ARLINGTON, VA – The Association of State and Territorial Health Officials (ASTHO) has launched an Innovation Advisory Council (IAC), a multisector forum designed to drive collaboration between state and territorial health leaders and private sector executives. The IAC will address critical public health challenges such as data modernization, healthcare access, and health security, with the goal of fostering transformative solutions through knowledge exchange and strategic partnerships.
“Response efforts in recent years, including the COVID-19 pandemic, highlighted opportunities for interconnection within our nation’s public health ecosystem, particularly in areas like data integration, resource allocation, supply chain, and rapid response capabilities,” says ASTHO CEO Joseph Kanter, MD, MPH. “Through the Innovation Advisory Council, we are building a platform for structured, cross-sector partnerships between public health leaders and the private sector, which will help ensure better preparedness and resilience in the future. The IAC offers a space for strategic engagement, aligning priorities and resources to drive innovation that strengthens the nation’s public health system.”
Founding cohort members include:

• Amazon Web Services
• BerryDunn
• CRISP Shared Services
• CVS Health
• Deloitte
• Envision Technology Partners
• Guidehouse
• Leidos
• Public Consulting Group
• STChealth

The council will engage year-round. Leaders will consult on complex issues including strengthening the U.S. public health infrastructure, enhancing visibility into supply chains and opportunities to increase inter-sector collaboration. The IAC model emphasizes open communication, shared goals, and the alignment of resources to address critical public health needs.
The inaugural Innovation Advisory Council Roundtable will be held in December to bring founding members of the IAC and ASTHO’s Board of Directors together to discuss emerging public health trends and opportunities for innovation. Learn more about the Innovation Advisory Council.

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ASTHO is the national nonprofit organization representing the public health agencies of the United States, the U.S. territories and Freely Associated States, and Washington, D.C., as well as the more than 100,000 public health professionals these agencies employ. ASTHO members, the chief health officials of these jurisdictions, are dedicated to formulating and influencing sound public health policy and to ensuring excellence in public health practice.

Written by: Angela K. Shen, Kristina Crane, Rebecca Coyle in Healthaffairs.org

Chronic underinvestment in public health at the federal, state, and local levels has weakened the nation’s infrastructure and threatens its ability to address basic disease prevention and maintain economic stability. One underfunded piece of infrastructure is the network of state and local immunization information systems (IIS), often called registries, that exchange immunization data with electronic health records (EHRs) and other systems.

IIS were the lynchpin of vaccination campaigns. During the COVID-19 pandemic, 58 IIS across the US and its territories captured patient data on vaccination regardless of where individuals were vaccinated (for example, a Federal Emergency Management Agency pop-up clinic, public health department, pharmacy) and made data available to immunization providers and public health authorities to manage the vaccination campaign. Every state and territory (and a handful of cities) has its own independent system with some limited interoperability to exchange data with another system. In short, a national picture of vaccination coverage on a population level is difficult to ascertain.

However, during the pandemic, all providers in every jurisdiction were required to report data on the COVID-19 vaccines they administered to an IIS within 24 hours. As large swaths of the population were vaccinated—through mass vaccination clinics, rather than through visits to a doctors’ office—scaling the IIS system to accommodate the tsunami of pandemic vaccination data meant processing a 10-fold or more increase in volume of records. Systems responded, with help from unprecedented infusions of emergency funding as part of the $2 billion appropriated by Congress to the states for immunization. A noble but unsuccessful attempt to dedicate $400 million from Congress for the Immunization Infrastructure Modernization Act also signaled some interest in focusing funds on IIS.

The infusion of funding enabled a handful of IIS to upgrade to newer systems operating on current standards and allowed others to expand capabilities. Most EHRs were already exchanging data such as patient and vaccine information with IIS, largely due to prior investments through the government’s meaningful use incentive program. In turn, this provided health agencies with a view of vaccine uptake and better equipped them to forecast vaccine needs for the population. The funding allowed public health programs to expand their connectivity with providers beyond routine vaccinators to more physicians, pharmacists, and long-term care facilities. Funding also enabled capabilities such as consumer access to official vaccination records that can be used for camp enrollment or employment requirements and the ability to schedule vaccination appointments.

Invest Over Time

The funds from COVID-19 response pushed systems to modernize, but at a monumental cost. A more titrated strategy that invests in preparedness over time could be more beneficial and less burdensome, and arguably a better use of public resources, given the long-term priority the US places in achieving global health security. Exponential spending in a short period of time can be hampered by key limiting factors, including the time it takes for a skilled workforce to implement solutions.

Few state preparedness activities accounted for rapidly scaling administrative and operational departments to meet the demands of creating new service contracts and procuring costly software and services such as cloud-hosted environments or implementing new functionalities for the IIS, all in an exceedingly short time frame. This was the first hurdle. The second hurdle was rapidly implementing effective solutions with aging systems and onboarding a flood of new data exchange partners (for example, pharmacies, long-term care facilities, and community-based organizations).

We describe a vision for IIS modernization, highlighting the US response to the COVID-19 pandemic. We propose supporting this vision through long-term sustained attention in resources and coordinated action with a focus on strategic investments in workforce, technology, and policies. Building resiliency within our current architecture is critical to being ready when triggered by an event for future emergencies.

Past, Present, And The Future: Three Examples Of Modernization

IIS systems have evolved since their inception in the early 1990s, when fewer than 65 percent of children younger than five years of age were fully vaccinated. The vision was to have consolidated vaccination records available for any provider delivering care for children in any setting, thus preventing missed vaccination opportunities and protecting more children. In 2020, 94 percent of children younger than six years of age, 84 percent of adolescents ages 11–17 years, and 68 percent of adults ages 19 years and older in the US had data in an IIS. As of December 31, 2022, two years after a COVID-19 vaccine was authorized, 98 percent of children younger than six years of age, 86 percent of adolescents ages 11–17 years, and 94 percent of adults ages 19 years and older are participating in an IIS, a dramatic improvement.

COVID-19 was the largest vaccination campaign in history, vaccinating primarily adults (who may not have had a vaccination record in an IIS) in a short period of time. In doing so, a tsunami of vaccination data flooded IIS systems as data were sent to IIS within 24 hours of vaccination. This provided near real-time visibility on the state of the vaccination campaign, a vision only possible during the emergency, because policies dictated that all COVID-19-administered vaccines be reported to the IIS. Only because providers reported vaccinations administered in near real time was it possible to have a view of how the campaign was progressing, although technically this could happen outside an emergency if all data were provided in a timely way. At the national level, an aggregate picture of the vaccine campaign helped policy makers decide where to invest resources and pointed to hotspots for attention at local levels. Data use agreements that are mindful of individual privacy and data safeguards make this national picture possible. These agreements allow for the flow of information to be consolidated in the IIS and aggregated nationally to stitch together a population-level picture of vaccination coverage as well as provide individual patient data.

Here, we describe three examples—cloud-based solutions, standardized basic functionality to exchange data, and the ability for IIS to integrate with other services—that illustrate what a modern system with modern infrastructure can do. A mix of investments in a skilled workforce to run the systems; federal, state, and local policies to support operations; and technology to execute tasks is required to actualize these modernized systems.

Technology: Cloud solutions. Initial IIS across the nation were conceived in the Information Age, progressing from mainframes to desktop PCs, networks, the internet, and now the cloud. Cloud-based systems offer scalable solutions and potential efficiencies and capabilities for storing and accessing information. Scalability is key to emergency readiness. Expanding on-site services requires procurement activities and time to purchase more server space. If data exchange skyrockets 10-fold, states may eclipse their capacity quickly. Many IIS have moved a portion of their operations to the cloud (hosting, storage, and so forth). To take full advantage of cloud solutions, some jurisdictions may have to revisit statutes or policies, such as those restricting out-of-state data storage, and ensure safeguards for privacy.

Policy: Population view with basic functionality in a standardized way. All 58 jurisdictions currently have the capability to collect and consolidate immunization data across the lifespan and share immunization histories and recommendations with authorized users. IIS capture standardized core data elements including demographic and vaccine administration data (for example, name, date of birth, vaccine type, manufacturer, lot number, and so forth) allowing electronic data exchange with other health data systems such as a provider’s EHR or pharmacy records. These systems are used at the micro (at the time of care) and macro (provider and public health population) levels. IIS were early adopters of standards and are leaders in the public health technology world as evidenced by the more than 30,000 independent electronic connections to IIS. However, new or refined standards are needed to allow for new use cases such as querying for large amounts of data at one time or for greater functionality such as inventory management (decrement doses that are administered from stock) and accounting for new fields of data. For example, many recommended vaccines for adults are not age-based, but rather risk-based (for example, occupational exposure, medical conditions); many EHR and IIS systems do not currently capture all data fields to account for these criteria.

IIS function within their jurisdiction; when combined, aggregate data from each jurisdiction form a quilt of the national picture. Unlike during the COVID-19 response, there is currently no way to see this complete quilt of information in near-real time. Each state can have a vivid picture if resources are invested to analyze the data, but a national perspective is incomplete due to state or local policies limiting data sharing. Arguably, this is a paramount shortfall to a modernized public health system. Ideally, anyone who administers any vaccine should report this administration to an IIS within 24 hours. Reporting all vaccines in a timely manner will improve public health’s visibility and allow for more strategic and accurate decisions.

Workforce: Integration with software services. Prior to the pandemic, many IIS had already connected to independent services, for example, address cleansing services (a third-party service that validates and corrects physical addresses). Ensuring addresses are correct is essential for improving data quality because addresses are often used to match individuals to existing records. The pandemic provided new opportunities and resources for IIS to link with new services, such as appointment scheduling and data analytics platforms.

Integrating public health data systems is a hallmark of modernized public health data systems. Examples of IIS and public health data integration exist in some jurisdictions where IIS may support lead toxicity screening, newborn screening, and oral health. Other desired connections, such as disease surveillance data (for example, reported cases of measles) with vaccination data (measles vaccination status), are desired but rare. Each jurisdiction must address systems integration from a technology, staffing, and policy perspective. Models of integration should be evaluated and implemented if feasible and cost-effective to maintain.

Underpinning modernization is the need for a skilled workforce. The long-standing human resources deficit in public health was exacerbated by the pandemic when public health workers were vilified, overworked, and burned out, leading to an urgent imperative to reimagine a public health workforce, one that is positioned to implement technology investments to meet current and future challenges. Workforce is the backbone of realizing the vision of modernization and the steps to get there.

The Cost Of Modernizing

Any data system requires development, operational, and maintenance costs. Development costs include one-time capital investments, such as the purchase of servers to host data. Operational costs (for example, annual expenditures in personnel, equipment, supplies and other direct costs to operate the IIS, manage data, and recruit providers) can be thought of like a monthly Netflix subscription versus the initial capital expense of purchasing a television or device (development cost). Maintaining connections with health data systems and the IIS can be tedious and perpetual, analogous to parenting, where the job does not end when the children leave for college. Connections to systems break, upgrades are required, and confirmation and validation that software functions as intended require constant measurement and improvement.

In 2006, IIS had between 2.9 and 3.2 million records with a cost-per-record estimate of $0.09 to $10.30. Today, in 2024, systems across all jurisdictions hold billions of immunization records with varying costs, which are not well-documented. Efficiently increasing the number of records requires resources. Costs to modernize will be affected by the total population in the IIS, the functionality incorporated into the IIS, and the development and operational costs for labor and technical infrastructure. Although there is some economy of scale as the number of records increase, some costs continue to increase per each record added, and overall maintenance costs to enable access to all data do not go away. Expecting modernized systems to allow for consumer access and other users (such as health plans), the estimated costs will widely vary, particularly for systems constantly sending and receiving data.

Moving Forward

A shortcoming of the current systems resides in monolithic systems architecture that is difficult to update. Systems should be developed in more nimble ways using a modular design, which gives the ability to keep central pieces (for example, patient information) untouched while allowing for discrete changes (for example, new inventory and order management) and the accommodation of new standards. The building block architecture approach allows different features and components of an IIS to evolve as needed within each jurisdiction. Second, as new standards are developed, they need to be adopted within a predetermined time frame to prevent supporting multiple standards simultaneously for an undetermined time. Lastly, validating IIS enhancements to the system is necessary to ensure the IIS functions as intended. Moreover, ensuring laws and policies address present-day challenges is vital for bringing public health systems in line within the broader public health data modernization initiative.

As the nation shifts from pandemic response back to routine operation, public health funding has been depleted while expectations for performance remain high. There is a keen recognition that support for modernizing IIS is critical to the public health infrastructure. IIS solutions that can more effectively scale and match patients and share data between jurisdictional boundaries more efficiently are essential. The infusion of funding during the pandemic illustrated what is possible. Continued success will require consistent and robust support at local levels to ensure the development and scalability of systems to meet increasing demands for data now and in the future.

Authors’ Note

Kristina Crane is an employee of STChealth, an immunization information system company. Rebecca Coyle is the executive director of the American Immunization Registry Association.