Predictors of Subspecialty Appointment Scheduling and Completion for Patients Referred From a Pediatric Primary Care Clinic.

Failure to complete subspecialty referrals decreases access to subspecialty care and may endanger patient safety. We conducted a retrospective analysis of new patient referrals made to the 14 most common referral departments at Boston Children's Hospital from January 1 to December 31, 2017. The sample included 2031 patient referrals. The mean wait time between referral and appointment date was 39.6 days. In all, 87% of referrals were scheduled and 84% of scheduled appointments attended, thus 73% of the original referrals were completed. In multivariate analysis, younger age, medical complexity, being a non-English speaker, and referral to a surgical subspecialty were associated with a higher likelihood of referral completion. Black and Hispanic/Latino race/ethnicity, living in a Census tract with Social Vulnerability Index (SVI) ≥ 90th percentile, and longer wait times were associated with a lower likelihood of appointment attendance. Future interventions should consider both health care system factors such as appointment wait times and community-level barriers to referral completion.

How much did it cost to develop and implement an eHealth intervention for a minority children population that overlapped with the COVID-19 pandemic?

BACKGROUND: eHealth interventions using active video games (AVGs) offer an alternative method to help children exercise, especially during a pandemic where options are limited. There is limited data on costs associated with developing and implementing such interventions. OBJECTIVES: We quantified the costs of delivering an eHealth RCT intervention among minority children during COVID-19. METHODS: We categorized the total trial cost into five subcategories: intervention material development, advertising and recruitment, intervention delivery, personnel salaries, and COVID-19-related equipment costs. RESULTS: The total RCT cost was $1,927,807 (Direct: $1,227,903; Indirect: $699,904) with three visits required for each participant. The average cost per participant completing the RCT (79 participants/237 visits) was $24,403 (Direct: $15,543; Indirect: $8860). Due to no-shows and cancellations (198 visits) and dropouts before study completion (61 visits; 56 participants), 496 visits had to be scheduled to ensure complete data collection on 79 participants. If all 496 visits were from participants completing the three-visit protocol, that would correspond to 165 participants, bringing the average cost per participant down to $11,684 (Direct: $7442; Indirect: $4242). Of the subcategories, intervention material development accounted for the largest portion, followed by personnel salaries. While the direct COVID-19-specific cost constituted <1% of the entire budget, the indirect effects were much larger and significantly impacted the trial. CONCLUSION: RCTs typically involve significant resources, even more so during a pandemic. Future eHealth intervention investigators should budget and plan accordingly to prepare for unexpected costs such as recruitment challenges to increase flexibility while maximizing the intervention efficacy.

Improving HPV Vaccination Rates in a Racially and Ethnically Diverse Pediatric Population.

BACKGROUND AND OBJECTIVES: Nationally, 54.2% of youth are fully vaccinated for human papilloma virus (HPV) with persistent gender and racial/ethnic disparities. We used a quality improvement approach to improve completion of the HPV vaccine series by age 13 years. As a secondary aim, we examined racial/ethnic and gender differences in vaccine uptake. METHODS: The study setting included 2 pediatric, academic, primary care practices in Massachusetts. We designed a multilevel patient-, provider-, and systems-level intervention addressing parental hesitancy, provider communication, and clinical operations. Rates of HPV series completion by age 13 were monitored using a control p chart. Bivariate and multivariate analyses evaluated vaccine completion differences on the basis of clinic size, gender, and race/ethnicity. RESULTS: Between July 1, 2014, and September 30, 2021, control p charts showed special cause variation with HPV vaccine initiation by age 9 years, increasing from 1% to 52%, and vaccine completion by 13 years, increasing from 37% to 77%. Compared with White and Black children, Hispanic children were more likely to initiate the HPV vaccine at age 9 (adjusted odds ratio [95% confidence interval] = (1.4-2.6)] and complete the series by age 13 (adjusted odds ratio [95% confidence interval] = 2.3 (1.7-3.0). CONCLUSIONS: A multilevel intervention was associated with sustained HPV vaccine series completion by age 13 years. Hispanic children were more likely to be vaccinated. Qualitative family input was critical to intervention design. Provider communication training addressed vaccine hesitancy. Initiation of the vaccine at age 9 and clinicwide vaccine protocols were key to sustaining improvements.

The impact of narratives and active video games on long-term moderate-to-vigorous physical activity: A randomized controlled trial protocol.

BACKGROUND: Although physical activity (PA) has been shown in helping prevent and treat obesity, current PA interventions are still not effective in ameliorating the obesity epidemic. Additional forms of PA need to be investigated to improve PA engagement and outcomes. We hypothesize that pairing a narrative (i.e., story) with an active video game (AVG), a less traditional form of PA, will increase participant engagement in PA. This paper presents the rationale, implementation, and pilot results of a study assessing the effect of narrative's impact on PA and a series of other health outcomes. OBJECTIVE: This paper presents the rationale, implementation, and pilot results of a study assessing the effect of narrative's impact on PA and a series of other health outcomes. METHODS/DESIGN: The Active Video Game Study is a six-month randomized controlled single-blind trial projected to include 210 participants. The intervention strategy will pair a narrative to an active video game (AVG). Participants will be randomized into 3 groups: condition A [Narrative + AVG], condition B [AVG Only], and condition C [Control]. Participants will undergo three in-person data collection visits over the course of six months. Inclusion criteria are that children are between the ages of 8-12 and have a BMI ≥ 85%. The primary outcome is change in moderate to vigorous physical activity (MVPA). Secondary outcome measures include change in BMI percentile, fasting insulin and glucose, lipid panel, C-reactive protein, and cognitive function. A pilot trial of n = 6 was conducted to help develop procedures and address problems that could arise in the main trial. DISCUSSION: Successful completion of this study will provide the empirical basis for novel intervention and design strategies to enhance the impact of AVGs on long-term MVPA.

Effect of Computer-Based Substance Use Screening and Brief Behavioral Counseling vs Usual Care for Youths in Pediatric Primary Care: A Pilot Randomized Clinical Trial.

Importance: Annual preventive health visits provide an opportunity to screen youths for unhealthy substance use and intervene before serious harm results. Objectives: To assess the feasibility and acceptability and estimate the efficacy of a primary care computer-facilitated screening and practitioner-delivered brief intervention (CSBI) system compared with usual care (UC) for youth substance use and associated risk of riding with an impaired driver. Design, Setting, and Participants: An intent-to-treat pilot randomized clinical trial compared CSBI with UC among 965 youths aged 12 to 18 years at 5 pediatric primary care offices and 54 practitioners. Patients were randomized to CSBI (n = 628) or usual care (n = 243) groups within practitioner with 12 months of follow-up. Data were collected from February 1, 2015, to December 31, 2017. Data analysis was performed January 1, 2018, to March 30, 2019. Interventions: Patients self-administered a computer-facilitated substance use screening questionnaire before their annual preventive health visits. Immediately after completing the screening, they received their score and level of risk and viewed 10 pages of scientific information and true-life vignettes illustrating health risks associated with substance use. Trained practitioners received the screening results, patients' risk levels, talking points designed to prompt brief counseling, and recommended follow-up plans. Main Outcomes and Measures: Feasibility and acceptability were assessed using adolescents' postvisit ratings. Days of alcohol use, cannabis use, and heavy episodic drinking were assessed at baseline and 3-, 6-, 9-, and 12-month follow-ups using Timeline Followback, and riding in the past 3 months with a driver who was impaired by use of alcohol or other drugs was assessed using 2 self-report items. The primary outcome was the intervention effect among at-risk youths who reported using alcohol or other drugs in the past 12 months or riding with an impaired driver in the past 3 months at baseline. The secondary outcome was the prevention effect among those with no prior use or risk. Results: Among 871 youths screened, 869 completed the baseline assessment; 211 of the 869 reported alcohol or cannabis use in the past 12 months at baseline (mean [SD] age, 16.4 [1.3] years; 114 [54.1%] female; 105 [49.8%] non-Hispanic white). Of the 211 youths, 148 (70.1%) were assigned to the CSBI group and 63 (29.9%) were assigned to the UC group. Among youths in the CSBI group, 105 (70.9%) reported receiving counseling about alcohol, 122 (82.4%) reported receiving counseling about cannabis, and 129 (87.2%) reported receiving counseling about not riding with an impaired driver. Adjusted hazard ratios for time to first postvisit use of alcohol or other drugs for CSBI vs UC were as follows: alcohol use, 0.69 (95% CI, 0.47-1.02); heavy episodic drinking, 0.66 (95% CI, 0.40-1.10); and cannabis use, 0.62 (95% CI, 0.41-0.94). At 12-month follow-ups among 99 youths who reported having ridden in the past 3 months at baseline with an impaired driver (64 in the CSBI group; 35 in the UC group), adjusted relative risk ratio of riding in the past 3 months with an impaired driver for CSBI vs UC groups was 0.58 (95% CI, 0.37-0.91). No intervention effect was observed among youths who reported no prior use of alcohol or other drugs (n = 658) or not having ridden with an impaired driver (n = 769) at baseline. Conclusions and Relevance: The CSBI system is a feasible and acceptable option for screening youths in primary care practice for use of alcohol and other drugs and for risk of riding with an impaired driver, and the estimated efficacy in this sample warrants further testing in larger samples. Trial Registration: ClinicalTrials.gov identifier: NCT00227877.

Improving rates of ferrous sulfate prescription for suspected iron deficiency anaemia in infants.

BACKGROUND: Iron deficiency anaemia (IDA) in infancy is prevalent and associated with impaired neurodevelopment; however, studies suggest that treatment and follow-up rates are poor. OBJECTIVES: To improve the rate of ferrous sulfate prescription for suspected IDA among infants aged 8-13 months to 75% or greater within 24 months. METHODS: We implemented a multidisciplinary process improvement effort aimed at standardising treatment for suspected IDA at two academic paediatric primary care clinics. We developed a clinical pathway with screening and treatment recommendations, followed by multiple plan-do-study-act cycles including provider education, targeted reminders when ferrous sulfate was not prescribed and development of standardised procedures for responding to abnormal lab values. We tracked prescription and screening rates using statistical process control charts. In post hoc analyses, we examined rates of haemoglobin (Hgb) recheck and normalisation for the preintervention versus postintervention groups. RESULTS: The prescription rate for suspected IDA increased from 41% to 78% following implementation of the intervention. Common reasons for treatment failure included prescription of a multivitamin instead of ferrous sulfate, and Hgb not flagged as low by the electronic medical record. Screening rates remained stable at 89%. Forty-one per cent of patients with anaemia in the preintervention group had their Hgb rechecked within 6 months, compared with 56% in the postintervention group (p<0.001). Furthermore, 30% of patients with anaemia in the postintervention group had normalised their Hgb by 6 months, compared with 20% in the preintervention group (p<0.05). CONCLUSIONS: A multipronged interdisciplinary quality improvement intervention enabled: (1) development of standardised practices for treating suspected IDA among infants aged 8-13 months, (2) improvement of prescription rates and (3) maintenance of high screening rates. Rates of Hgb recheck and normalisation also increased in the intervention period.​.

Resident Experience and Education in Academic and Community Pediatric Primary Care Sites: Lessons for a Changing Healthcare Landscape.

INTRODUCTION: Efforts to improve pediatric primary care training in residency are important both for the residents and for the patients cared for in residency clinics. Pediatric residents typically get their primary care training at primary care centers affiliated with an academic center or at community-based locations. We aimed to compare residents' experience of continuity clinic in academic centers and community settings, and to identify relative strengths and weaknesses of each. METHODS: Survey data was evaluated for residents at one large pediatric residency program. RESULTS: Community sites had relative strengths in patient flow, population management, and perception of overall quality of care. Academic sites had relative strengths in continuity of care and ease of follow-up of results. CONCLUSIONS: Community and academic pediatric primary care training sites have varied strengths that could inform efforts to improve residency training to better meet the needs of residents and patients.

Shared Care: Using an Electronic Consult Form to Facilitate Primary Care Provider-Specialty Care Coordination.

OBJECTIVE: The quality of children's health is compromised by poor care coordination between primary care providers (PCPs) and specialists. Our objective was to determine how an electronic consultation and referral system impacts referral patterns and PCP-specialist communication. METHODS: The primary care clinic at Boston Children's Hospital piloted an electronic referral and consultation system with the neurology and gastroenterology departments from April 1, 2014, to October 31, 2016. PCPs completed an electronic consult form, and if needed, specialists replied with advice or facilitated expedited appointments. Specialist response times, referral rates, wait times, and completion rates for specialty visits were tracked. PCPs and specialists also completed a survey to evaluate feasibility and satisfaction. RESULTS: A total of 82 PCPs placed 510 consults during the pilot period. Specialists responded to 88% of requests within 3 business days. Eighteen percent of specialty visits were deferred and 21% were expedited. Wait times for specialty appointments to both departments significantly decreased, from 48 to 34 days (P < .001), and completion rates improved from 58% to 70% (P < .01), but referral volumes remained stable (25 per month to 23 per month; P = .29). Most PCPs said the Shared Care system facilitated better communication with specialists (89%) and enabled them to provide superior patient care (92%). Specialists reported that the system required a minimal amount of time and enabled them to educate PCPs and triage referrals. CONCLUSIONS: Implementation of an electronic referral and consultation system was feasible and provided timely access to specialty care, but did not affect referral volume. This system could serve as a model for other health care organizations and specialties.

Barriers to HPV immunization among blacks and latinos: a qualitative analysis of caregivers, adolescents, and providers.

BACKGROUND: Despite recommendations that 11-12-year-olds receive the full three-shot Human papillomavirus (HPV) vaccine series, national HPV immunization coverage rates remain low. Disparities exist, with Blacks and Latinos being less likely than Whites to complete the series. We aimed to identify and compare barriers to HPV immunization perceived by healthcare providers, Black and Latino adolescents, and their caregivers to inform a clinic-based intervention to improve immunization rates. METHODS: We conducted semi-structured interviews between March and July 2014 with Black and Latino adolescents (n = 24), their caregivers (n = 24), and nurses (n = 18), and 2 focus groups with 18 physicians recruited from two pediatric primary care clinics. Qualitative protocol topics included: general perceptions and attitudes towards vaccines; HPV knowledge; and perceived individual and systems-level barriers affecting vaccine initiation and completion. RESULTS: Themes were identified and organized by individual and systems-level barriers to HPV immunization. Adolescents and their caregivers, particularly Blacks, expressed concerns about HPV being an untested, "newer" vaccine. All families felt they needed more information on HPV and found it difficult to return for multiple visits to complete the vaccine series. Providers focused on challenges related to administering multiple vaccines simultaneously, and perceptions of parental reluctance to discuss sexually transmitted infections. CONCLUSIONS: Optimizing HPV immunization rates may benefit from a multi-pronged approach to holistically address provider, structural, and individual barriers to care. Further research should examine strategies for providing multiple modalities of support for providers, including a routinized system of vaccine promotion and delivery, and for addressing families' concerns about vaccine safety and efficacy.

In vitro cytokine induction by TLR-activating vaccine adjuvants in human blood varies by age and adjuvant.

Most infections occur in early life, prompting development of novel adjuvanted vaccines to protect newborns and infants. Several Toll-like receptor (TLR) agonists (TLRAs) are components of licensed vaccine formulations or are in development as candidate adjuvants. However, the type and magnitude of immune responses to TLRAs may vary with the TLR activated as well as age and geographic location. Most notably, in newborns, as compared to adults, the immune response to TLRAs is polarized with lower Th1 cytokine production and robust Th2 and anti-inflammatory cytokine production. The ontogeny of TLR-mediated cytokine responses in international cohorts has been reported, but no study has compared cytokine responses to TLRAs between U.S. neonates and infants at the age of 6months. Both are critical age groups for the currently pediatric vaccine schedule. In this study, we report quantitative differences in the production of a panel of 14 cytokines and chemokines after in vitro stimulation of newborn cord blood and infant and adult peripheral blood with agonists of TLR4, including monophosphoryl lipid A (MPLA) and glucopyranosyl lipid Adjuvant aqueous formulation (GLA-AF), as well as agonists of TLR7/8 (R848) and TLR9 (CpG). Both TLR4 agonists, MPLA and GLA-AF, induced greater concentrations of Th1 cytokines CXCL10, TNF and Interleukin (IL)-12p70 in infant and adult blood compared to newborn blood. All the tested TLRAs induced greater infant IFN-α2 production compared to newborn and adult blood. In contrast, CpG induced greater IFN-γ, IL-1ß, IL-4, IL-12p40, IL-10 and CXCL8 in newborn than in infant and adult blood. Overall, to the extent that these in vitro studies mirror responses in vivo, our study demonstrates distinct age-specific effects of TLRAs that may inform their development as candidate adjuvants for early life vaccines.

Missed Appointments: Factors Contributing to High No-Show Rates in an Urban Pediatrics Primary Care Clinic.

BACKGROUND: Missed appointments complicate primary care services. OBJECTIVE: To determine factors associated with missed pediatric appointments. DESIGN/METHODS: A convenience sample of 1537 patients who missed appointments were called and 386 (25%) families completed the 26-item survey. Those with high no-show rates were compared with the rest using χ(2) and Fisher's exact tests. Initial covariates with P < .2 were included in a multivariate logistic regression model. RESULTS: Common reasons for missing appointments were the following: forgot (27%), transportation problems (21%), and time off of work (14%). The high no-show group had more African Americans (P = .030) and older patients (P = .003). Higher no-show rates correlated with well child visits (P = .029) and perception of "excellent health" (P = .022). In the logistic regression model, well child appointments (odds ratio = 2.56) and increasing age in years (odds ratio = 1.11) were associated with higher no-show rates. CONCLUSIONS: Efforts to decrease no-show rates should target older patients and well child visits.

Improving immunization rates in a hospital-based primary care practice.

OBJECTIVE: We implemented a quality improvement initiative aimed at reaching a 95% immunization rate for patients aged 24 months. The setting was a hospital-based pediatric primary care practice in Boston, Massachusetts. We defined immunization as full receipt of the vaccine series as recommended by the Centers for Disease Control and Prevention. METHODS: The initiative was team-based and structured around 3 core interventions: systematic identification and capture of target patients, use of a patient-tracking registry, and patient outreach and care coordination. We measured monthly overall and modified immunization rates for patients aged 24 months. The modified rate excluded vaccine refusals and practice transfers. We plotted monthly overall and modified immunization rates on statistical process control charts to monitor progress and evaluate impact. RESULTS: We measured immunization rates for 3298 patients aged 24 months between January 2009 and December 2012. Patients were 48% (n = 1576) female, 77.3% (n = 2548) were African American or Hispanic, and 70.2% (n = 2015) were publicly insured. Using control charts, we established mean overall and modified immunization rates of 90% and 93%, respectively. After implementation, we observed an increase in the mean modified immunization rate to 95%. CONCLUSIONS: A quality improvement initiative enabled our pediatric practice to increase its modified immunization rate to 95% for children aged 24 months. We attribute the improvement to the incorporation of medical home elements including a multidisciplinary team, patient registry, and care coordination.

Home safety practices in an urban low-income population: level of agreement between parental self-report and observed behaviors.

Home-related injuries are overrepresented in children from low-income households. The objectives of this study were to determine frequencies of home safety behaviors and the level of agreement between parental self-report and observed safety practices in low-income homes. In a prospective, interventional home injury prevention study of 49 low-income families with children <5 years old, a trained home visitor administered baseline parental home safety behavior questionnaires and assessments. There was high agreement between caregiver self-report and home visitor observation for lack of cabinet latch (99%, 95% confidence interval [CI] = 88%-99%) and stair gate use (100%, 95% CI = 88-100%). There was lower agreement for the safe storage of cleaning supplies (62%, 95% CI = 46%-75%), sharps (74%, 95% CI = 59%-85%), and medicines/vitamins (83%, 95% CI = 69%-92%) because of the overreporting of safe practices. Self-reports of some home safety behaviors are relatively accurate, but certain practices may need to be verified by direct assessment.

Overweight prevention in pediatric primary care: a needs assessment of an urban racial/ethnic minority population.

The authors studied the prevalence of overweight-related behaviors in an urban clinic population, parents' perceived willingness to change, and identified potential gaps in nutrition and physical activity promotion. A total of 324 parents of children aged 3 to 13 years were surveyed. Clinical heights and weights were used to calculate body mass index (BMI). Of the 324 children in the study, 55% were black and 28% were Hispanic. Approximately 151 (47%) children had a BMI > or =85th percentile, and overweight-related behaviors, such as TV viewing, were highly prevalent. Overall, parents reported a need for counseling to help their children eat healthier and be more active and seemed willing to make behavior changes in these areas. However, their willingness to change appeared lowest in areas that may improve their child's weight status such as decreasing sedentary time and portion sizes. Overweight prevention efforts in primary care should include strategies to help clinicians negotiate behavior change with families.

Paediatric experiences with work-hour limitations.

OBJECTIVES: To evaluate the perceived impact of work-hour limitations on paediatric residency training programmes and to determine the various strategies used to accommodate these restrictions. METHODS: A three-page pre-tested survey was administered to programme directors at the 2004 Association of Paediatric Programme Directors meeting. The impact of work-hours was evaluated with Likert-type questions and the methods used to meet work-hour requirements were compared between large programmes (>or=30 residents) and small programmes. RESULTS: Surveys were received from 53 programme directors. The majority responded that work-hour limitations negatively impacted inpatient continuity, time for education, schedule flexibility and attending staff satisfaction. Supervision by attending staff was the only aspect to significantly improve. Perceived resident satisfaction was neutral. To accommodate work-hour limitations, 64% of programmes increased clinical responsibility to existing non-resident staff, 36% hired more non-resident staff and 17% increased the number of residents. Only one programme hired additional non-clinical staff. Large programmes were more likely to use more total methods on the inpatient wards (P < 0.01) and in the intensive care units (P < 0.05) to accommodate work-hour limitations. CONCLUSIONS: Programme directors perceived a negative impact of work-hours on most aspects of training without a perceived difference in resident satisfaction. While a variety of methods are used to accommodate work-hour limitations, programmes are not widely utilizing non-clinical staff to alleviate clerical burdens.

Immunizations in children with special health care needs in a medical home model of care.

OBJECTIVE: To assess whether a model of care with augmented services within an existing medical home could improve immunization rates for Children with Special Health Care Needs (CSHCN) and to evaluate the influence of family and practice characteristics on these children's immunization rates. METHOD: Participants were six general pediatric practices, CSHCN, and their families. Enhancements were added to the medical home for CSHCN, including additional nurse practitioner time. A prospective survey and chart review of volunteer families was made in 1998 repeating the chart review in 2000. RESULTS: The immunization rates of CSHCN in the practices before the intervention was 83.4% for DTaP, polio and MMR and 80% if HIB and HepB were added. The intervention did not improve these already high rates. In regression models, children with late onset disorders were more likely NOT to be up-to-date (UTD) by 2 years of age (OR 3.29). CSHCN cared for by non-birth parents and CSHCN whose family incomes were greater than $40,000 per year were also more likely NOT to be UTD (OR 3.81, 2.75 respectively) as were patients of providers not satisfied with any aspect of serving patients (OR 3.29). CONCLUSIONS: In these practices already committed to a medical home model of care for CSHCN, immunization rates were at or above state and national averages before any intervention took place. Some groups of patients among these CSHCN were more likely to be delayed with immunizations, including those with late onset disorders and those with high family incomes.

Pediatric residents address critical child health issues in the community.

BACKGROUND: Practicing pediatricians are challenged to look beyond the clinical settings for local resources to address health threats to children and families. Pediatric residents' perceptions of the realities faced by families that they frequently see in the emergency room and outpatient or inpatient units are inadequate. OBJECTIVES: The Community Pediatrics Training Initiative (CPTI) is a national initiative within the American Academy of Pediatrics designed to prepare future pediatricians to serve families from traditionally underserved communities. The three unique components of this CPTI at Children's Hospital of Wisconsin (CHW) and the Medical College of Wisconsin (MCW) support child health improvement through (1) interactive discussions with families, (2) exposure to programs in community agencies, and (3) community initiatives. METHODS: Pediatric residents, along with community partners, have implemented more than 25 community initiatives in the areas of access to care, adolescent health, child advocacy, and environmental and public health. RESULTS: The immediate assessment from our CPTI curriculum demonstrates community experiences significantly promote their competencies in child advocacy and system-based practice while expanding their knowledge of the impact of poverty. In 2005, a survey of 84 postgraduates (75% response rate) assessed the effectiveness of community pediatrics training. All graduates self-reported that they are moderately to greatly prepared to respond to children's culture, age, gender, and disabilities. Of the 43 (68%) graduates who are currently in practice, 10 (23%) are working directly with underserved populations. CONCLUSIONS: The development of community initiatives by pediatric residents in partnership with community stakeholders greatly expanded residents' competencies in child health improvement.

Service-oriented architecture for pediatric immunization decision support.

We integrate a personally-controlled health record (PCHR) with a Department of Public Health (DPH) immunization registry and clinical decision support (CDS) tool, creating an immunization information system using a service-oriented architecture (SOA). This SOA enables the DPH, a trusted authority, to provide CDS to both clinicians and patients/parents.