Public Health Data Standards Consortium

The Consortium is a unique entity made up of federal, state and local agencies, professional associations, academia, health IT vendors and individuals that collectively represent the interests of public health in the health IT standardization.

PHDSC Ad Hoc Task Force on Electronic Health Record-Public Health (EHR-PH)

Goal: To provide a public health perspective to the evaluation of the HL7 EHR-S Functional Model Objectives: ■ Bring the state and local public health agencies and public health research community’s perspectives into the on-going efforts to develop the HL7 Functional Model for the EHR-S ■ Demonstrate the benefits of an organized interaction between the public health and clinical health care 2004 PHDSC EHR-PH Task Force

WHITE PAPER “Electronic Health Record: Public Health Perspectives” Purpose: ■ To communicate to the public health community a need for broader involvement in the national effort to standardize clinical and public health data and information systems ■ To describe public health perspectives on the EHR 2004 PHDSC EHR-PH Task Force

Re-evaluation of HL7 EHR-S FM V1.1 from Public Health Perspectives Supported by the National Center for Health Statistics (NCHS) Centers for Disease Control and Prevention (CDC) Grant No. 5U38HM PHDSC EHR-PH Task Force

Project Objective: Conduct re-evaluation of HL7 EHR-S FM Release 1.1 to identify necessary functionality for public health reporting and information sharing across clinical EHR-S and public health information systems 2010 PHDSC EHR-PH Task Force

Why Now? ■ HL7 EHR-S FM has undergone a series of enhancements ■ Public Health better positioned itself at HL7 by  Participation in Public Health and Emergency Response Work Group (PHER WG)  Participation in HL7/ONC/EHR Biosurveillance Use Case Alignment Project ■ Public Health has been involved in the national HIT standardization efforts at HITSP, IHE and other initiatives ■ “Meaningful use of EHR-S” warrants meaningful use of public health information systems ■ CDC/NCHS contract with PHDSC Re-evaluation of HL7 EHR-S FM from PH Perspectives

Participants:  93 members joined the Task Force  50% increase in comparison with 2004 EHR-S FM evaluation with 63 members Limitations:  All public health domains are not represented 2010 PHDSC EHR-PH Task Force

Participants Affiliation* StakeholdersNumber of Participants Local Public Health12 State Public Health25 Federal Agencies25 (CDC=22, VA=1, NIST=1, FDA=1) Professional Associations4 (PHDSC, NAPHIT, AHIMA) Academia4 Payor2 Clinicians1 IT vendors19 (EHR=4, PH=15) Total92 *We were unable to specify stakeholder category for 1 participant PHDSC EHR-PH Task Force

Public Health Participant Jurisdictions:  Public health participants range from local and state health departments in 17 states as follows: 2010 PHDSC EHR-PH Task Force AKCACODEILKY MAMIMNNCNENY OHORSDTNTX

Domain/Stakeholder Representation*, ** *Participants may have expertise in several domains. **Several participants did not specify their area of expertise PHDSC EHR-PH Task Force DomainNumber of Participants Communicable Diseases13 Chronic Diseases (including Cancer)11 Immunization9 Vital Records9 Environmental Health1 Public Health Informatics24 IT, HIT Standards, HIM, EMR, EHR38 Law (including HIPAA)2 Primary Care3 Behavioral & Occupational Health2 Birth Defects1

Electronic Reporting from EHR-S to Public Health on:  Communicable diseases (N=13)  Immunizations (N=9)  Biosurveillance (N= 24)  Communicable and chronic disease surveillance based on ASTHO definition Plus expertise in:  Chronic diseases (11)  Vital records (9)  Information Technology (38)  Public Health Informatics (24) Participants have sufficient expertise for evaluating domains included in the Meaningful Use of Health IT 2010 PHDSC EHR-PH Task Force

TimelineMethodology 12/ /2010 Recruit participants for the HL7 EHR FM Re-evaluation 1/14/10Re-launch the PHDSC Ad Hoc Task Force on EHR-PH 3/30/10Solicit feedback on the Model from Task Force Participants 5/14/10Build an agreement among participants on proposed revisions/additions 5/22/10Present proposed revisions/additions to the HL7 EHR SWAT team for inclusion in the ballot 5/31/10Generate Recommendation Report document 9/2009 1/2010 5/2010 Present project updates at the HL7 Working Group Meetings 5/26/10Deliver a webinar for a public health community

2010 PHDSC EHR-PH Task Force Reviewed sections of the EHR-S FM Submitted revisions to the Project Team via using Excel spreadsheet Received spreadsheet with proposed revisions prior calls Reviewed proposed revisions during the calls Participated in the revisions resolution with the HL7 EHR SWAT Team Review revision resolution outcomes Work with the HL7 EHR WG to incorporate proposed revisions in the HL7 EHR-S FM R2 ballot Participation Process

Comments 2010 PHDSC EHR-PH Task Force

HL7 EHR-S Functional Model Source: HL7 EHR-S FM Overview Chapter Direct Care DC.1Care Management DC.2Clinical Decision Support DC.3Operations Management and Communication Supportive S.1Clinical Support S.2Measurement, Analysis, Research and Reports S.3Administrative and Financial Information Infrastructure IN.1Security IN.2Health Record Information and Management IN.3Registry and Directory Services IN.4Standard Terminologies & Terminology Services IN.5Standards-based Interoperability IN.6Business Rules Management IN.7Workflow Management CDC PHDSC HL7 EHR-S FM Evaluation 17

Layout of the FM:  Functional Identification Number  Function Type  Functional Name  Functional Statement  Functional Description  “See also” column  Conformance Criteria IDTypeNameStatementDescriptionSee AlsoConformance Criteria (Normative) HL7 EHR-S Functional Model

IDTypeNameStatementDescription DC.1.5FManage problem list Create and maintain patient-specific problem list A problem list may include, but is not limited to: Chronic conditions, diagnoses, or symptoms, functional limitations, visit or stay-specific conditions, diagnoses, or symptoms. Problem lists are managed over time, whether over the course of a visit or stay… See AlsoConformance Criteria IN IN The system SHALL display all active problems associated with a patient. 2. The system SHALL create a history of all problems associated with a patient. 3. The system SHALL retrieve a history of all problems associated with a patient. 4. The system SHALL provide a user interface to deactivate a problem. 5. The system MAY provide the ability to re-activate a previously deactivated problem. 6. … Source: HL7 EHR-S FM Direct Care Chapter CDC PHDSC HL7 EHR-S FM Evaluation 19 HL7 EHR-S Functional Model

Evaluation Outcomes: 2010 PHDSC EHR-PH Task Force HL7 EHR-S FM Functions Categories Total Comments Received Newly Proposed Conformance Criteria Comments Resolution Outcomes (Accepted / Rejected) Direct Care / 0 Supportive13113 / 0 Infrastructure12012 / 0 TOTAL

Comments Examples 2010 PHDSC EHR-PH Task Force

Direct Care Comments SectionRecommendationcomments New- Facility Demographics Add Country, province, address elements 4 Capture mode of transport (e.g. airplane birth) 1 DC.1 Care Management Capture information surrounding incident (e.g. trauma, foodborne illness, communicable disease) 1 Care communications to/from public health (e.g. alerts) 2 MAY…SHALL Existing infrastructure support 3

Direct Care Comments SectionRecommendation# DC.1.1 Record management MAY…SHOULD provide ability to store/reference imaged documents -data SHOULD be captured using standardized code sets or nomenclature -provide the ability to store/reference imaged documents 3 MAY…SHALL provide the ability to receive, store and present text-based externally-sourced documents and reports -ability to receive/store/present text-based externally-sourced docs/reports 2 SHOULD…SHALL provide the ability to request correction of the administrative or financial data 1 Defer elevate in domain-specific profiles; covered in the externally sourced information; To be covered by Data Profiles; not universal need 9 NEW: Lab Orders SHOULD contain complete demographic info -SHALL prevent patient-sourced data from overriding provider-sourced -SHALL provide the patient the ability to annotate provider-sourced data -Add to supportive functions S as another example, there may be standard reports for public health -SHALL provide ability to Capture and Maintain multiple patient names -shall provide the ability to capture and maintain historical demographic data -Ability to combine demographic and clinical data for PH submission 7

Direct Care Comments SectionRecommendationcomments DC.1.2 Manage Patient History MAY…SHOULD provide the ability to capture the relationship between patient and others. 1 SHOULD…SHALL conform to function IN.1.4 (Patient Access Management) 1 Not in most systems at this time; cover under Data Profiles 5 DC.1.3 Preferences, Directives, Consents and Authorizations cover under Data Profiles2 MAY…SHOULD provide the ability to generate printable consent and authorization forms. -display the authorizations associated with a specific clinical activity 2 NEW: the system SHOULD provide the ability to manage electronic signature of the patient for consents and authorizations 1

Direct Care Comments SectionRecommendationcomments DC.1.4 Summary Lists Update Add to description … of a health risk (e.g. notifiable and reportable conditions such as communicable disease, adverse drug event or patient safety reports) within the cared for population SHOULD…SHALL provide the ability to capture a report of No Known Drug Allergies 1 Description addition: Medication lists are not limited to medication orders recorded by providers, but may include, for example, pharmacy dispense/supply records, patient-reported medications and additional information such as age specific dosage. Medication provided by public health during a mass prophylaxis (e.g. H1N1 vaccinations) would also be included. 5 Include in Data Profiles; already covered in supportive2 Description addition: Medication provided by public health during a mass prophylaxis (e.g. H1N1 vaccinations) would also be included. 1 MAY…SHOULD provide the ability to capture information regarding the filling of prescriptions 1

Direct Care Comments SectionRecommendationcomments DC.1.4 Summary Lists Description Addition: For example, Behavioral risk factors such as tobacco/alcohol use, social history, significant trends (lab results, weight); Description Addition: problem list Description Addition: for clinical, administrative, public health, financial decision-making 3 MAY…SHOULD provide the ability to re-activate a previously deactivated problem -provide the ability to associate encounters, orders, medications, notes with one or more problems 2 NEW: SHOULD prepare a report of a patient ‘s immunization history upon request of the patient, personal representative or for appropriate authorities such as schools or day-care centers 1

Direct Care Comments SectionRecommendationcomments DC.1.5 Manage Assessm ents Added Social history examples to cover under Data Profiles1 MAY…SHOULD provide the ability to link data from external sources, laboratory results, and radiographic results to the standard assessment. 1 DC.1.6 Care Plans, Treatment Plans, Guideline s, and Protocols Description addition: Guidelines and protocols presented for planning care may be site specific, community, industry-wide standards or as specified by public health. Description addition: Provide administrative tools for healthcare organizations and public health authorities 2 Not in most systems at this time;1 MAY…SHOULD provide the ability to use information from DC (Support for Patient and Family Preferences) to improve the effectiveness of care and treatment plans. 1

Direct Care Comments SectionRecommendation# DC.1.7 Orders and Referrals Manage- ment Description addition: Different medication orders, including discontinue, refill, and renew, and disposal require - Orders should be communicated to the correct service provider for completion and. - Order status will be monitored and alerts sent for uncompleted orders. 3 cover under Data Profiles; covered in supportive/infrastructure functions; Not universal need;8 MAY…SHALL make common content available for prescription details to be selected by the ordering clinician - conform to function S MAY…SHOULD provide the ability for the ordering clinician to create prescription detail - make available common patient med instruction content to be selected by tordering clinician. - provide the ability to include prescriptions in order sets - provide the ability to re-prescribe medication by allowing a prior prescription to be reordered - -provide order sets for referral preparation - provide guidelines to the provider about the appropriateness of a referral - Update DC to SHOULD - provide the ability for a provider to choose from among the order sets pertinent to a certain disease or other criteria 7 NEW: the system SHOULD provide the ability to communicate order activity to public health authorities as required by jurisdictional law. - The system should report medication orders, where appropriate, to public health authorities (e.g. oncology related medi.orders should be communicated or transmitted to cancer registry). 2

Direct Care Comments SectionRecommendation# DC.1.8 Document ation of Care, Measure ments and Results Description addition: The system should report medication administration, where appropriate, to public health authorities (e.g. oncology …). - Results of tests presented in easily accessible manner to appropriate providers and to PH agencies where public health is a care provider (e.g. newborn screening results) - route results to other care providers, e.g. nursing home, consulting physicians, PH provider… 3 cover under Data Profiles; covered in supportive/infrastructure functions; Not universal need;2 MAY…SHOULD notify the clinician when specific doses are due - conform to function DC /2 (Support for Drug Interaction Checking/Patient Specific Dosing /Warnings), and check/report allergies, drug-drug interactions, and other - - provide the ability for providers to annotate a result. - -display a link to an image associated with results. 4 SHOULD…SHALL provide ability to recommend required immunizations per pt. risk factors; provide the ability to capture other clinical data pertinent to the immunization administration; SHALL transmit/receive required immunization info to PH immunization registry either directly or via an intermediary, indicate normal and abnormal results; notify relevant providers (ordering, copy to) that new results have been received 4 NEW: If a public health immunization registry is available, the system SHALL provide the ability to extract the required information to submit to a public health immunization registry. - New Subsection ( patient level surveillance) The system SHALL transmit appropriate patient-level clinical information (e.g. results) to public health notifiable condition programs - system SHALL provide ability to present numerical/non-numerical current/historical test results to appropriate provider and to public health entities meeting disease reporting criteria. 3

Direct Care Comments - pending SectionRecommendation# DC.1.8 Documentation of Care, Measurements and Results MAY…SHOULD4 SHOULD…SHALL1 NEW:- When available, a clinical decision support system MAY provide target values indicated by public health (e.g., Health People 2010 goal mean total blood cholesterol) - Add: system functionality Should track and report when decision support alerts have been disabled. The system may be configured to notify the user of the status of alerts - -Add: the system SHOULD be able to provide the patient with this information electronic as well as in paper form 1 Recommendation for future policy modeling work for Public Health1 DC.1.9 Generate /Record Patient- Specific Instructions Add: The instructions shall not only be available to the patient through screen prints/paper form -- but also electronically. 1

Direct Care Comments - pending SectionRecommendation# DC.2 Clinical Decision Support Description:-append Including failure to report a reportable condition to public health -add geographic proximity (e.g., zip codes) to the list of potentially shared items of interest -extend resource examples to include information on local disease incidence rates and open public health investigations. -add (e.g. public health education materials) 4 MAY…SHOULD28 SHOULD…SHALL15 NEW: The system SHOULD provide the ability to configure rules defining abnormal trends and public health reportable conditions -The system SHALL have the capacity to identify, track and provide alerts, notifications and reports about variances from standard care plans, guidelines and protocols. -The system SHOULD make data available for aggregation. -A system MAY provide the patient pop. health measures specific to their condition /location -The EHR system MAY accept question sets supporting outbreak investigation (eg., exposure questionnaires, contact tracing) from public health authorities to facilitate information gathering from the patient. 5 DC.3.1 Clinical Workflow Tasking Description: Include PH authorities in the 1 st sentence to emphasize the importance of including PH 1 MAY…SHOULD10 SHOULD…SHALL4 Recommendation for future policy modeling work for Public Health6

Supportive/Infrastructure Functions Comments SectionRecommendation# S.1 Clinical SupportMAY…SHOULD3 S.2 Measurement, Analysis, Research and Reports MAY…SHOULD1 S.3 Administrative and FinancialDescription: Add: The system SHALL provide the ability to report to public health 1 MAY…SHOULD5 IN.1.1 Entity AuthenticationDescription: Replace "disaster" with "emergency"1 IN.2.4 Extraction of Health Record Information SHOULD…SHALL5 IN.3 Registry and Directory ServicesMAY…SHOULD6

Recommendations 2010 PHDSC EHR-PH Task Force

Our Recommendations:  Incorporate revisions identified by the Task Force members into the HL7 EHR FM release 2 ballot  Add 16 new conformance criteria as extensions to the EHR-S FM  Consider the development of a Public Health Functional Profile as a basic approach for identifying certification criteria for standards-based HIT products 2010 PHDSC EHR-PH Task Force

Our Recommendations (continued):  Work with HL7 EHR WG on defining a new specification entitled “Data Profile” as a supporting document to the Functional Profile that will define standardized data set(s) for information exchanges  Additional work is needed to better define the need for an independent HL7 Public Health Functional Model that will define functions for non-clinical data sources, e.g., environmental and socio-economic data 2010 PHDSC EHR-PH Task Force

Next Steps: --Current Project--  Continue working with HL7 EHR Working Group on the comment reconciliation for the EHR-S FM Release 2 ballot during PHDSC EHR-PH Task Force

Next Steps: -- New Project --  Conduct a pilot project in in collaboration with HL7 EHR WG and PHER WG to develop a methodology for using Functional Profiles and Data Profiles to establish certification criteria for standards-based HIT products  Work with Early Hearing Detection and Intervention program on defining an approach for setting certification criteria with support from CDC 2010 PHDSC EHR-PH Task Force

More Information about Our Project: PHDSC web-site PHDSC project wiki PHDSC EHR-PH Task Force

Why is This Work Important for Public Health? 2010 PHDSC EHR-PH Task Force

Potential Impacts to Public Heath Influence of ARRA and HIE on Health IT Standards Public Health Infrastructure Public Health Policy and Legislation Practice of Public Health 2010 PHDSC EHR-PH Task Force

Influence of ARRA and HIE These initiatives explicitly mention cooperation/collaboration with “public health”  Many jurisdictions will focus on “low hanging fruit” and high priority areas:  Immunization registries  Disease surveillance  ANY standardization will help public health sift through the data that will be sent to public health departments 2010 PHDSC EHR-PH Task Force

Public Health Infrastructure Public Health will need to be able to accept the information that will soon be collected at the Point of Care via EHR-S  Substantially MORE information is expected to flow into public health departments as the collection of data moves from a paper-based collection/reporting approach to an electronic collection/reporting approach Advanced knowledge of the structure/nature of the data will help when adapting, modifying or creating systems to capture this information PHDSC EHR-PH Task Force

Public Health Policy and Legislation HIE and ARRA will likely cause evaluations of public health policy, legislation and administrative rules governing public health Understanding the EHR-S Functional Model from public health perspectives can help shape the discussion of the dialogue on policy changes 2010 PHDSC EHR-PH Task Force

Practice of Public Health Better understanding of current health of the community through more accurate and timely reporting of data Evidence-based data also results in greater potential for quantifiable measurements and predictions Data-driven model will help manage the collection AND subsequent evaluation of the public health interventions 2010 PHDSC EHR-PH Task Force

Anna Orlova, PhD, Executive Director 624 N. Broadway Room 325 Baltimore MD Phone: Fax: Copyright 2008 © Public Health Data Standards Consortium - All Rights Reserved Click here to review the PHDSC's Legal and Privacy StatementLegal and Privacy Statement Get Involved!

Questions? Comments? 2010 PHDSC EHR-PH Task Force