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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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.

12. 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.

13. 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

14. 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.

15. 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.

16. 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.

17. 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)

18. 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

19. Contact Information
Janet L. Balog, RN, BS
Scientific Technologies Corporation
Sr. Public Health Specialist
Richard Bradley
Arizona Department of Health Services
ASIIS