1. Interoperability Between Electronic Health Records and Immunization Information Systems: The New York City Experience National Immunization Conference Online March 28, 2012 Amy Metroka, MSW, MPH Kristen Forney, MPH Angel Aponte Paul Schaeffer, MPA New York City Department of Health and Mental Hygiene, Bureau of Immunization, Citywide Immunization Registry

2. Overview  CIR background  New York City (NYC) Immunization Information System (IIS) interoperability technologies  Bi-directional data exchange, workflow  Electronic Health Records (EHR) retrieval and display of IIS data  Benefits - to providers, immunization program, schools, health plans  NYC progress; other states  Challenges  Next Steps

3. Citywide Immunization Registry (CIR)  Started in 1997  Contains more than 53 million immunizations for 4.3 million individuals  1,810 active pediatric provider sites  City and state law mandate reporting of immunizations for patients 18 and under (as of 2005); written consent required for 19+

4. CIR (cont.)  Interfaces with vital records, lead registry, VFC program, NYC Schools  All electronic, no paper reporting  Three options for reporting: Online Registry, batch file upload (non-standard format), or HL7 Web Service  HL7 interface is a real-time, bi-directional Web Service (no HL7 batch file option)

5. CIR Technologies  SOAP Web Service  Real-time, bi-directional messaging ; accepts multiple, parallel threads  HL7 2.3.1  HL7 2.5.1 in development - complete by 8/31/2012  Integration guide for EHR vendors, other data exchange partners (NYC public schools, health plans)

6. Bi-directional Workflow - Reporting Provider documents an immunization in the patient’s record within the EHR Upon saving of the record, EHR transmits the immunization data to the CIR in real-time The HL7 Web Service sends an acknowledgement message indicating whether or not the information was processed successfully Provider documents an immunization in the patient’s record within the EHR Upon saving of the record, EHR transmits the immunization data to the registry in real-time The HL7 Web Service sends an acknowledgement message indicating whether or not the information was processed successfully EHR automatically sends a query to the registry in order to display updated decision support

7. Bi-directional Workflow - Querying Provider opens patient record; clicks a button to query the immunization registry EHR sends HL7 query message to the registry. All possible identifiers are included in the query message Consolidated immunization record is displayed along with clinical decision support (vaccine forecast) EHR consumes and displays IIS data -- EHR displays registry immunizations, provider selects immunizations to import -OR- -- EHR automatically imports all registry immunizations, allows provider to edit/delete HL7 Web Service sends an acknowledgment with “Patient Not Found” message (2-3 seconds) Unique match No match or multiple matches

8. EHR Retrieval and Display of IIS Data

9. Display Data, Providers Select to Import

10. New Patient - Blank Record

11. New Patient - Record Imported

12. EHR Data Integration  EHRs must parse HL7 response to query, and display information to provider  Reconcile existing immunizations with IIS immunizations  Simple Process: If a shot from the IIS has the same CVX code and the same date as a shot in the existing record, consider a duplicate and do not import  Advanced Process: If a shot from the IIS has the same CVX code or is the same vaccine type and is within 10 days of a shot in the existing record, consider a duplicate and do not import

13. Benefits of Real-Time Bi-directional Data Exchange

14. Benefits for Providers  Allows providers to stay in EHR workflow  No need to switch between applications  Eliminates double data entry  Reduces potential for transcription errors  Improved patient search rate, more demographic fields used to search  Immediate access to consolidated immunization record and accurate forecast during patient visit  Reduce missed opportunities to vaccinate  Increase documented immunization coverage  Columbia Presbyterian experience

15. Columbia Presbyterian Experience * P < 0.05; ** P <0.01; *** P <.001; **** P <.0001 Stockwell, et al, 2010. http://cdc.confex.com/cdc/nic2010/recordingredirect.cgi/id/6746

16. Benefits for IIS and Programs  More timely data  More complete data- VFC eligibility, lot number, etc.  More accurate/consistent data- data in IIS and provider’s record match  Improved patient search rate

17. Improved VFC and Lot Number Capture Data source Percent of immunizations with VFC status* Percent of immunizations with lot number** Flat File82.853.8 Online Registry86.037.3 HL7 Web Service96.698.2 Total85.852.7 *Data from all newly administered immunizations reported to the CIR between Feb 1 st, 2011 and Feb 1 st, 2012 for patients < 19 years **Data from all newly administered immunizations reported to the CIR between Feb 1 st, 2011 and Feb 1 st, 2012

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19. Benefits of Real-time Querying for Schools, Health Plans  Schools – expedite student immunization data collection  Large savings in time spent on compliance activities by schools, immunization program, parents  NYC public schools used Web Service to download 1,028,934 imms for 146,112 students into own database in Fall 2011  Reduced number of schools with < 95% of students in compliance from 1024 in October 2010 to 717 in October 2011  Health Plans (currently a pilot)  Ongoing access to timely immunization data for outreach, quality measures  Eliminate time wasted on outreach based on outdated information from batch file exchange  Reduce unnecessary letters to providers, parents

20. NYC Progress  216 facilities in production (out of 1,810 pediatric facilities)  94 bi-directional  122 unidirectional– public hospital and health facilities network  Represents approximately:  25% of total immunizations reported to the CIR in Feb 2012  12% of all active pediatric facilities (216/1810)  8 different EHRs in production  2 EHR vendors in testing for bi-directional, representing approximately 250 facilities

22. Progress in Other States Using SOAP Web Services in Production StateUnidirectional Sites Bi-directional Sites Alabama5345 Colorado045 Indiana347200 Oregon10231 Wisconsin5719

23. Challenges - NYC Perspective  NY State and Regional Health Information Exchanges in incipient stages. State not currently supporting real-time, bi-directional HL7 exchange  Large number of EHR vendors to work with; many with small numbers of provider sites  Vendors have different levels of knowledge with regard to Web Services  Many EHR vendors not utilizing clinical decision support returned in response to queries

24. Challenges - Nationally  EHR perspective  Variability in implementation of HL7 standards – must build different interface for each IIS  Bi-directional not required for Meaningful Use  May charge providers additional fees  IIS Perspective  Support for real-time, bi-directional HL7 Web Services from State, local Information Technology (IT) Departments not in place  Resources  Funding to build, maintain, update Web services and bring on new providers  Technical expertise

25. Next Steps - NYC  Continue connecting new practices to the HL7 Web Service- goal of 450 by August 2012  Implement bi-directionality at sites that are currently unidirectional  Measure increases in reporting volume, timeliness, completeness, and coverage  Immunization Calculation Engine - open source clinical decision support engine with a Web Service interface

26. Next Steps - Nationally  Address EHR concerns  IIS work to implement a common, standard interface-- SOAP Web Service interface recommended by the CDC expert panel  IIS community, through a collaboration of the American Immunization Registry Association (AIRA) and Centers for Disease Control and Prevention (CDC):  Update HL7 Implementation Guide (IG) to minimize any variability in message content for unidirectional  Update HL7 IG for standard bi-directional interface  Meaningful Use Federal Policy  Stage 2 - point EHRs to HL7 IG for required, standard unidirectional interface  Stage 3 – point EHRs to HL7 IG for required, bi-directional interface

27. Next Steps (cont.)  Advocate for State, local IT departments to support SOAP Web service for real-time bi- directional data exchange  Need for additional resources for IIS and state, local IT departments  Increase and expand CDC interoperability grant funding  AIRA, CDC convene community of practice for sharing of best practices, lessons learned in implementation of bi-directional data exchange  AIRA, CDC provide expert technical assistance as needed

28. Acknowledgments  Melissa Stockwell, Columbia Presbyterian Hospital, NYC  Ben McGhee, Alabama  Diana Herrero, Colorado  Cameron Minich, Indiana  Deborah Rochat, Oregon  Thomas Maerz, Wisconsin

29. Contact Information Amy Metroka: ametroka@health.nyc.govametroka@health.nyc.gov Paul Schaeffer: pschaeff@health.nyc.govpschaeff@health.nyc.gov Angel Aponte: aaponte@health.nyc.govaaponte@health.nyc.gov Kristen Forney: kforney@health.nyc.govkforney@health.nyc.gov