Assessment of select electronic health information systems that support immunization data capture – Kenya, 2017

In Kenya, routine immunization services are primarily documented and the information stored at the point of service, usually health facilities, using standardized paper-based immunization information systems (IIS). With the recent advances in technology, global interest is growing to transition from standardized paper-based to electronic IIS at all levels of the health service system. The benefits of an electronic IIS include an efficient way to 1) collect immunization data systematically, 2) access and retrieve immunization data easily, and 3) analyze, report, and facilitate use of immunization data for public health decision-making [1‐3]. The Kenya Ministry of Health (MOH) has an interest in expanding use of electronic health information systems (EHIS) [4], as evidenced by the EHIS that have been introduced in Kenya for various health related functions such as management of data on maternal and child health [5]. The Kenya MOH National Vaccine and Immunization Program (NVIP) is also interested in moving from the use of paper-based systems to electronic IIS.

A move from paper to electronic IIS would support use of immunization data to guide the NVIP goal of reducing morbidity, mortality, and disability from vaccine preventable diseases. For an electronic IIS to be useful to NVIP, a number of discussions about the system should be held with relevant stakeholders on the purpose and the objectives of the system, how it should be designed, what type of data it should collect and so forth. The discussions ensure the design, development, and use of a system align with the system’s intended purpose and NVIP goal. To facilitate the use of immunization data by NVIP, the electronic IIS should include immunization specific standards. Immunization specific standards are useful for supporting access to individual immunization status, forecasting recommended vaccines, immunization coverage reporting, adverse effects following immunization(AEFI) reporting, interoperability with other systems, and improved defaulter tracking and reduction of delayed vaccinations. NVIP can also use the immunization specific standards to facilitate the larger country effort discussions to strengthen and harmonize the integration of immunization systems with existing health systems in Kenya.

Although EHIS with immunization components exist in Kenya, questions and concerns remain about their potential use and alignment with the Kenya NVIP mission: for example, do the EHIS produce immunization-specific NVIP required reports; do the EHIS support tracking of defaulters and those lost to follow up; and can the EHIS share information with each other? The EHIS that capture and report immunization data function either as a stand-alone system or via an immunization-specific data module added to an existing system. Furthermore, no public documentation is available on how the EHIS compare in terms of functionality, data elements, workflow, or capacity to share information with other EHIS. This article reports on the findings of a rapid assessment of select EHIS with immunization components in Kenya. The assessment provides lessons learned to guide future efforts on the design, development and implementation of EHIS to support the immunization needs of the NVIP and Kenya.

We conducted a rapid assessment of select EHIS with immunization components to understand the design, development, implementation of the EHIS including the lessons learned from their use. We also assessed how the data elements in the EHIS compared to the data elements in the Maternal and Child Health Booklet used in the existing paper based system in Kenya.

From the six EHIS reviewed, only one system was built to focus specifically on immunization data. The one EHIS was also the only one focused on the inclusion of outreach data on immunization. This finding supports the notion of leveraging existing EHIS to incorporate immunization components. In this assessment, the reach (immunization and non-immunization) of these existing systems (EHIS 4 with 470 participating facilities and EHIS 5 with 353 participating facilities) was high which shows the potential to reach many more children than the other EHIS examined in this assessment. This would be especially be the case if the EHIS expanded their target population to include populations other than children with HIV only as was reported in this assessment. The NVIP could also advocate for the expansion of the purpose of the system and inclusion of components such as outreach that are important for the planning and delivery of immunization services. Expansion of the purpose of the system could facilitate the use of the system for immunization in addition to the other purposes designed for the system. Future assessments should explore the benefits to immunization programs of standalone versus integrated electronic IIS.

Although this assessment only looked at EHIS in comparison to one of the standardized paper-based system tools – the MCHB, our findings showed that none of the EHIS had all the data elements necessary to fully replace or operate independently from the standardized paper-based system for tracking immunizations in Kenya. Perhaps the use of a hybrid model of both paper and electronic IIS may be the next step in the future of data collection and reporting in Kenya. As countries transition from standardized paper-based systems to electronic IIS, there is a desire for the data collected in the former to also be collected in the latter. Given the challenges of staffing capacity and workload in the implementation of EHIS [9, 10] consideration should be given to what data needs to be collected in both paper and electronic IIS. In this assessment for all but one system, health facility staff were in charge of data entry, adding to staff work burden that could impact data completeness and quality from the EHIS. Although our assessment did not look at data quality, the findings suggest a need for periodic assessments of the quality of immunization data captured by EHIS.

The assessment showed substantial differences in the functionality and immunization-related data elements included in the EHIS, which might reflect a lack of nationally endorsed immunization specific standards for electronic IIS. The lack of immunization-specific standards and data elements limited the usefulness of these systems, especially concerning the ability to share data with national-level health information systems. In some countries (e.g., United States, Canada) immunization specific standards for electronic IIS are available to promote consistent data collection and reporting processes [11, 12]. The immunization specific standards also guide the development of electronic IIS to ensure alignment with government information policies and relevant data requirements on immunization. Although Kenya has guidance on standards for EMRs [6, 7], the guidance primarily focuses on HIV-related information with a few sections for immunization content in electronic systems in the “Standards and guidelines for primary health care electronic medical record systems in Kenya” [7]. Development of immunization specific standards and minimum data elements consistent with the goals of NVIP, and aligned with other national health information systems, would greatly facilitate collection and reporting of immunization data in Kenya.

The facilitators and barriers reported in this assessment are similar to those reported in the literature on implementation of EHIS generally. A systematic review among users in developed countries reported time, cost, and technical support as factors related to the successful use of EHIS [13]. Reviews and studies focused on developing countries found that internet connectivity, availability of electricity, computer literacy, staffing capacity, data quality, and availability of standard operating procedures for the systems affected the implementation of EHIS [9, 10]. NVIP should consider the facilitators reported to enhance the use of EHIS once the country is ready to transition from standardized paper-based systems to electronic IIS. Only two barriers reported related to immunization specific issues of an EHIS – inability of the EHIS to update/include previously given vaccines and inability of the EHIS to generate reports required by NVIP. Development of immunization specific standards on data to be collected in an EHIS and type of reports to include can help address the two barriers. Addressing the other barriers to the use of EHIS reported in this assessment can include reference to efforts on EHIS in general and not specific to immunization related EHIS e.g. power outages and staff shortages.

This rapid assessment had limitations. The interviews included in this assessment were all self-reports, and responses from staff for the different EHIS might have been subject to bias. Similarly, given the open-ended format of certain questions, interviewer bias could have been introduced as interviews proceeded. This assessment only included EHIS identified by the Ministry of Health NVIP. Consequently, the sample might not have included all EHIS with immunization components in Kenya. We reached out to all the EHIS that the NVIP was aware of and all agreed to participate in this assessment. The health facilities we visited were identified by the management of the EHIS, which might have influenced the findings on the barriers and facilitators to use of the EHIS.

Overall, the findings of this assessment highlight substantial variation in the EHIS with immunization components and provide lessons learned for the Kenya MOH NVIP, immunization partners, vendors of EHIS, and users of EHIS to consider as Kenya considers the transition from paper-based to electronic IIS. Is a hybrid version of both paper and electronic IIS best for Kenya? Which is more beneficial for Kenya, standalone or integrated IIS? Development of immunization specific standards for electronic IIS that align with those of other national EHIS is one way that might help reduce variation in the systems as newly developed electronic IIS are introduced in Kenya. The immunization specific standards will allow for sharing of data across systems if one system is not an option for Kenya.