Depicting EHRs Immunization capability HL7 WGM - May 8, 2006 Immunization Storyboard project Storyboard Subgroup

Milestones May 2005 WGM Storyboard project scope June 2005 Topic selection Definition of Storyboard vs. Use case July 2005 Storyboard/Activity diagram Webinar (Dan Russler) CHCA Sharepoint August 2005 IZ topic selection Storyboard iterations Activity Diagram building September 2005 WGM Presented IZ storyboard and activity diagram at WGM October 2005 Glossary Webinar (Dan Russler) November 2005 Glossary iterations Scoping for future directions HL7 v3 IZ project (Pharmacy SIG) December 2005 Storyboarding strategy January 2006 WGM Official engagement with HL7 v3 IZ project Submitted project to Patient Care TC Storyboard Activity diagram Glossary

Immunization Storyboard topic Domain experts within PeDS SIG Public Health Public Health Data Standards Consortium – presence of existing standards American Immunization Registry Assn (AIRA) CDC Primary Care CCHIT PeDS SIG High Impact factor EHR-S DSTU (context)

EHR-S DSTU IDFunctionality DC Support for context-sensitive care plans, guidelines, protocols DC.2.3Medication and immunization management DC.2.3.1Support for medication and immunization ordering DC.2.3.2Support for medication and immunization administration or supply DC.2.5Support for Health Maintenance: Preventive Care 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.2.2Report generation S.3.1.2Encounter 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.

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

PeDS SIG Immunization Registry Storyboard iteration #4 Precondition: Billy Newpatient is 4 years old. He has been seen at other clinics in the state. However, he is a new patient at Dr. Shotzs clinic. He is there for a pre-school physical. Dr. Shotz's clinic EMR is able to interface with state/local immunization registry. The state/local immunization registry conforms to CDC Minimal Functional Standards for Immunization Registries. The clinic EMR conforms to HL-7 EHR-S Functional Model. The state/local registry is able to locate the patients immunization record. Storyboard: Billy has previously been seen at other clinics in the same state. The caretaker does not have his immunization record. In preparing his new patient record for Dr. Shotz to review, the nurse initiates the clinic EMR to query the state immunization registry. The immunization registry finds and sends data to clinic EMR. The clinic EMR populates Billys patient record with that data. The clinic EMR generates immunization recommendations using a decision support engine. Alternate Flow #1: The state registry uses a decision support engine and sends recommendations along with Billys immunization data. Dr. Shotz reviews the record and notes (amongst other data) Billys 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 clinics 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 Billys immunizations. Alternate Flow #2: Dr. Shots 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 state registry has successfully sent Billys immunization history. The state registry has successfully recorded Billys new immunizations. The clinic EMR has an updated immunization record. The patient has an updated immunization record.

PatientState/Local RegistryClinic EMRPhysicianRN Prepares pt record for review Initiates immunization record retrieval No immunization record Generates recommendations using decision support Sends immunization history to Clinic EMR Populates immunization data in patient record Searches for Immunization history Requests immunization record from registry Populates new Immunization data Administers shots Orders immunization Hx and PE; reviews Px record and recommendations Unique patient identifier: Query Unique patient identifier, Immunization record: Send Accepts/Updates new Immunization information to patient record Prints updated Immunization record for patient Updates immunization Information in EMR Unique patient identifier, Update immunization record: Send

PatientState/Local RegistryClinic EMRPhysicianRN Prepares pt record for review Initiates immunization record retrieval No immunization record Populates immunization data in patient record; displays recommendation Sends immunization history and Recommendations (using decision support engine) to Clinic EMR Searches for Immunization history Requests immunization record from registry Populates new Immunization data Administers shots Orders immunization Hx and PE; reviews Px record and recommendations Unique patient identifier: Query Unique patient identifier, Immunization record, Recommendations: Send Accepts/Updates new Immunization information to patient record Prints updated Immunization record for patient Updates immunization Information in EMR Unique patient identifier, Update immunization record: Send Alternate Flow 1

PatientState/Local RegistryClinic EMRPhysicianRN Prepares pt record for review Initiates immunization record retrieval No immunization record Generates recommendations using decision support Sends immunization history to Clinic EMR Populates immunization data in patient record Searches for Immunization history Requests immunization record from registry Withholds immunization Hx and PE; reviews Px record and recommendations Unique patient identifier: Query Unique patient identifier, Immunization record: Send Patient waits for next shot schedule Prints updated Immunization record for patient Alternate Flow 2

Lessons learned Significant domain expert involvement Considerable iterations Constant communication during the build Balance between level of detail and granularity vs. degree of consensus vs. work effort Requires a standardized building approach

Updates 1 st Immunization Storyboard deliverable HL7 Immunization project – Scott Robertson Part of submitted IZ projects HL7 Version 3 Standard Previously included in the Care Provision domain for May ballot; for information only 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)

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

Next Steps Scope of future project (focus on Immunization) Breadth – requires more domain expertise Depth – requires more technical expertise (i.e., informatics, engineers, developers, etc.) Pediatric focus? PeDS SIG resources Clinicians Registry experts Public health Informaticians Vendors? International?

Examples of Breadth Information System and Registry communication Hospital Military Health systems (i.e., Indian Health Service) School health systems RHIO Surveillance system Registry to Registry communication (high level) HL7 Continuity of Care Document Harmonization of CCR and CDA Immunization section Others?

Examples of Depth 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 Process map for 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 Divide and conquer Breadth? Depth? Engage with HL7 IZ project Follow-up Patient Care TC Follow-up leading to message definitions Pursue evidence of tangible impact/contribution within HL7 development process Begin project documentation (storyboarding process) Publish Guidebook

Process documentation for the storyboarding activities Storyboarding How to choose topic Priorities How to choose domain experts How to update versions (group editing process/procedure) How to add granularity Activity Diagram Glossary build