Kristen Forney, MPHCitywide Immunization Registry

New York City Department of Health and Mental Hygiene

Meaningful Use and Bi-directional Exchange of Immunization Data in

New York City

Public Health Informatics Conference 2014

Citywide Immunization Registry (CIR) Background: HL7 Data Exchange

DefinitionsInteroperability StandardsInteroperability DemoBenefits for Providers Benefits for IISSupporting DataFuture DirectionsConclusion

OVERVIEW

Started in 1997Contains 70 million immunizations for 5.2 million

patientsApproximately 1800 active provider sitesReporting is mandated for patients 0-18, consent is

required for reporting immunizations given to adultsPaper reporting Online registry Flat file

real-time HL7

CIR HISTORY

Real-time, bi-directional exchange through a SOAP web service

No batch file option for providersFirst facility began submitting data through the web

service in February 2011Currently 465 provider sites + 400 pharmacies

sending HL7 data through the web service; (189 provider sites are bi-directional)

CIR’S HL7 DATA EXCHANGE

Real-time Synchronous Transport- User submits an HL7 message, and

as part of that transaction/connection to the IIS, the application waits for an acknowledgment response

Synchronous Processing- Upon receipt of an HL7 message, IIS processes the message and acknowledges the results of processing. Data is immediately accessible to users of the IIS.

Bi-directional EHR sends an HL7 query message (VXQ or QBP) and

receives a response containing patient’s immunization history, evaluation and decision support

EHR imports IIS data and stores it as structured data

DEFINITIONS

HL7 2.5.1Supported by 44 immunization registries as of Sep 2013Well-defined standard for immunization reporting (VXU)

and query/response (QBP/RSP)SOAP Web Services

National standard recommended by CDC’s Transport Layer Expert Panel

Supported by 30 immunization registries as of Sep 2013

INTEROPERABILITY STANDARDS

[BI-DIRECTIONAL DEMO]

For Providers:

Avoid double data entry (89 CIR facilities have moved from online registry to HL7 web service)Accessibility of information (both immunization history and clinical decision support) within provider workflowAccuracy of data within provider EHRData immediately available in IIS for use with school forms, other pre-completed formsParticularly beneficial for first-time EHR implementers

BENEFITS OF REAL-TIMEBI-DIRECTIONAL EXCHANGE

* P < 0.05; ** P <0.01; *** P < .001; **** P < .0001

Stockwell, et al, 2010. http://cdc.confex.com/cdc/nic2010/recordingredirect.cgi/id/6746

COLUMBIA PRESBYTERIAN HOSPITAL

For an IIS:

TimelinessCompleteness of immunization information (lot number, manufacturer, expiration date, etc)Providers have continuous interaction with the IIS

BENEFITS OF REAL-TIMEBI-DIRECTIONAL EXCHANGE

IMPROVED VFC AND LOT NUMBER CAPTURE

Data source

Percent of immunizations

with VFC status*

Percent of immunizations

with lot number**

Flat File 88.1 59.0

Online Registry 93.6 45.3

HL7 Web Service 94.1 97.4

Total 90.5 68.4

*Data from all newly administered immunizations reported to the CIR during calendar year 2013 for patients < 19 years**Data from all newly administered immunizations reported to the CIR during calendar year 2013

IMPROVED VFC ELIGIBILITY AND LOT NUMBER CAPTURE

INCREASE IN ADULT DATA CAPTURE

CIR built HL7 web service in 2009

Stage 1:

Began January 2011; Eligible providers and hospitals must perform a test of EHRs capability to send data to an IIS in HL7 format

Stage 2:

Began January 2014; Eligible providers and hospitals must institute ongoing reporting to an IIS in HL7 2.5.1 format

MEANINGFUL USE AND IIS

Start of MU (Jan)

INCREASE IN HL7 SITES

SHIFT IN REPORTING METHOD

How can we ensure that the IIS finds and returns the correct patient? EHR should send all possible demographic information Exchange unique IDs (Medical record number, IIS ID)

Will the EHR display IIS data correctly? Thorough testing with the EHR vendor Involve providers in testing

How will the EHR de-duplicate immunizations?EHR record and IIS record must be fully synced to

ensure accurate clinical decision support

CHALLENGES OF BI-DIRECTIONAL HL7 EXCHANGE

For IIS:Webinars (or site visits) with providers to understand how their EHR worksSet up the ability to restrict queries from specific accounts Store unique IDs sent by the EHRData quality monitoring; daily e-mails

For EHRs:Store patient’s registry ID and send in all transactionsAutomatic re-query to get decision support updatedFull sync of registry record with EHR record—critical for accurate decision support

BEST PRACTICES FOR REAL-TIME BI-DIRECTIONAL EXCHANGE

Advocate for MU Stage 3 to include bi-directional exchange

Reduce Variability in HL7 implementations between IIS

Find ways to partner with EHR vendors that will be mutually beneficial

Create a set of recommendations to EHR vendors for best practices

FUTURE DIRECTIONS- IIS COMMUNITY

Meaningful Use has facilitated increased adoption of HL7 standards among practices reporting to CIR

Real-time, bi-directional exchange is feasible and scalable to a large number of facilities

Presents a number of benefits to both providers and IISIIS nationally have well-defined standards for message

content and transportPreference of EHR vendors in MU stages 1 and 2 has

been for a unidirectional HL7 interface; inclusion of a bi-directional requirement in stage 3 would accelerate implementation of bi-directional interfaces

CONCLUSIONS

Amy MetrokaVikki Papadouka

Angel ApontePaul Schaeffer

Contact Information

Kristen ForneyDirector, EHR-IIS Interoperability Project

kforney@health.nyc.gov347-396-2578

THANK YOU!