Improving vaccine registries through mobile technologies: a vision for mobile enhanced Immunization information systems

Parent and family characteristics associated with reported pediatric influenza vaccination in a sample of Canadian digital vaccination platform users. An exploratory, cross-sectional study in the 2018-2019 influenza season

Seasonal vaccination remains one of the best interventions to prevent morbidity and mortality from influenza in children. Understanding the characteristics of parents who vaccinate their children can inform communication strategies to encourage immunization. Using a cross-sectional study, we described parental characteristics of people who reported vaccinating their children against influenza during 2018/2019 in a cohort of Canadian digital immunization record users. Data was collected from a free, Pan-Canadian digital vaccination tool, CANImmunize. Eligible accounts contained at least one parental and one "child/dependent" record. Each parental characteristic (gender, age, family size, etc) was tested for association with pediatric influenza vaccination, and a multivariate logistic regression model was fit. A total of 6,801 CANImmunize accounts met inclusion criteria. After collapsing the dataset, the final sample contained 11,381 unique dyads. Influenza vaccination was reported for 32.3% of the children and 42.0% of the parents. In the multivariate logistic regression analysis, parents receiving the seasonal influenza vaccine were most strongly associated with reporting pediatric influenza vaccination (OR 17.05, 95% CI 15.08, 19.28). Having a larger family size and fewer transactions during the study period was associated with not reporting pediatric influenza vaccination. While there are several limitations to this large-scale study, these results can help inform future research in the area. Digital technologies may provide a unique and valuable source of vaccine coverage data and to explore associations between individual characteristics and immunization behavior. Policy makers considering digital messaging may want to tailor their efforts based on parental characteristics to further improve pediatric seasonal influenza vaccine uptake.

Immunization of Solid Organ Transplant Candidates and Recipients: A 2022 Update

Immunizations are a relatively safe and cost-effective intervention to prevent morbidity and mortality associated with vaccine preventable infection (VPIs). As such, immunizations are a critical part of the care of pre and posttransplant patients and should be prioritized. New tools are needed to continue to disseminate and implement the most up-to-date vaccine recommendations for the SOT population. These tools will help both primary care providers and multi-disciplinary transplant team members taking care of transplant patients to stay abreast of evidence-based best practices regarding the immunization of the SOT patient.

The association between health information technology and influenza vaccine uptake among adults with heart disease

Aim: Assess the association of health information technology (HIT) on influenza vaccine (IV) uptake among adults with heart disease. Methods: The association of four different uses of HIT - (1) look up health information, (2) schedule medical appointments, (3) refill prescriptions online and (4) communicate with healthcare providers on IV uptake - was analyzed using multiple logistic regression. Results: Adults with heart disease who use the internet to look up information (adjusted odds ratio [AOR] = 1.48, 95% CI: 1.39-1.59; p < 0.001), fill up prescription (AOR = 1.87, 95% CI: 1.69-2.06; p < 0.001), and communicate with a healthcare provider (AOR = 1.95, 95% CI: 1.23-3.10; p = 0.005) had a higher uptake of IV unlike those who did not. Conclusion: Using the internet in patient-healthcare system engagement via HIT was associated with increase IV uptake. Future studies should assess the impact of population-level variables on this relationship.

Can Bar Code Scanning Improve Data Capture in a National Register? Findings from the Irish National Orthopaedic Register

BACKGROUND

The Irish National Orthopaedic Register (INOR) provides a national mechanism for managing data on THA and TKA in Ireland, including a detailed implant record populated by intraoperative implant bar code scanning. It is critically important that implant details are recorded accurately for longitudinal outcome studies, implant recalls, and revision surgery planning. Before INOR's 2014 launch, Irish hospitals maintained separate, local institutional arthroplasty databases. These individual databases typically took the form of hardcopy operating room (OR) logbooks with handwritten patient details alongside the descriptive stickers from the implant packaging and/or individual institution electronic records using manual electronic implant data input. With the introduction of the INOR, a single, unifying national database was established with the ability to instead collect implant data using bar code scanning at time of implant unpackaging in the OR. We observed that bar code data entry represented a novel and potentially substantial change to implant recording methods at our institution and so sought to examine the potential effect on implant data quality.

QUESTIONS/PURPOSES

We compared the new bar code scanning method of implant data collection used by the INOR to the previously employed recording methods at our institution (in our case, the previous methods included both an electronic operation note database [Bluespier software] and a duplicate hardcopy OR logbook) and asked (1) Does bar code scanning improve the completeness of implant records? (2) Does bar code scanning improve the accuracy of implant records?

METHODS

Although the INOR was launched in 2014, our institution went live with it in 2019. To avoid any potential recording issues that may have occurred during the 2019 introduction of the novel system, a clear period before the introduction of INOR was selected at our institution to represent an era of manual data input to Bluespier software: July 2018. Although we initially aimed for 2 months of data from July 1, 2018, to August 31, 2018 (n = 247), we decided to proceed to 250 consecutive, primary THAs or TKAs for clarity of results. No procedure meeting these criteria was excluded. A second recent period, January 2021, was identified to represent an era of bar code data input; 250 consecutive, primary THAs or TKAs were also included from this date (to February 15, 2021). No case meeting these criteria was excluded. A total of 4244 implant parameters from these 500 primary THAs or TKAs were manually cross-referenced for missing or incorrect data. Eleven THA and six TKA parameters were chosen for comparison, including implant names and component sizes. For each case, either the 2018 Bluespier electronic record or the 2021 INOR electronic record was manually interrogated, and implant details were recorded by two authors before they were compared against the duplicate record for every case (the reference-standard OR logbook containing the corresponding implant product stickers) for both completeness and accuracy. Completeness was defined binarily as the implant parameter being either present or absent; we did likewise for accuracy, either that parameter was correct or incorrect. The OR logbooks were chosen as the reference standard because we felt the risk of product stickers containing errors (inaccuracies) was negligible, and in our collective experience, missing stickers (incompleteness) has not been encountered. Logbook case completeness was also confirmed by comparison to our inpatient management system.

RESULTS

With the introduction of the automated bar code data entry in the INOR, the proportion of missing data declined from 7% (135 of 2051) to 0% (0 of 2193), and the proportion of incorrectly recorded implant parameters declined from 2% (45 of 2051) to 0% (0 of 2193). The proportion of procedures with entirely accurate implant records rose from 53% (133 of 250) to 100% (250 of 250).

CONCLUSION

The completeness and accuracy of implant data capture was improved after the introduction of a contemporary electronic national arthroplasty registry that utilizes bar code data entry.

CLINICAL RELEVANCE

Based on the results of this study, other local and national registers may consider bar code data entry in the OR to achieve excellent implant data quality. Future studies may examine implant data quality at a national level to validate the bar code-populated data of the INOR.

A Smartphone App to Increase Immunizations in the Pediatric Solid Organ Transplant Population: Development and Initial Usability Study

Background

Vaccine-preventable infections result in significant morbidity, mortality, and costs in pediatric transplant recipients. However, at the time of transplant, less than 20% of children are up-to-date for age-appropriate immunizations that could prevent these diseases. Smartphone apps have the potential to increase immunization rates through their ability to provide vaccine education, send vaccine reminders, and facilitate communication between parents and a multidisciplinary medical group.

Objective

The aim of this study was to describe the development of a smartphone app, Immunize PediatricTransplant, to promote pretransplant immunization and to report on app functionality and usability when applied to the target population.

Methods

We used a mixed methods study design guided by the Mobile Health Agile Development and Evaluation Lifecycle. We first completed a formative research including semistructured interviews with transplant stakeholders (12 primary care physicians, 40 parents or guardians of transplant recipients, 11 transplant nurse coordinators, and 19 transplant subspecialists) to explore the acceptability of an immunization app to be used in the pretransplant period. Based on these findings, CANImmunize Inc developed the Immunize PediatricTransplant app. We next held 2 focus group discussions with 5-6 transplant stakeholders/group (n=11; 5 parents of transplant recipients, 2 primary care physicians, 2 transplant nurse coordinators, and 2 transplant subspecialists) to receive feedback on the app. After the app modifications were made, alpha testing was conducted on the functional prototype. We then implemented beta testing with 12 stakeholders (6 parents of transplant recipients, 2 primary care doctors, 2 transplant nurse coordinators, and 2 transplant subspecialists) to refine the app through an iterative process. Finally, the stakeholders completed the user version of the Mobile Application Rating Scale (uMARS) to assess the functionality and quality of the app.

Results

A new Android- and Apple-compatible app, Immunize PediatricTransplant, was developed to improve immunization delivery in the pretransplant period. The app contains information about vaccine use in the pretransplant period, houses a complete immunization record for each child, includes a communication tool for parents and care providers, and sends automated reminders to parents and care providers when immunizations are due. During usability testing, the stakeholders were able to enter a mock vaccine record containing 16 vaccines in an average of 8.1 minutes (SD 1.8) with 87% accuracy. The stakeholders rated engagement, functionality, aesthetics, and information quality of the app as 4.2/5, 4.5/5, 4.6/5, and 4.8/5, respectively. All participants reported that they would recommend this app to families and care teams with a child awaiting solid organ transplant.

Conclusions

Through a systematic, user-centered, agile, iterative approach, the Immunize PediatricTransplant app was developed to improve immunization delivery in the pretransplant period. The app tested well with end users. Further testing and agile development among patients awaiting transplant are needed to understand real-world acceptability and effectiveness in improving immunization rates in children awaiting transplant.

Barriers to Pretransplant Immunization: A Qualitative Interview Study of Pediatric Solid Organ Transplant Stakeholders

OBJECTIVES

To describe the experiences and beliefs of pediatric transplant stakeholders regarding factors that contribute to low pretransplant immunization rates.

STUDY DESIGN

Semistructured interviews were conducted with transplant team members (hepatologists, cardiologists, nephrologists, transplant nurse coordinators, and transplant infectious diseases physicians), primary care physicians, and parents of heart, liver, and kidney transplant recipients at 3 geographically diverse large pediatric transplant centers in the US. Interviews were conducted between July 2017 and February 2020 until thematic saturation was reached within each stakeholder subgroup. Content analysis methodology was used to identify themes.

RESULTS

Stakeholders participated in 30- to 60-minute interviews (16 transplant subspecialists, 3 transplant infectious diseases physicians, 11 transplant nurse coordinators, 12 primary care physicians, and 40 parents). Five central themes emerged: (1) gaps in knowledge about timing and safety of pretransplant immunizations, (2) lack of communication, coordination, and follow-up between team members regarding immunizations, (3) lack of centralized immunization records, (4) subspecialty clinic functioning as the medical home for transplant candidates but unable to provide all needed immunizations, and (5) differences between organ type in prioritization and completion of pretransplant immunization.

CONCLUSIONS

There are multiple factors that contribute to low immunization rates among pediatric transplant candidates. New tools are needed to overcome these barriers and increase immunization rates in transplant candidates.

The digital immunization system of the future: imagining a patient-centric, interoperable immunization information system

To ensure the effectiveness of increasingly complex immunization programs in upper-middle and high-income settings, comprehensive information systems are needed to track immunization uptake at individual and population levels. The maturity of cloud systems and mobile technologies has created new possibilities for immunization information systems. In this paper, we describe a vision for the next generation of digital immunization information systems for upper-middle and high-income settings based on our experience in Canada. These systems center on the premise that the public is engaged and informed about the immunization process beyond their interaction with primary care, and that they will be a contributor and auditor of immunization data. The digital immunization system of the future will facilitate reporting of adverse events following immunization, issue digital immunization receipts, permit identification of areas of need and allow for delivery of interventions targeting these areas. Through features like immunization reminders and targeted immunization promotion campaigns, the system will reduce many of the known barriers that influence immunization rates. In light of the global COVID-19 pandemic, adaptive digital public health information systems will be required to guide the rollout and post-market surveillance of the SARS-CoV-2 vaccine.

Vaccination as a scheduled demand: a day in the life of users

OBJECTIVES

to understand vaccination as a scheduled demand and access to this demand in a day in the life of health services, from the perspective of users.

METHODS

holistic-qualitative multiple case study, based on the Quotidian Comprehensive Sociology, with 74 users from four health microregions of the Extended Western Region of Minas Gerais State.

RESULTS

scheduling vaccination demand in a day in the life of services is compromised by the fragility in data record, by computerized systems underutilization and by the loss of the immunization tracking card, resulting in missed opportunities of immunization and unnecessary revaccinations. The Primary Health Care team's non-involvement also compromised access to this action. Final Considerations: there is a need for more effort to be dispensed with for the effective use of computerized systems and Permanent Education of professionals in order to take advantage of all the opportunities of orientations and referrals of users to the vaccination room.

Under-immunization of pediatric transplant recipients: a call to action for the pediatric community

Vaccine-preventable infections (VPIs) are a common and serious complication following transplantation. One in six pediatric solid organ transplant recipients is hospitalized with a VPI in the first 5 years following transplant and these hospitalizations result in significant morbidity, mortality, graft injury, and cost. Immunizations are a minimally invasive, cost-effective approach to reducing the incidence of VPIs. Despite published recommendations for transplant candidates to receive all age-appropriate immunizations, under-immunization remains a significant problem, with the majority of transplant recipients not up-to-date on age-appropriate immunizations at the time of transplant. This is extremely concerning as the rate for non-medical vaccine exemptions in the United States (US) is increasing, decreasing the reliability of herd immunity to protect patients undergoing transplant from VPIs. There is an urgent need to better understand barriers to vaccinating this population of high-risk children and to develop effective interventions to overcome these barriers and improve immunization rates. Strengthened national policies requiring complete age-appropriate immunization for non-emergent transplant candidates, along with improved multi-disciplinary immunization practices and tools to facilitate and ensure complete immunization delivery to this high-risk population, are needed to ensure that we do everything possible to prevent infectious complications in pediatric transplant recipients.

Evaluation of digital vaccine card in nursing practice in vaccination room

OBJECTIVE

develop and evaluate a vaccine application for mobile devices, with update integrated with the National Immunization Program Information System, for care in vaccination rooms.

METHOD

methodological research based on the Pressman System Development Life Cycle theory developed in three stages: integrative literature review, computational development, and application evaluation. The product was evaluated as to satisfaction, using a validated questionnaire, and as to usability by the System Usability Scale.

RESULTS

the application functionalities were based on the survey of technological Innovations on immunization, published in the scientific literature. It displays user vaccines directly from the National Immunization Program Information System, notifies about upcoming vaccines, and enables the inclusion of vaccine cards of dependents. The evaluation resulted in users' mean score of 90.5 ± 11.1 and health professionals' mean score of 84.2 ± 19.4.

CONCLUSION

the application is a technological tool with potential to improve the work process in vaccination rooms and to reach the goals of vaccine coverage. It synchronizes data with the National Immunization Program Information System, thus enabling the maintenance of people's vaccination history.

Countering vaccine hesitancy through immunization information systems, a narrative review

Immunization is one of the most important public health interventions to contrast infectious disease; however, many people nowadays refuse vaccination. Vaccine hesitancy (VH) is due to several factors that influence the complex decision-making process. Information technology tools might play an important role in vaccination programs. In particular, immunization information systems (IISs) have the potential to improve performance of vaccination programs and to increase vaccine uptake. This review aimed to present IIS functionalities in order to counter VH. In detail, we analyzed the automatic reminder/recall system, the interoperability of the system, the decision support system, the web page interface and the possibility to record adverse events following immunization. IIS could concretely represent a valid instrument to increase vaccine confidence, especially trust in both health-care workers and decision makers. There are not enough trials aimed to evaluate the efficacy of IIS to counter VH. Further researches might focalize on this aspect.

Barriers and facilitators to the use of an immunization application: a qualitative study supplemented with Google Analytics data

Background

Barriers and facilitators of mobile app adoption are not known. This study examined usage of a new Pan-Canadian immunization app to identify factors that contributed to usage.

Methods

Women in their third trimester of pregnancy or had given birth in the previous 3 months were recruited from a hospital obstetrical unit. Fifty-five participants were instructed to download the ImmunizeCA app. After at least 6 months, 10 interviews were conducted, transcribed and coded. Themes identified were compared with aggregate ImmunizeCA usage data (n = 74 212 users).

Results

Facilitators included features that address logistical challenges, improved convenience and information access. Barriers included absence of system integration. Concerns regarding the privacy and security of personal health information were not an inhibitor as long as best practices are followed. Google Analytics data on usage supported qualitative findings.

Conclusion

Future studies should evaluate the quantitative impact of factors we identified on app uptake and usage. Subsequent mobile app studies may benefit from the use of analytic data as they were found to be effective in helping to validate qualitative data derived from interviews with study participants.

Immunization information systems in Canada: Attributes, functionality, strengths and challenges. A Canadian Immunization Research Network study

OBJECTIVES

Canada does not have a national immunization registry. Diverse systems to record vaccine uptake exist, but these have not been systematically described. Our objective was to describe the immunization information systems (IISs) and non-IIS processes used to record childhood and adolescent vaccinations, and to outline the strengths and limitations of the systems and processes.

METHODS

We collected information from key informants regarding their provincial, territorial or federal organization's surveillance systems for assessing immunization coverage. Information collection consisted of a self-administered questionnaire and a follow-up interview. We evaluated systems against attributes derived from the literature using content analysis.

RESULTS

Twenty-six individuals across 16 public health organizations participated over the period of April to August 2015. Twelve of Canada's 13 provinces and territories (P/Ts) and two organizations involved in health service delivery for on-reserve First Nations people participated. Across systems, there were differences in data collection processes, reporting capabilities and advanced functionality. Commonly cited challenges included timeliness and data completeness of records, particularly for physician-administered immunizations. Privacy considerations and the need for data standards were stated as challenges to the goal of information sharing across P/T systems. Many P/Ts have recently implemented new systems and, in some cases, legislation to improve timeliness and/or completeness.

CONCLUSION

Considerable variability exists among IISs and non-IIS processes used to assess immunization coverage in Canada. Although some P/Ts have already pursued legislative or policy initiatives to address the completeness and timeliness of information, many additional opportunities exist in the information technology realm.

Modernizing Immunization Practice Through the Use of Cloud Based Platforms

Collection of timely and accurate immunization information is essential for effective immunization programs. Current immunization information systems have important limitations that impact the ability to collect this data. Based on our experience releasing a national immunization app we describe a cloud-based platform that would allow individuals to store their records digitally and exchange these records with public health information systems thus improving the quality of immunization information held by individuals and public health officials.

Feasibility and Limitations of Vaccine Two-Dimensional Barcoding Using Mobile Devices

Background

Two-dimensional (2D) barcoding has the potential to enhance documentation of vaccine encounters at the point of care. However, this is currently limited to environments equipped with dedicated barcode scanners and compatible record systems. Mobile devices may present a cost-effective alternative to leverage 2D vaccine vial barcodes and improve vaccine product-specific information residing in digital health records.

Objective

Mobile devices have the potential to capture product-specific information from 2D vaccine vial barcodes. We sought to examine the feasibility, performance, and potential limitations of scanning 2D barcodes on vaccine vials using 4 different mobile phones.

Methods

A unique barcode scanning app was developed for Android and iOS operating systems. The impact of 4 variables on the scan success rate, data accuracy, and time to scan were examined: barcode size, curvature, fading, and ambient lighting conditions. Two experimenters performed 4 trials 10 times each, amounting to a total of 2160 barcode scan attempts.

Results

Of the 1832 successful scans performed in this evaluation, zero produced incorrect data. Five-millimeter barcodes were the slowest to scan, although only by 0.5 seconds on average. Barcodes with up to 50% fading had a 100% success rate, but success rate deteriorated beyond 60% fading. Curved barcodes took longer to scan compared with flat, but success rate deterioration was only observed at a vial diameter of 10 mm. Light conditions did not affect success rate or scan time between 500 lux and 20 lux. Conditions below 20 lux impeded the device’s ability to scan successfully. Variability in scan time was observed across devices in all trials performed.

Conclusions

2D vaccine barcoding is possible using mobile devices and is successful under the majority of conditions examined. Manufacturers utilizing 2D barcodes should take into consideration the impact of factors that limit scan success rates. Future studies should evaluate the effect of mobile barcoding on workflow and vaccine administrator acceptance.

Apps for immunization: Leveraging mobile devices to place the individual at the center of care

Mobile technology and applications (apps) have disrupted several industries including healthcare. The advantage of apps, being personally focused and permitting bidirectional communication, make them well suited to address many immunization challenges. As of April 25, 2015 searching the Android app store with the words 'immunize app' and 'immunization app' in Canada yielded 225 apps. On the Apple App Store a similar search produced 98 results. These include apps that provide immunization related information, permit vaccine tracking both for individuals and for animals, assist with the creation of customized schedules and identification of vaccine clinics and serve as sources of education. The diverse functionality of mobile apps creates the potential for transformation of immunization practice both at a personal level and a system level. For individuals, mobile apps offer the opportunity for better record keeping, assistance with the logistics of vaccination, and novel ways of communicating with and receiving information from public health officials. For the system, mobile apps offer the potential to improve the quality of information residing in immunization information systems and program evaluation, facilitate harmonization of immunization information between individuals, health care providers and public health as well as reduce vaccine hesitancy. As mobile technology continues to rapidly evolve there will emerge new ways in which apps can enhance immunization practice.

Can mobile technologies improve on-time vaccination? A study piloting maternal use of ImmunizeCA, a Pan-Canadian immunization app

Mobile applications have the potential to influence vaccination behavior, including on-time vaccination. We sought to determine whether the use of a mobile immunization app was associated with the likelihood of reporting on-time vaccination in a cohort of 50 childbearing women. In this pilot study, we describe participant reported app use, knowledge, attitudes or beliefs regarding pediatric vaccination and technology readiness index (TRI) scores. To explore if app use is associated with change in attitudes, beliefs or behavior, participants were instructed complete a baseline survey at recruitment then download the app. A follow up survey followed 6-months later, reexamining concepts from the first survey as well as collecting participant TRI scores. Changes in Likert scores between pre and post survey questions were compared and multivariate logistic regression was used to assess the relationship between TRI score and select survey responses. Thirty-two percent of participants perceived that the app made them more likely to vaccinate on time. We found some individuals' attitudes toward vaccines improved, some became less supportive and in others there was no change. The mean participant TRI score was 3.25(IQR 0.78) out of a maximum score of 5, indicating a moderate level of technological adoption among the study cohort population. While the app was well received, these preliminary results showed participant attitudes toward vaccination moved dichotomously. Barriers to adoption remain in both usability and accessibility of mobile solutions, which are in part dependent on the user's innate characteristics such as technology readiness.

An evaluation of the feasibility and usability of a proof of concept mobile app for adverse event reporting post influenza vaccination

The Canadian National Vaccine Safety network (CANVAS) gathers and analyzes safety data on individuals receiving the influenza vaccine during the early stages of annual influenza vaccination campaigns with data collected via participant surveys through the Internet. We sought to examine whether it was feasible to use a mobile application (app) to facilitate AEFI reporting for the CANVAS network. To explore this, we developed a novel smartphone app, recruited participants from a hospital influenza immunization clinic and by word of mouth and instructed them to download and utilize the app. The app reminded participants to complete the CANVAS AEFI surveillance surveys ("AEFI surveys") on day 8 and 30, a survey capturing app usability metrics at day 30 ("usability survey") and provided a mechanism to report AEFI events spontaneously throughout the whole study period. All survey results and spontaneous reports were recorded on a privacy compliant, cloud server. A software plug-in, Lookback, was used to record the on-screen experience of the app sessions. Of the 76 participants who consented to participate, 48(63%) successfully downloaded the app and created a profile. In total, 38 unique participants completed all of the required surveillance surveys; transmitting 1104 data points (survey question responses and spontaneous reports) from 83 completed surveys, including 21 usability surveys and one spontaneous report. In total, we received information on new or worsening health conditions after receiving the influenza vaccine from 11(28%) participants. Of the usability survey responses, 86% agreed or strongly agreed that they would prefer to use a mobile app based reporting system instead of a web-based system. The single spontaneous report received was from a participant who had also reported using the Day 8 survey. Of Lookback observable sessions, an accurate transmission proportion of 100% (n=290) was reported for data points. We demonstrated that a mobile app can be used for AEFI reporting, although download and survey completion proportions suggest potential barriers to adoption. Future studies should examine implementation of mobile reporting in a broader audience and impact on the quality of reporting of adverse events following immunization.

Travel Vaccines Enter the Digital Age: Creating a Virtual Immunization Record

At present, proof of immunization against diseases such as yellow fever is required at some international borders in concordance with the International Health Regulations. The current standard, the International Certificate of Vaccination or Prophylaxis (ICVP), has limitations as a paper record including the possibility of being illegible, misplaced, or damaged. We believe that a complementary, digital record would offer advantages to public health and travelers alike. These include enhanced availability and reliability, potential to include lot specific information, and integration with immunization information systems. Challenges exist in implementation, particularly pertaining to verification at border crossings. We describe a potential course for the development and implementation of a digital ICVP record.