1. Meaningful Use and Bi-directional Exchange of Immunization Data in New York City
Kristen Forney, MPH Citywide Immunization Registry
New York City Department of Health and Mental Hygiene
Public Health Informatics Conference 2014

2. Overview
Citywide Immunization Registry (CIR) Background: HL7 Data Exchange
Definitions
Interoperability Standards
Interoperability Demo
Benefits for Providers
Benefits for IIS
Supporting Data
Future Directions
Conclusion

3. CIR history
Started in 1997
Contains 70 million immunizations for 5.2 million patients
Approximately 1800 active provider sites
Reporting is mandated for patients 0-18, consent is required for reporting immunizations given to adults
Paper reporting  Online registry  Flat file
 real-time HL7

4. CIR’s HL7 Data exchange
Real-time, bi-directional exchange through a SOAP web service
No batch file option for providers
First facility began submitting data through the web service in February 2011
Currently 465 provider sites pharmacies sending HL7 data through the web service; (189 provider sites are bi-directional)

5. Definitions Real-time Bi-directional
Synchronous Transport- User submits an HL7 message, and as part of that transaction/connection to the IIS, the application waits for an acknowledgment response
Synchronous Processing- Upon receipt of an HL7 message, IIS processes the message and acknowledges the results of processing. Data is immediately accessible to users of the IIS.
Bi-directional
EHR sends an HL7 query message (VXQ or QBP) and receives a response containing patient’s immunization history, evaluation and decision support
EHR imports IIS data and stores it as structured data

6. Interoperability StandardsHL
Supported by 44 immunization registries as of Sep 2013
Well-defined standard for immunization reporting (VXU) and query/response (QBP/RSP)
SOAP Web Services
National standard recommended by CDC’s Transport Layer Expert Panel
Supported by 30 immunization registries as of Sep 2013

7. [bi-directional demo]

8. Benefits of real-time bi-directional exchange
For Providers:
Avoid double data entry (89 CIR facilities have moved from online registry to HL7 web service)
Accessibility of information (both immunization history and clinical decision support) within provider workflow
Accuracy of data within provider EHR
Data immediately available in IIS for use with school forms, other pre-completed forms
Particularly beneficial for first-time EHR implementers

9. Columbia presbyterian hospital
* P < 0.05; ** P <0.01; *** P < .001; **** P < .0001
Stockwell, et al,

10. Benefits of real-time bi-directional exchange
For an IIS:
Timeliness
Completeness of immunization information (lot number, manufacturer, expiration date, etc)
Providers have continuous interaction with the IIS

11. Improved VFC and Lot Number Capture
Improved vfc eligibility and lot number capture
Data source
Percent of immunizations with VFC status*
Percent of immunizations with lot number**
Flat File
88.1
59.0
Online Registry
93.6
45.3
HL7 Web Service
94.1
97.4
Total
90.5
68.4
*Data from all newly administered immunizations reported to the CIR during calendar year 2013 for patients < 19 years
**Data from all newly administered immunizations reported to the CIR during calendar year 2013

12. Increase in adult data capture

13. Meaningful USE and IIS
CIR built HL7 web service in 2009 Stage 1: Began January 2011; Eligible providers and hospitals must perform a test of EHRs capability to send data to an IIS in HL7 format Stage 2: Began January 2014; Eligible providers and hospitals must institute ongoing reporting to an IIS in HL format

14. increase in HL7 sites
Start of MU (Jan)

15. shift in reporting method
-Legend darker

16. Challenges of bi-directional HL7 exchange
How can we ensure that the IIS finds and returns the correct patient?
EHR should send all possible demographic information
Exchange unique IDs (Medical record number, IIS ID)
Will the EHR display IIS data correctly?
Thorough testing with the EHR vendor
Involve providers in testing
How will the EHR de-duplicate immunizations?
EHR record and IIS record must be fully synced to ensure accurate clinical decision support
Work with the vendor that goes into developing a bi-directional interface

17. Best practices for real-time bi-directional exchange
For IIS:
Webinars (or site visits) with providers to understand how their EHR works
Set up the ability to restrict queries from specific accounts
Store unique IDs sent by the EHR
Data quality monitoring; daily s
For EHRs:
Store patient’s registry ID and send in all transactions
Automatic re-query to get decision support updated
Full sync of registry record with EHR record—critical for accurate decision support

18. Future Directions- IIS Community
Advocate for MU Stage 3 to include bi-directional exchange
Reduce Variability in HL7 implementations between IIS
Find ways to partner with EHR vendors that will be mutually beneficial
Create a set of recommendations to EHR vendors for best practices

19. CONCLUSIONS
Meaningful Use has facilitated increased adoption of HL7 standards among practices reporting to CIR
Real-time, bi-directional exchange is feasible and scalable to a large number of facilities
Presents a number of benefits to both providers and IIS
IIS nationally have well-defined standards for message content and transport
Preference of EHR vendors in MU stages 1 and 2 has been for a unidirectional HL7 interface; inclusion of a bi-directional requirement in stage 3 would accelerate implementation of bi-directional interfaces

20. Director, EHR-IIS Interoperability Project
Thank you!
Amy Metroka
Vikki Papadouka
Angel Aponte
Paul Schaeffer
Contact Information
Kristen Forney
Director, EHR-IIS Interoperability Project