Depicting EHRs Immunization capability HL7 WGM – September 11, 2006 Immunization Storyboard project update

Milestones May 2005 WGM Storyboard project scope January 2006 WGM Submitted project to Patient Care TC Storyboard Activity diagram Glossary May 2006 WGM Collaborated with HL7 Immunization project Immunization storyboard in Patient Care TC Now formally part of the Care Provision DSTU - see the Care Provision Domain-Storyboard Section. Not attached to specific immunization messages

Pediatric Immunization (DOPC ST000030)

September 2006 update Miscellaneous Cerner EHR Immunization module James Broselow – color coding method Storyboard progress HL7 IZ project Advancing from Storyboard to HL7 Messaging standards Patient Care TC guidance Training Activities

HL7 Version 3.x Mapping Steps Immunization Storyboard Subgroup

Two main issues How to link functional standards and messaging standards How to move to messaging standards

Where we can impact standards IZ Storyboard EHRS-DSTU HL7 Messaging Standards

EHR-S DSTU Release 1 IDFunctionality DC.1.4.1Manage Allergy, Intolerance and Adverse reaction list DC.1.4.4Manage Immunization List DC.1.8.2Manage Immunization Administration DC Support for context-sensitive care plans, guidelines, protocols DC.2.3.1Support for Medication and Immunization ordering DC.2.3.2Support for Medication and Immunization administration DC.2.5.1Present Alerts for preventive services and wellness DC.2.5.2Notifications and reminders for preventive services and wellness DC.3.2.5Communication with Medical devices S.1.1Registry notification S.3.2.1Encounter specific functionality S.3.3.2Eligibility verification and determination of coverage S.3.3.6Health Service reports at the conclusion of an episode of care S.3.7.3Patient Reminder Information updates IN.6Business rule management

Depicting EHRs Immunization capability Focus on function than patient scenario immunization registry connectivity of EHR Four basic functions from EHR-S DSTU Storage of IZ data Retrieval of IZ data Connection to the state/local registry Decision support capability (EHR or registry) High level representation Consensus building Room for expansion Allow broad-based input

1.3.3 Pediatric Immunization (DOPC_ST000030) Purpose: This storyboard demonstrates the interaction between a Primary Care Physician (GP) to an immunization registry for the region Pediatric Immunization (DOPC_SN000030) Precondition: Billy Newpatient is 4 years old. He has been seen at other clinics in the region. However, he is a new patient at Dr. Primary's clinic. He is there for a pre-school physical. Dr. Primary's clinic EMR is able to interface with a regional immunization registry. The regional immunization registry conforms to public health standards, e.g. CDC Minimal Functional Standards for Immunization Registries. The clinic EMR conforms to HL-7 EHR-S Functional Model. The regional immunization registry is able to locate the patient's immunization record. Activities: By interview, the nurse discovers Billy's caretaker does not have his immunization record. In preparing his new patient record for Dr. Primary to review, the nurse initiates the clinic EMR to query the regional immunization registry. The immunization registry finds and sends data to clinic EMR. The clinic EMR populates Billy's patient record with that data. The clinic EMR generates immunization recommendations using a decision support engine. Alternate Flow #1: The regional registry uses a decision support engine and sends recommendations along with Billy's immunization data. Dr. Primary reviews the record and notes (amongst other data) Billy's immunization record (or its absence thereof) and recommendations. After taking history from the caretaker and performing physical exam, she orders immunizations. The nurse administers the shots and documents them in the clinic's EMR. The clinic EMR sends the message about the new immunizations to the state registry which updates its record. The nurse also prints an updated paper record of Billy's immunizations. Alternate Flow #2: Dr. Primary determines that Billy does not require or decides to withhold immunizations at this stage. No updates are made to the immunization history in the patient record. No data is sent to the registry. Post-condition: The regional registry has successfully sent Billy's immunization history. The regional registry has successfully recorded Billy's new immunizations. The clinic EMR has an updated immunization record. Billy's caretaker has an updated immunization record.

HL7 Messaging Standard Activities 1. Storyboards 2. Interaction Models 3. Models (e.g. DMIM/s, RMIM/s, etc.) 4. HL7 Ballot 5. Message Specifications 6. Implementation Guide/s 7. Vocabulary 8. Serialized list of fields, by message 9. Message Samples 10. Mapping to existing applications and/or standards 11. Conformance and Compliance 12. Communication protocols 13. Tools

Road to HL7 Standard Devt Process Storyboard Text UML Storyboard Activity Diagram Domain Glossary UML Domain Analysis Model Static Model Cross-Reference ( to HL7 RIM ) SIG HL7 Engineers Domain Experts TC PeDS SIG Immunization Storyboard

Immediate steps to developing HL7 conformant messages Developing the interaction models Domain Message Information Model (D-MIM) Refined Message Information Model (R-MIM) Hierarchical Message Definitions (HMD) Submit for HL7 Ballot process Approve the D-MIMs, R-MIMs and HMDs Any new messages that require additions/modifications to the RIM, then these will need to be submitted to the RIM review process.

Messaging areas EMR requests immunization history from registry Immunization Record Detail Query EMR receives immunization record from registry Immunization Record Detail Query Response EMR receives immunization recommendations from registry or other systems Immunization Recommendations Query Immunization Recommendations Query/Response EMR updates the immunization record of a patient in the registry Immunization Event Record Request

Examples of other message areas EMR process EMR queries registry EMR receives info from registry EMR updates registry EMR updated by registry EMR IZ decision support processes EMR and Registry Indications to withhold IZ (contraindications, previous disease, etc) Inventory information exchange between registry and EMR Reporting of adverse reactions Sending batched requests from registry Registry processes Registry receives query for a client from a registry or other IS Registry receives answer to query for client info Registry receives unsolicited update of a client record Registry receiving batched request for a number of patients

Next steps Continue to engage with HL7 IZ project Contact Canadian IZ work to see if it applies to US/Pediatric domain Move our storyboard towards messages Ask for technical assistance Modeling and Methodology facilitator (to assist in developing DMIM, RMIM, HMD, etc) Publishing facilitator (learn how to use the publishing tools to build the topic) Vocabulary facilitator (to understand the vocabulary) Develop expertise to evaluate what has been done - understand how messages are developed HL7 Development Framework HDF document HL7 tutorials