The Pharmacy Gave the Flu Shot, the Clinic Gave It Again: Data Standards, the State Immunization Registry and Why Moving Records Is Not the Same as Using Them
[Student Name]
University of Phoenix
DNP/715: Information Systems and Health Care Delivery Technology
Week 2 Assignment
[Instructor Name]
[Date]
The clinic and scenario are composites written for a model paper.
Last fall, our rural family practice gave influenza vaccine to 23 patients who had already received it at a local pharmacy within the previous month. No one was harmed, but duplicate doses waste vaccine, time and patients' trust. The pharmacy reports doses to the state immunization registry, and our electronic record can query the registry. This paper examines why the information did not reach our nurses in time and what standards and interoperability concepts explain the failure.
The Promise of Immunization Registries
Groom et al. (2015), in a Community Guide systematic review, examined 240 studies and abstracts on immunization information systems and found that these registries make possible reminder messages to families, performance feedback and prompts for clinicians; help determine vaccination status to inform clinical decisions; guide outbreak response; inform assessments of coverage, missed opportunities and invalid doses; and support vaccine management. The registry is designed to prevent exactly the duplicates we gave, if its information reaches the clinician at the point of decision.
Levels of Interoperability
Holmgren et al. (2017) measured U.S. hospitals' engagement in four domains of interoperability: finding, sending, receiving and integrating outside patient information. In 2015, only 29.7% of hospitals engaged in all four, gains were mainly in sending and receiving, integration did not improve, and only 18.7% of hospitals reported often using outside data in patient care. They concluded that progress focused on moving information rather than making it usable in clinical decisions.
Tracing the Data
The pharmacy records the dose in its system with a vaccine code, lot number, date and patient identifiers, then transmits a standardized message to the registry, usually within a day. The registry matches the patient and stores the dose. Our record can query the registry, but only when a nurse opens a separate tab and clicks a button. Returned doses appear in a separate window; they do not update the immunization list or the health maintenance reminder unless someone reconciles them manually.
The pharmacy sent the dose, the registry received it and our record could fetch it; the failure was the last step, where nobody's screen changed.
Where the Failure Lies
In Holmgren et al.'s (2017) terms, sending and receiving worked: the pharmacy sent and the registry received. Finding worked in principle, since our record could query the registry. Integration failed. The outside dose never entered our structured immunization list, so the reminder still showed influenza vaccine as due, and nurses acted on the reminder.
Standards That Worked
Content standards allowed the dose to travel intact: a standard vaccine code identified the product, and a standard message format carried it. Without these, the registry could not have combined doses from hundreds of providers. The problem was not the vocabulary or the message but how our system used the message.
Terminology and Matching
Two of the 23 duplicates had a different cause: the registry held the pharmacy dose under a slightly different name spelling, so our query did not match the patient. Identity matching is a quiet but persistent barrier to interoperability, and it cannot be solved by coding standards alone.
The Policy Context
Adler-Milstein and Jha (2017) found that the HITECH Act's incentive program drove large gains in hospital electronic record adoption, with annual adoption increases among eligible hospitals rising from 3.2% before the program to 14.2% after, far more than among ineligible hospitals. Adoption, however, is not integration. Many small practices, including ours, adopted records that exchange data but do not integrate it well.
Timing Matters
Most pharmacies report doses within a day, but some batch their reports weekly. A patient vaccinated on Monday and seen at our clinic on Wednesday may not appear in the registry yet. Even perfect integration cannot show data that have not arrived, which is why asking the patient remains necessary.
Workflow Fixes
While awaiting technical changes, we changed workflow: medical assistants now query the registry for every patient at rooming during influenza season, and any dose found is reconciled into the immunization list before the nurse sees the patient. This adds about 30 seconds per visit, a cost staff accepted once they saw the duplicate count.
Technical Fixes
With our vendor, we requested automatic registry queries the day before each scheduled visit, with outside doses shown in the main immunization list as pending reconciliation and the reminder suppressed until a nurse accepts or rejects them. This moves the practice from receiving to integrating.
Extending the Fix to Other Vaccines
Influenza was the most visible duplicate, but the same gap affects COVID-19, pneumococcal and shingles vaccines, which adults increasingly receive at pharmacies. The workflow and technical fixes apply to all of them, and I will review duplicates for each after one season.
Measuring the Result
We will count duplicate influenza doses per 1,000 vaccinations this season and next, and track the percentage of visits with a registry query and the time spent reconciling.
Why Nurses Trusted the Reminder
Nurses acted on the health maintenance reminder because it had been reliable for years and because checking the registry took extra clicks in a separate window. Trust in a single screen is reasonable when that screen is complete. The problem was that the screen looked complete when it was not, a hazard of partial integration.
Patient Communication
We also changed how we ask patients. Rooming staff now ask directly, "Have you had a flu shot anywhere this season, including a pharmacy or work?" Patient report is imperfect, but it is a useful check when data systems fail, and it engages patients in keeping their own records accurate.
Cost of the Duplicates
Twenty-three duplicate doses cost the clinic about $500 in vaccine and nurse time, a modest sum. The larger cost was trust: several patients asked why the clinic did not know they had been vaccinated, and one said she would go elsewhere next year.
The DNP Role
My role was to recognize the duplicates as an information problem, trace the data path, name the failed domain and lead both a workflow change and a request to the vendor framed in terms the vendor could act on. Understanding standards and interoperability let me ask for the right fix.
Broader Lessons
The same pattern, data that arrive but do not integrate, affects allergies, medication lists and outside laboratory results. Fixing immunizations first creates a template for other data types.
Conclusion
Duplicate influenza doses at our clinic occurred not because standards failed or data were missing, but because outside doses were received and not integrated into the record where nurses make decisions. A systematic review shows what registries can do when their data reach the point of care, and national data show that integration lags behind sending and receiving. Workflow and technical fixes aimed at integration, and measurement of duplicates, will close the gap.
References
Adler-Milstein, J., & Jha, A. K. (2017). HITECH Act drove large gains in hospital electronic health record adoption. Health Affairs, 36(8), 1416-1422. https://doi.org/10.1377/hlthaff.2016.1651
Groom, H., Hopkins, D. P., Pabst, L. J., Murphy Morgan, J., Patel, M., Calonge, N., Coyle, R., Dombkowski, K., Groom, A. V., Kurilo, M. B., Rasulnia, B., Shefer, A., Town, C., Wortley, P. M., & Zucker, J. (2015). Immunization information systems to increase vaccination rates: A community guide systematic review. Journal of Public Health Management and Practice, 21(3), 227-248. https://doi.org/10.1097/PHH.0000000000000069
Holmgren, A. J., Patel, V., & Adler-Milstein, J. (2017). Progress in interoperability: Measuring US hospitals' engagement in sharing patient data. Health Affairs, 36(10), 1820-1827. https://doi.org/10.1377/hlthaff.2017.0546
How this DNP 715 Week 2 example is structured
The DNP/715 Week 2 work usually covers data standards, terminologies and interoperability. This paper follows one kind of data across organizational boundaries, identifies where standards, transport and integration each succeed or fail and turns the diagnosis into specific actions. Students search this week as DNP 715 Week 2, DNP715 Wk 2 or DNP/715 Wk 2; all three are the same assignment.
DNP/715 Week 2 questions, answered
What does DNP/715 Week 2 usually ask for?
Many sections ask students to explain data standards, clinical terminologies and levels of interoperability and to apply them to an information exchange problem in practice.
What are the domains of interoperability?
National surveys of hospitals measure four: finding, sending, receiving and integrating electronic patient information from outside providers; integration, bringing outside data into the record in usable form, lags behind the others.
What is an immunization information system?
A confidential, population-based registry, usually run by a state, that records vaccine doses from many providers and supports reminders, clinical decisions, outbreak response and coverage assessment.
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