End to End Data Quality Testing in Electronic Data Exchange April 2. 2009 Janet L. Balog, RN, BS Richard Bradley

EMR – IIS answer to data quality? Not uptopia Not an IIS “Junk in / Junk out” As good as the user using it Vendor’s rush to the market

MOTIVATION FOR USE of EMRs Improved documentation for improved reimbursement quality quantity legibility Data integration Cumulative record of patient data in one source Gateway to other services E prescribing; Lab / x-ray orders and results Time savings / convenience for physician and patient Documentation at point of care Laptops / Hand held devices Continuity of Care Record available to other care givers as needed Decreased medical errors templates, practice standards, decrease liability, documentation by clinicians

EMR – Data Source for IIS Practice Management systems (Billing) data for IIS Used for many years Only source of electronic data Questioned data accuracy Transcribed from Super Bill Non-professional staff not skilled to question errors May still be used when EMR in place Not all EMRs can export complete data

EMR – Data Source for IIS Preferred source of data Usually offers all fields to capture immunization event Vaccine lot numbers, manufacturer name, expiration date Sometime VFC status Data entered by clinicians HL7 data transfer Sometimes automatic upload to IIS Sometimes real-time data transfer

EMR – Data Source for IIS CCHIT standards for interoperability with EMRs Providers motivated to work with IIS Pay for Performance measurements Child Health template in EMR EMR vendors making products ‘IIS ready’ Differentiate products from other EMRs Some EMRs preferred by pediatricians

Arizona Statewide Immunization Information System (ASIIS) Mandatory reporting state 1,419 private providers 221 public 89 community health centers 55 Indian Health Service facilities 559 schools Total patients in ASIIS = 3,646,141 (March 2009) Active patients = 3,501,915 (95.4%) Total immunizations = 36,305,649 (March 2009) Many flat file transfers in place; Few HL7

Arizona Project Ten Providers Seven Vendors Public Health Community Health Centers Private providers Seven Vendors Next Gen □ iMedica eClinical Works □ eMD GE Logician □ EHS Cerner Power Chart Office

End to End Data Quality Review Process Each provider completed Export Initiation Form Initial interview with provider site and vendor Installed HL7 bridge where necessary CPT/ CVX / OBS terms reviewed for accuracy Tested for technical data transfer Compared sample charts from EMR with electronic file Monitored files after LIVE

Lessons Learned Each data exchange is unique Custom changes made for or by the individual provider can cause technical and data quality errors. Four of the 10 provider sites used the same software product and version. Each had a server of their own with different configuration settings. Vendor made changes on each server for the data exchange to work correctly.

Lessons Learned (cont.) Review vaccine codes before data exchange started and intermittently once the data exchange is LIVE. Vaccine codes (CPT or CVX) are not always up to date or accurate. EMR vendor’s CPT / CVX code updates vary by company. Update only when and how the provider directs Dispatch regular updates but providers ‘takes’ the update as desired and updates system themselves. Only in new releases Provider may or may upgrade soon or ever.

Lessons Learned (cont.) Coding errors identified Discontinued vaccine codes used for administered vaccines Vaccine codes for discontinued vaccines used for administered vaccine Administered doses of Varicella vaccine were being used in lieu of documenting history of Varicella Vaccine descriptions in EMR linked to the wrong vaccine code. Vaccine lists in the EMR were not comprehensive. Td chosen when Tdap was administered because there was no Tdap choice.

Lessons Learned (cont.) Identify ongoing vaccine code update process Who will do it? How often? Specify vaccine code type IIS accepts prior to testing files HL7 data files may contain CPT codes, CVX codes or both. All vaccines do not have both a CPT code and a CVX codes. IIS may not be able to receive all data in electronic file

Lesson Learned (cont.) HL7 file uploads to IIS are not necessarily automatic Not all EMR vendors are capable of automatic send Request at the time the interface is developed Manual uploads subject to failure or interruption. Fields for all vaccine data IIS wants may not be available. Vaccine expiration date Vaccine manufacturer name VFC status Opt Out Some vendors have set up the interface so that the data is routinely ‘pushed’ to IIS.

Lessons Learned (cont.) Clinicians may not fully populate the available vaccination fields May be inconsistent ASIIS found that clinicians who were entering data into both IIS and the EMR chose to fully populate ASIIS and were doing minimal documentation in the EMR Lot numbers populated part of the time; Manufacturer name and expiration date rarely populated. Have vendor demonstrate EMR application prior to developing the interface See various places where data COULD be documented. Clarify what fields need to be consistently populated Onsite visit from the IIS can be useful for provider to understand value of complete vaccination information to the IIS.

Lessons Learned (cont.) Opt Out or Opt In provisions not in EMR Custom interface work for Opt In Opt Out Rare – managed through direct contact with IIS Not all EMRs contain guardian information Next of Kin Guarantor (person responsible for the bill) fields Frequently the same as guardian ASIIS ultimately decided to accept these alternate fields because the guardian is usually captured in these fields and it assists in the deduplication module.

Predictors of data exchange success Availability of technical and programmatic staff with high level of expertise in EMR use and capabilities EMR immunization data fields from choice list versus free text Full understanding of State IIS and commitment to data exchange at staff and provider level Existing EMR data exchange in place with IIS application EMR product commitment to data exchange with IIS (pre-tested release)

Conclusion EMRs are introduced into the office environment in various ways Make no assumptions about How EMR is used How the vaccine codes are maintained What data can be collected Review of the provider’s application is valuable No two interface projects are the same

Contact Information Janet L. Balog, RN, BS Scientific Technologies Corporation Sr. Public Health Specialist Janet_Balog@stchome.com 520.488.9593 Richard Bradley Arizona Department of Health Services ASIIS BRADLER@azdhs.gov 602.364.3622