IIS functionality. Until these issues are resolved and communication among providers, EHRs, and IISs are truly standardized, using common data sets for entering vaccine information seamless data interchange via an IIS cannot be expected to occur.

Ideally, vaccines should be administered to patients through their medical homes. However, in the rapidly changing health care environment, patients often receive vaccines in other nonprimary care settings, including pharmacies, school-based health clinics, emergency departments, retail-based clinics, urgent care centers, and vaccine distribution centers or pods. Such vaccine sources have continued to proliferate. In 1995, only 9 states allowed pharmacists to immunize. As of June 2020, pharmacists have authority to administer IZs in all 50 states, the District of Columbia, and Puerto Rico.²⁷  It is necessary that pharmacies have the capability to query an IIS to verify that a vaccine is indicated.

At the time of publication, 4 jurisdictions limit pharmacists to vaccinating only individuals 18 years and older, and 20 allow IZ by pharmacists beginning at various ages; 28 states have no age limitations. Reporting requirements also vary by state. There have been improvements in efforts to facilitate the transfer of information on pharmacy-administered vaccines to IZ registries. For example, California has mandatory reporting of pharmacy vaccinations to the California IZ Registry within 14 days of administration.²⁸  Minnesota law requires pharmacists to use the Minnesota IZ Information Connection to assess patient IZ status before giving any IZs, with a few exceptions, and to report all administered doses.²⁹  It is critical that mandatory reporting requirements and enforcement apply equally to any entity that administers any vaccines.

The Healthy People 2020 program, which lists the US federal government’s 10-year national goals and objectives for health promotion and disease prevention, included the specific objective of increasing the percentage of children 6 years and younger participating in an IIS from a baseline of 75% in 2008 to 95% by 2020.

Defining pediatric participation in an IIS as having at least 2 recorded vaccine doses, the government’s 2020 IZ Information Systems Annual Report survey, completed by 64 federal grantees (including all 50 states, 6 cities, and 8 territories), indicated that 94% of all United States children younger than 6 years participated in an IIS, part of a steady annual increase from 43% in 2002 and 82% in 2010 (Fig 1). Among the 64 jurisdictions, 35 (54%) reported that ≥95% of children 4 months through 5 years of age in their geographic area participated in their IIS in 2020, compared with 24 (44%) in 2013.³⁰  Adolescent reporting continues to make steady progress as well, with 84% of children aged 11 to 17 years participating in an IIS, an increase from 60% in 2010. However, recording just 2 vaccine doses in an IIS is not an indicator of meaningful participation, because this amount of data likely overestimates the level of significant participation; for the purpose of population research studies, participation in an IIS should require a much greater threshold of information and should increase with the age of the child. Data for IIS participation by adults is far less robust; lacking that baseline data, the Healthy People 2030 objective of increasing the number of people whose data appears in an IIS is still considered to be in the developmental stage, indicating that it is high priority but not ready for implementation.³¹ 

Because of the expanded data and clinical support requirements of IISs as outlined by the CDC, along with the widespread adoption of EHRs by physicians, hospitals, and other health care entities providing IZs to patients, logistics and standards of successful IIS use have become more specific as electronic connectivity and data standards for health care have matured. The major categories of logistical issues that directly affect the practicing pediatrician, as well as the patients and families receiving IZs, are those involving data quality and access, cost, grantee-specific regulatory policies, and the development of seamless integration between IISs and EHRs.

Since data have been collected by IISs over a number of years, using both different data formats and evolving standards for minimum (or core) data elements reported, there is significant data quality heterogeneity, both within an individual IIS and between IISs in independent jurisdictions, which can impair the free flow of IZ data between providers and IISs. Complexities in handling demographic changes, including patient name changes, Vaccines for Children Program eligibility, and patient relocation may result in both duplication and incompleteness of the IZ record contained within the IIS.

Incomplete IZ records may result if pediatricians and other IZ providers, including hospitals, school-based clinics, walk-in-clinics, and pharmacies, among others, do not consistently submit all patient IZs to the IIS. Although some states or jurisdictions mandate that all IZs be reported to the IIS, this is not universally true, and even where mandated, enforcement is costly, time-consuming, and incomplete.¹⁰  Furthermore, although health care practitioners may be enrolled with the state IIS, they may not be reporting complete core IZ data to the IIS in all cases. Reasons for not reporting include failure of the EHR to submit data to the IIS, data exports from practice management billing applications that lack the complete recommended data array, and the cost and potential human errors during manual data entry. Different local regulations and statutes affect the completeness of IIS data. Although the majority of states are opt-out, meaning patients are automatically enrolled at the time of birth or when IZs are administered, several grantees operate on an opt-in model, which means the patient or guardian must consent to have the patient’s demographic and IZ data entered into the IIS registry. Ironically, IIS grantees that chose the opt-in model experience higher per-enrollee costs, estimated at nearly 10 times those of opt-out states because of the low number of individuals who actually chose to opt out of the local IIS registry.³²  Modification of EHRs and practice workflows to accommodate opt-in reporting further increases costs to physician practices, as well. Additionally, some IISs only require enrollment and data submission for infants, children, and adolescents through age 18 years rather than requiring or accepting IZ data regardless of patient age, also known as “cradle to grave” enrollment.³³ 

Incomplete or incompatible data transmission between IZ providers and IISs may result in incorrect data input or even complete rejection of submitted data, and providers may be unaware of this transmission failure, allowing it to remain uncorrected. Efforts by numerous stakeholders are underway to increase IZ data quality and data use through collaboration, measurement, and technical support to improve IIS and EHR interoperability (https://www.himss.org/what-we-do-initiatives/himss-immunization-integration-program). Incomplete records may also result from technical heterogeneity of individual IISs, as well as regulations and policies regarding who can submit and access patient IZ data to IISs. Lack of interoperability—the ability of different IIS systems to exchange data across differing data/information technology architectures and configurations—remains a continuing challenge.³⁴  With patients moving geographically and receiving IZs in various settings, whether because of family choice or in the wake of natural disasters, the inability to have patient data follow the patient is problematic and may also affect disaster preparedness and response. Despite meaningful use certification requirements for EHRs and IIS systems to electronically exchange data, as well as the CDC IIS Functional Standards (https://www.cdc.gov/vaccines/programs/iis/func-stds.html) specifying real-time point-of-care decision support, this ability to transfer patient IZ information directly between the IIS and the EHR, or via a community health information exchange, is inconsistent, because bidirectional information exchange functionality is not universally available in EHRs. Because IISs are managed at the state or local level, variability of these regulations presents yet another obstacle to the free exchange of data with providers. Pediatricians and other physicians are generally unable to access patient information in localities where they are not licensed to practice. This restriction commonly affects children living near state borders who reside in one state but receive medical care in another. Schools are often not able to access their local IIS, which can result in missed opportunities to identify students needing IZ, as well as unnecessary exclusion from school because of apparently incomplete IZ records.

The American IZ Registry Association has developed a Public Health IIS interjurisdictional memorandum of understanding (available at: https://repository.immregistries.org/resource/public-health-iis-interjurisdictional-memorandum-of-understanding-mou/) that provides a template agreement among IISs about sharing data. Fifty-two IISs have signed the memorandum of understanding expressing agreement with the idea, but implementation will still require each IIS to develop procedures and provide funding to support this interjurisdictional sharing of IIS data.

The CDC initiated development of the IZ Gateway in 2016. The IZ Gateway communicates (transmits) requests for data from an IIS to another IIS and also transmits the responses to these requests, all without storing any of the data transmitted. Rollout of the IZ Gateway and onboarding of the state IISs are in progress, including standardization of data transmission formats. Once all IISs onboard to the IZ Gateway, the resulting network will ensure that each patient can have a consolidated IZ record while respecting each jurisdiction’s data-sharing laws and policies (https://www.cdc.gov/vaccines/covid-19/reporting/iz-gateway/overview.html).

Because patient access to medical records through patient portals has become more common, some IISs have begun to make IZ records directly available to patients or their families. This access varies by state, but increased availability of these records to the public will increase, especially under the terms of the 21^st Century Cures Act. Log-on requirements for access may vary by each jurisdiction and procedures for such access are posted on the public Web site for each IIS.^35–39  However, by making such access a federal requirement, parents will be able to have their children’s IZ records available when moving or changing health care practitioners, which may also serve to reduce gaps or duplications in care.

The Health Insurance Portability and Accountability Act (HIPAA) governs the use and sharing of protected health information (PHI), which includes IZ records. HIPAA contains requirements for the authorization to share such PHI between any type of individual or entity, generally requiring the affirmative consent to such sharing. However, the US Department of Health and Human Services makes it clear that, when such sharing of PHI is required by state law (such as the requirement that health care practitioners disclose proof of a student’s IZs to a school), neither affirmative consent nor agreement of the student or parents is required.³³  This ruling allows sharing of IZ records between a provider or an IIS and a school, but only in states where such sharing is required by law and may be problematic given the variation among state laws establishing and governing the function of IISs. Physicians must be cognizant of their state-specific regulations, as well as HIPAA requirements, to avoid violation of patient privacy regulations.

Financial burdens to creating and maintaining functional IIS exist at the federal, state, and local grantee levels, as well as for the individual physician or other IZ provider. Funding for each individual IIS comes from a variety of sources, including state programs, which vary from one state to another in terms of both dollar amount and restrictions on use. Some of the money from the Section 317 discretionary federal grants program provided by the CDC to all states and territories for the purpose of providing IZ program services and infrastructure can be used to finance IISs. Some states and jurisdictions provide full operational funding for their IISs, but many other IISs receive only partial funding, even when Section 317 funds are included. In addition, unlike Vaccines for Children Program funding, these Section 317 monies can vary with each year’s federal budget. Additional sources of funding have included the Robert Wood Johnson Foundation, federal Medicaid partial matching funds to help support operations of a functional IIS, and approximately $20 million from the American Recovery and Reinvestment Act and the Health Information Technology for Economic and Clinical Health Act of 2009. Although the cost–benefit analysis of IISs has been shown to be beneficial overall to the health care system,⁴⁰  the benefits and savings do not necessarily accrue to the entities that must cover the costs of such systems and may fail to cover state and local resources required to staff and operate the IIS.

For the individual pediatric practice and other IZ service providers, costs incurred, and resources allocated to participating in an IIS include providing for transfer of IZ data to the IIS, either through direct connectivity and interfacing of EHR systems to the IIS or via a bridging health information exchange. For practices not yet utilizing EHRs, this information transfer is generally not automated and may consume significant staff time and resources. In addition, because automated downloading of IZ data to an EHR may not be available in many state IISs or in every EHR, duplication of data entry may be required to populate a new EHR from the IIS. Costs of EHR–IIS electronic interfaces are highly variable and typically are several thousand dollars. Although the Current Procedural Terminology codes for vaccine administration are defined to include the costs of submitting IZ data and have an RVU that includes this expense, this RVU has recently been severely reduced, and many payers, particularly Medicaid, do not pay adequately for these codes to cover the entire cost of providing IZ services. In addition, because it has failed to adopt the current IZ codes that recognize the counseling and support services for every component of a multiple-antigen vaccine, Medicaid may significantly shortchange IZ providers on payment for IZ services.

Although there has been significant interest in developing a single federal IIS (ie, a national registry), there are significant technical, financial, and political barriers that have thus far prevented the development of a single system. Consolidation of records from multiple state IISs utilizing different technological platforms, along with elimination and consolidation of duplicate patient entries, would be a huge undertaking. Consistent and appropriate federal funding for a national IIS would need to be ensured and could not be left to the uncertainties of the yearly budget process. Local autonomy in terms of IIS policies and procedures would need to be surrendered to the national IIS so there could be consistent rules for data entry and retrieval across the country.

1. IISs serve a critical and vital public health function, especially in times of crisis. Adequate and assured resources and funding, ideally provided to states on a uniform basis by the federal government, should support the continued development, use, operation, integration, and improvement of IISs to improve data availability and to ensure timely, appropriate, and efficient IZ of all children. These costs cannot be shouldered by the health care practitioner.

2. Appropriate payment for all IZ-related services, including biologic IZ products and the services (including reporting of data to the IIS) required to complete the IZ and documentation process, should be ensured. Applicable principles are contained in the American Academy of Pediatrics resources “The Business Case for Pricing Vaccines” and “The Business Case for Pricing IZ Administration.”^41,42  Appropriate payment should be required from both private and public payers.

3. IIS participation should include all persons receiving IZs, regardless of age (ie, cradle to grave), and patient participation should be “opt-out” rather than “opt-in” as a means to minimize IIS operating costs and maximize completeness of IZ data. All entities administering IZs should be mandated to report those IZs to the local IIS, and penalties for noncompliance when EHR technology supporting reporting exists or when a health care practitioner without an EHR refuses to develop a system for compliance should be enforced.

4. EHR systems and IISs should be required to develop bidirectional data exchange functionality to improve IZ provider participation in submitting IZ transaction data, ensure accurate IZ data in provider records, create a robust public health database, and optimize the data integrity of the IIS database. Standardization of IIS data exchange elements, formats, and transport layer protocols are essential to minimize cost variability for all parties involved, including IISs, EHR vendors, and IZ service providers. When interoperability issues interfere with reporting, it is the ultimate responsibility of the local IIS to develop a solution that does not impose additional financial, duplicative, or punitive burdens on the provider of the IZs.

5. Access to all IIS information, for both data entry and record retrieval, should be available without regard to geographical, legal, and medical licensing jurisdictions. All IISs should be required to develop and implement agreements that would facilitate the entry of IZ data and sharing of records across boundaries. Data sharing across IIS boundaries must occur freely, as in the case of a child who receives an IZ in an IIS jurisdiction different from the one where he or she lives or attends school. Changes in patient location or health care health care practitioner should not be allowed to stand in the way of exchange of complete IZ data. These data should be available, with appropriate safeguards, to all authorized health care health care practitioners, as well as to the patient via the ability to directly query any IIS holding data on a patient.

6. Given the challenges of a mobile patient population and the existence of multiple separate IISs across the United States, in the likely continued absence of a single national registry, EHR systems and the CDC should support a model of integration that allows authorized users to perform a single query to retrieve all IZ data available on a patient that may exist across multiple registries, essentially mimicking the functionality of a national IIS. Such a single integrated, virtual national IZ registry should allow one-time provider enrollment to provide access to all IZ records across the nation. Funding for the construction and implementation of a single national registry is not currently available. There has been acknowledgment in Congress that more investment is needed in public health infrastructure, which could also help with IIS capability. Recognition of the need for improved IIS capability and funding is likely to be directed to improve bidirectional exchange of IZ information and enhance interoperability between IZ information systems. Interoperability with seamless data exchange among all IISs should be financed by government as a public health goal.

Information on the benefits of IIS is widely available for pediatricians and other pediatric health care practitioners, health care plans, and parents. Vaccinate Your Family: The Next Generation of Every Child By Two, founded by Former First Lady Rosalynn Carter and Former First Lady of Arkansas Betty Bumpers in 1991 as Every Child By Two, has developed a Web site with materials on the topic of IZ registries (https://www.vaccinateyourfamily.org/questions-about-vaccines/vaccination-records/). Contact information for individual IISs by state is available through the CDC.⁷  The CDC maintains an IISs Web site (http://www.cdc.gov/vaccines/programs/iis/index.html) that includes information on meaningful use and technical guidance. The Association of State and Territorial Health Officers maintains a summary of state IZ legislation which includes state bills related to IZ registries (http://www.astho.org/Programs/Immunization/Legislative-Tracking/).

Jesse M. Hackell, MD, FAAP

Sheila L. Palevsky, MD, MPH, FAAP

Micah Resnick, MD, FAAP

Jesse M. Hackell, MD, FAAP, chairperson

Joseph J. Abularrage, MD, MPH, MPhil, FAAP

Yvette Almendarez, MD, FAAP

Abeba Berhane, MD, FAAP

Patricia Cantrell, MD, FAAP

Lisa Kafer, MD, FAAP

Katherine Schafer, DO, FAAP

Robin Warner, MD, FAAP

Robert Wiskind, MD, FAAP

Family Liaison

Alisa Skatrud

Alexy D. Arauz Boudreau, MD, MPH, FAAP

Julia Richerson, MD, FAAP

Elisha Ferguson

Caroline Castleforte, MD, FAAP, chairperson

Heather Abraham, MD, FAAP

Bolanle Akinsola, MD, FAAP

Stephanie Annor, MD, FAAP

Carmel Bogle, MD, FAAP

Elizabeth Copenhaver, MD, FAAP

Lauren Jen, MD, FAAP

Erin Teresa Kelly, MD, FAAP

Deepa Mokshagundam, MD, FAAP

Bethany Nunez, MD, FAAP

Melissa Julia Ruiz, MD, FAAP

Mitali Sahni, MBBS, FAAP

Vanessa Salcedo, MD, MPH, FAAP

Crystal Shen, MD, MPH, FAAP

Katie Soe, MD, FAAP

Piyush Srivastava, MD, FAAP

Amanda Stewart, MD, MPH, FAAP

Christine Thang, MD, FAAP

Eliza A.Varadi, MD, IBCLC, FAAP

Carmelle Wallace, MD, FAAP

Britt Nagy, MPH

Emily Chui Webber, MD, FAAP, FAMIA, chairperson

Sandy Lee Chung, MD, FAAP, vice chairperson

Kevin Reid Dufendach, MD, MS, FAAP

Marvin Bruce Harper, MD, FAAP

Brandan P. Kennedy, MD, FAAP

Eli M. Lourie, MD, FAAP

Eli M. Lourie, MD, FAAP

Heather C. O’Donnell, MD, FAAP

Reza Sadeghian, MD, MBA, MSc, FAAP

Eric Shelov, MD, MBI, FAAP

Srinivasan Suresh, MD, MBI, FAAP

Andrew Michael Wiesenthal, MD, SM, FAAP

Francis Chan, MD, FAAP, Section on Advances in Therapeutics and Technology

Han Yu (Stephanie) Liou, MD, Section on Pediatric Trainees

Lisa Krams, MS

CDC

Centers for Disease Control and Prevention

EHR

electronic health record

HIPAA

Health Insurance Portability and Accountability Act

IIS

immunization information system

IZ

immunization

LINKS

Louisiana Immunization Network for Kids Statewide

PHI

protected health information

RVU

relative value unit