1. February 22, 2011 Interoperability and Public Health CDC Efforts to Move Public Health IT Interoperability Towards Meaningful Implementation

2. Background CDC is a unique federal government structure with the purpose of protecting the Nations health and equity. CDC also plays a vital role in “Collaborating to create the expertise, information, and tools that people and communities need to protect their health – through health promotion, prevention of disease, injury and disability, and preparedness for new health threats.” (http://www.cdc.gov/about/organization/mission.htm)http://www.cdc.gov/about/organization/mission.htm In 2010 CDC continued improvement of informatics initiatives and services that were consistent with the CDC’s Vision for the 21 st Century: “Health Protection…Health Equity”. Many of CDC’s activities rely on collaboration between public health and the healthcare community, especially in the areas of: Health monitoring; Detection and investigation of health problems; Conduction of research; and Development and implementation of health policies and prevention strategies.

3. In 2010 the National Center for Public Health Informatics (NCPHI) was reorganized into the new Office of Surveillance, Epidemiology and Laboratory Services (OSELS) that includes the Public Health Informatics and Technology Program Office (PHITPO). The PHITPO focus areas include: 1.Helping public health programs benefit from major changes in health informatics created by the HITECH Act. 2.Exploring the use of electronic health records, electronic personal health records and health information exchange for prevention and public health. 3.Increasing workforce competence in public health informatics through training, technical assistance and conferences. 4.Improving interoperability and reducing cost of public health information systems through shared planning, standards, policies and services (like messaging and directory systems). 5.Focusing public health informatics funding, design and acquisition practices on users and their public health objectives 6.Applied research and evaluation of public health information technologies. Background (cont.)

4. 2010 CDC Informatics Initiatives 1.EHR Meaningful Use Advisory Group This advisory body of CDC leaders is providing strategic planning to advance the exchange of information from EHRs to include syndromic surveillance, immunization registries, and electronic laboratory reporting between laboratories and the health departments. 2.CSTE and CDC Joint Electronic Laboratory Reporting (ELR) Taskforce This Taskforce was established to work on the following tasks: Building on work with large national labs to ensure full implementation of ELR; Working effectively with LIMS and EHR vendors to support the adoption and use of interoperable standards-based systems; Addressing legal and policy issues at state and local levels; Using effective means to ensure ELR implementation (e.g., resources through CDC cooperative agreements, shaping guidance, providing technical assistance, monitoring progress); Identifying additional resources, as needed, for national ELR implementation; and Identifying and addressing unresolved issues regarding standards (e.g., message structure, content, vocabulary) and architecture. 3.Release of Several Key Data Requirements and Guides HL7 Version 2.5.1: Implementation Guide for Immunization Messaging, Release 1.1. Core EHR Data Requirements for Syndromic Surveillance, Preliminary Recommendations

5. Electronic Health Record (EHR) and Vital Record (VR) Systems Information Exchange  The National Vital Statistics System provides essential data on births and deaths within the U.S.  Current birth and death registration processes are characterized by:  Higher expectations of data quality and timeliness by stakeholders and the public;  Separate, costly reengineering projects in various jurisdictions;  Limited integration among internal vital records systems and with other stakeholder systems;  A need for a standards-based, uniform, and systematic approach to collecting and exchanging data from vital records.

6. CDC/NCHS Vital Records Standards Initiatives  Health Level Seven (HL7) Vital Records Domain Analysis Model (VR DAM)  identifies and describes the activities and data required for processing birth, death and fetal death records in compliance with the U.S. Standard Certificates of Birth and Death, and the U.S. Standard Report of Fetal Death  HL7 Electronic Health Record System (EHR-S) Vital Records Functional Profile (VRFP)  defines the functional requirements needed to capture vital records data at the point of contact or care with a patient

7. CDC/NCHS Vital Records Standards Initiatives (cont.)  Healthcare Information Technology Standards Panel (HITSP) C-170 Vital Records Pre-populate Component Document specified data sets that may be pre-populated from an EHR to a VR system  Integrating the Healthcare Enterprise (IHE) Maternal Child Health (MCH) Profile aligned the HITSP C170 Component document with the IHE MCH Profile provides a technical framework for developing interoperable systems that will support transmitting EHR systems data to VR systems

8. CDC/NCHS Vital Records Standards Initiatives (cont.)  Future activities to support VR Standards will:  Focus on identifying required VR data exchanges and the potential for developing technical messaging and document requirements to support vital registration  Include state pilot tests to determine interoperability between EHR and Vital Records Systems based on FY 2011 funding

9. National Program of Cancer Registries Almost two million cancers are diagnosed each year in the United States. Cancer surveillance serves as the “foundation for a national comprehensive strategy to reduce illness and death from cancer. Such surveillance is the indispensable tool that enables public health professionals at all levels to better understand and tackle the cancer burden while advancing clinical, epidemiologic, and health services research”. UICC: International Union against Cancer There are 241 cancer surveillance systems (registries) on 6 continents participating in the International Association of Cancer Registries (part of the World Health Organization).

10. Time Period Number of New Registries 19302 19402 19606 197014 198014 1990- 1995 5 1996- 2000 8 2001+2 From: NAACCR CINA: 2001-2005 The US requires reporting of cancer to the national cancer programs

11. Standards and Systems Used IHE Retrieve Form for Data Capture (RFD) IHE Shared Value Set (SVS) IHE Audit Trail and Node Authentication (ATNA) IHE Cross Enterprise Document Sharing (XDS) HITSP C76: Case Report Pre-populate Component HITSP TP50: Retrieve Form for Data Capture Transaction Package HITSP T66: Retrieve Value Set Transaction Supporting Infrastructure Form Filler, Forms Manager, Form Archiver, Form Receiver, Security

12. IHE Profiles for Cancer Reporting from EHRs to Public Health Anatomic Pathology Reporting to Public Health – Cancer Registry (ARPH) – Demonstrate standardized collection and transmission – Demonstrate methods to electronically receive and process reports – Identify data elements to be reported from the pathology laboratory – Use existing terminology, data elements, and secure data exchange standards Physician Reporting to a Public Health Repository – Cancer Registry (PRPH-Ca) – Demonstrate mechanism to identify cancer cases – Identify data elements to be reported from the EMR – Demonstrate use of standards vocabulary from PHINVADS (IHE SVS) – Use existing terminology, data elements, and secure data exchange standards

13. Clinic/Physician Office (CPO) Infrastructure State Public Health Agency Public Health Cancer Registry System Public Health Cancer Reporting Solutions Anatomic Pathology Laboratory IHE ARPH IHE RFD, PRPH-Ca IHE RFD, SVS IHE ARPH Decision Support Tool Pathology Report indicates patient has cancer IHE PRPH-Ca (RFD) Patient presents with symptoms and cancer is diagnosed CPO transmits patient data to Public Health Cancer Registry IHE PRPH-Ca (XDS)

14. Immunization: Meaningful Use Final Rule Final rule specifies use of either V2.3.1 IG or V2.5.1 IG CDC recommends use of V2.5.1 IG – More tightly constrained – Improved clarity and query capabilities IIS is eager and ready to move to V2.5.1

15. Immunization: Interoperability CDC is providing support to the IIS community – ARRA-HITECH grants were awarded to 20 states and municipalities to enhance the interoperability of EHR- IIS data exchange – Expert panels will be established, focusing on transport, de-duplication, and support of HL7 2.5.1 IG – Expert panel will be formed to plan, draft, and finalize Clinical Decision Support standards

16. Electronic Health Record Systems (EHR-S) and Early Hearing Detection and Intervention Information System (EHDI-IS) : Improving Population and Public Health  Newborn hearing screening captures most of the entire newborn population, providing one of the first meaningful interoperability opportunities in an individual’s healthcare lifespan  Provides an opportunity to establish bi-directional information exchange between clinical care and public health in a relatively simple and feasible way

17. EHDI Scenarios  Support Patient Care Device (PCD) result transmission to EHR-S and/or Public Health  Include an Early Hearing Care Plan (EHCP) in support of Clinical Decision Support  Reduce provider burden with standardized electronic EHDI Quality Measures for both inpatient and ambulatory point of care settings

18. Courtesy of OZ Systems

19. EHDI Project Partners  Public Health Data Standards Consortium (PHDSC)  OZ Systems The Consortium (www.phdsc.org) is a not-for- profit membership-based organization of federal, state and local agencies, professional associations, academia, health IT vendors and individuals that collectively represent the interests of public health in the health IT standardization. OZ Systems (www.oz-systems.com) creates innovative technological solutions and services so that public health and education providers can make good decisions for children.

20. PHIN VADS  In 2004, CDC developed a web-based enterprise vocabulary system called the Public Health Information Network Vocabulary Access and Distribution System (PHIN VADS) for accessing, searching, and distributing HL7 messaging value sets used within the PHIN and NHIN.PHIN VADS  Hosts multiple versions of value sets that allow implementers to have access to the current, past and the future versions of value sets and value set collections.  Provides web services (API) that allows HL7 interface engines, medical and public health applications to obtain the value sets as well as validate the vocabulary present in HL7 messages.  PHIN VADS can be accessed at a public web site - http://phinvads.cdc.gov http://phinvads.cdc.gov

21. PHIN VADS Content  Currently, PHIN VADS has 750 value sets supporting 60 HL7 and CDA message implementation guides related to public health such as Case Notification, Electronic Lab Reporting, Immunization and Syndromic Surveillance.  PHIN VADS content standards are based upon White house E-Gov Consolidated Health Informatics Initiative, HITSP C80 and ONC Meaningful Use.  PHIN VADS vocabulary hyperlinks for Meaningful Use : a)MU Stage 1- Immunization HL7 2.5.1 IG VocabularyImmunization HL7 2.5.1 IG Vocabulary b)MU Stage 1- ELR HL7 2.5.1 IG VocabularyELR HL7 2.5.1 IG Vocabulary c)MU Stage 1 – Syndromic SurveillanceSyndromic Surveillance  PHIN VADS hyperlinks for IHE Quality Research Public Health (QRPH) profile: a)IHE MCH - Vital Records requirements for Birth & Fetal Death ReportingIHE MCH - Vital Records requirements for Birth & Fetal Death Reporting b)IHE EHDI: Screening, Short-Term Care, and Clinical Surveillance for Hearing LossIHE EHDI: Screening, Short-Term Care, and Clinical Surveillance for Hearing Loss c)IHE Physician Reporting to a Public Health Repository - Cancer Registry(PRPH-Ca)IHE Physician Reporting to a Public Health Repository - Cancer Registry(PRPH-Ca)

22. PHIN VADS can be accessed using one of the following methods: 1)PHIN VADS Web Browser. 2)PHIN VADS Web Service – System to System exchange of vocabulary data. 3)PHIN VADS Lite – Local instance of VADS web services and database PHIN VADS vocabulary can also be authored and maintained by the owners using the web based value set authoring tool “Universal Authoring Framework (UAF)”. PHIN VADS Content Access

23. PHIN VADS Web Services: System-to-System Exchange of vocabulary data PHIN VADS web services are public and built upon open standards such as HL7 Common Terminology Services (CTS) and IHE Sharing Value Sets Specification (IHE SVS). Sample code and a detailed API are available in the PHIN VADS Developer’s Toolkit -http://phinvads.cdc.gov/vads/developersGuide.actionhttp://phinvads.cdc.gov/vads/developersGuide.action

24. For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.atsdr.cdc.gov Thank you Contacts: CDC Standards & Interoperability Contact, Nikolay Lipskiy, NLipskiy@cdc.gov Cancer Reporting: Sandy Thames, SThames@cdc.gov Public Health Alerting: Nedra Garrett, NGarrett@cdc.gov NCHS: Missy Jamison, MJamison@cdc.gov PHIN VADS: Michael Pray (Northrop Grumman), MPray@cdc.govMPray@cdc.gov Email: phinvs@cdc.govphinvs@cdc.gov Online Forum: http://www.phconnect.org/group/phinvadshttp://www.phconnect.org/group/phinvads The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the views of the Centers for Disease Control and Prevention