1. To protect the health and environment of all Kansans by promoting responsible choices. Making an Electronic Interface with IIS Most Useful for All Involved: Lessons Learned about Two-Way Electronic Exchange Mike McPherson, Nichole D. Lambrecht, MSc, Sue Bowden, RN, Kristin Shore, Mike Parsons, and Susan Dickman Immunization Program Kansas Department of Health and Environment 43 rd National Immunization Conference March 31, 2009

2. To protect the health and environment of all Kansans by promoting responsible choices. Objectives Background and status of project Background and status of project Current IIS architecture Current IIS architecture Lessons learned Lessons learned Recommendations Recommendations Slide 2

3. To protect the health and environment of all Kansans by promoting responsible choices. Kansas IIS History Kansas IIS (KSWebIZ) started summer 2005. Kansas IIS (KSWebIZ) started summer 2005. Imported ~414,000 patient records from Vital Records department. Imported ~414,000 patient records from Vital Records department. Spanned 1994-2005 Spanned 1994-2005 At present we average 113 patients nightly (98% of birth cohort). At present we average 113 patients nightly (98% of birth cohort). Provider enrollment started Aug 2005 Provider enrollment started Aug 2005 First tier direct entry LHDs (42 of 105 CHDs) First tier direct entry LHDs (42 of 105 CHDs) Legacy data was extracted and then imported. Legacy data was extracted and then imported. Historically data rich source Historically data rich source Slide 3

4. To protect the health and environment of all Kansans by promoting responsible choices. HL7 System 1 - LHD Live HL7 System 1 - LHD testing HL7 System 2 – LHD Live HL7 System 2 - LHD testing Direct Entry Slide 4

5. To protect the health and environment of all Kansans by promoting responsible choices. KSWebIZ Patient Data Sources Slide 5 Statistics as of March 21 st, 2009. CreatedUpdated MMIS = Medicaid Management Information System

6. To protect the health and environment of all Kansans by promoting responsible choices. KSWebIZ Vaccine Data Sources Slide 6 Statistics as of March 21 st, 2009. CreatedUpdated MMIS = Medicaid Management Information System

7. To protect the health and environment of all Kansans by promoting responsible choices. KSWebIZ Architecture HL7 Interface HL7 Interface Capable of 2-way and 1-way HL7 communications. Capable of 2-way and 1-way HL7 communications. Bi-directional, real-time IIS. Bi-directional, real-time IIS. Focus is on 2-way – allows provider to enter data on their own system once and avoids multiple system sign-ons. Focus is on 2-way – allows provider to enter data on their own system once and avoids multiple system sign-ons. Secure messaging via SOAP or POST Secure messaging via SOAP or POST Audit all HL7 traffic Audit all HL7 traffic Direct Entry Direct Entry Web-enabled user interface over SSL. Web-enabled user interface over SSL. Vaccine inventory module Vaccine inventory module IIS IIS Training registry for direct entry training, EHR testing, pre- certification, certification phases. Training registry for direct entry training, EHR testing, pre- certification, certification phases. High Availability Environment High Availability Environment Slide 7

8. To protect the health and environment of all Kansans by promoting responsible choices. Interface Implementation Process Pre-certification (Extract) Pre-certification (Extract) Extract immunization data, run data reports, and provider cleans up reported data quality issues. Extract immunization data, run data reports, and provider cleans up reported data quality issues. Certification (Training Site) Certification (Training Site) Send all immunization data to our training registry via HL7. HL7 errors, duplicate patients, and duplicate vaccinations are addressed. Send all immunization data to our training registry via HL7. HL7 errors, duplicate patients, and duplicate vaccinations are addressed. Production (Live Site) Production (Live Site) After certification data is sent to production site and is considered “live” but continuous data quality checks are run. After certification data is sent to production site and is considered “live” but continuous data quality checks are run. Pre-certificationCertificationProduction Slide 8

9. To protect the health and environment of all Kansans by promoting responsible choices. Pre-Certification - Extract Reports look for atypical data (city, zip, county, race, …). Reports look for atypical data (city, zip, county, race, …). Understand formats for particular fields. Understand formats for particular fields. e.g. SSN (9 digits, not all 9s or 0s, or any similarity to DoB). e.g. SSN (9 digits, not all 9s or 0s, or any similarity to DoB). e.g. LN, FN (Prefixes/Suffixes in appropriate places). e.g. LN, FN (Prefixes/Suffixes in appropriate places). e.g. DoB not generic (01/01/1900). e.g. DoB not generic (01/01/1900). Issues with data entry Issues with data entry e.g. Invalid/unknown CVX and/or CPT codes. e.g. Invalid/unknown CVX and/or CPT codes. Pre-certificationCertificationProduction Slide 9

10. To protect the health and environment of all Kansans by promoting responsible choices. Certification Process – Training Site Provider sends all Immunization data to training registry via HL7. Provider sends all Immunization data to training registry via HL7. Compare provider data with existing registry data. Compare provider data with existing registry data. Look for HL7 ACK errors and duplicates. Look for HL7 ACK errors and duplicates. Share information with provider via A/D/D reports. Share information with provider via A/D/D reports. Assuring DQ upfront saves time and effort and helps conform to a standard. Assuring DQ upfront saves time and effort and helps conform to a standard. Pre-certificationCertificationProduction Slide 10

11. To protect the health and environment of all Kansans by promoting responsible choices. Production Process – Live Site Ongoing data quality checks. Ongoing data quality checks. De-centralized databases require continuous synchronization effort. De-centralized databases require continuous synchronization effort. Apply tools to deal with duplicates. Apply tools to deal with duplicates. Provide support for: Provide support for: Duplicates found by provider. Duplicates found by provider. HL7 features, bugs. HL7 features, bugs. Verification. Verification. Pre-certificationCertificationProduction Slide 11

12. To protect the health and environment of all Kansans by promoting responsible choices. Lessons Learned (LL): Overall Data Quality Immediate increase in duplicates. Immediate increase in duplicates. Vaccines and Patients Vaccines and Patients HL7 exposed mass amount from MMIS and Vital Import HL7 exposed mass amount from MMIS and Vital Import Other DQ issues: Other DQ issues: Accuracy – vaccinating at the right age. Accuracy – vaccinating at the right age. Timeliness – time between encounter and entry into the registry. Timeliness – time between encounter and entry into the registry. Completeness – all data being sent to us. Completeness – all data being sent to us. How error prone – HL7 ACK errors. How error prone – HL7 ACK errors. Slide 12

13. To protect the health and environment of all Kansans by promoting responsible choices. LL: Overall DQ Solution Enforce Pre-Certification, Certification phases. Enforce Pre-Certification, Certification phases. Urge usage of standard formats. Urge usage of standard formats. Ongoing A/D/D reports Ongoing A/D/D reports A – HL7 ACK Errors A – HL7 ACK Errors D – Duplicate Vaccine D – Duplicate Vaccine D – Duplicate Patient D – Duplicate Patient Matrices to evaluate patient & vaccine duplicates. Matrices to evaluate patient & vaccine duplicates. Manually weighted system Manually weighted system Automated scripts to remove billing (Medicaid) and Vital duplicates. Automated scripts to remove billing (Medicaid) and Vital duplicates. Slide 13

14. To protect the health and environment of all Kansans by promoting responsible choices. LL: DQ Solution… Regular review of DQ at the system and provider level. Regular review of DQ at the system and provider level. Duplicate vaccine and patient reports. Duplicate vaccine and patient reports. Provider Profile Reports. Provider Profile Reports. Accuracy Accuracy Timeliness Timeliness Completeness Completeness HL7 usage HL7 usage Business rules for HL7 – identifies ideal HL7 traffic: Business rules for HL7 – identifies ideal HL7 traffic: VXQ = VXR + VXX + QCK VXQ = VXR + VXX + QCK VXU ≤ VXQ = normal VXU ≤ VXQ = normal VXU > VXQ = batch or legacy upload VXU > VXQ = batch or legacy upload VXU > ACK{AE|AR} VXU > ACK{AE|AR} VXX:VXQ >.5 = duplicate issue? VXX:VXQ >.5 = duplicate issue? Slide 14

15. To protect the health and environment of all Kansans by promoting responsible choices.

16. LL: EMR System Functionality Update (VXU) mechanism Update (VXU) mechanism Manual - have to remember. Manual - have to remember. Automated – adds complexity. Automated – adds complexity. Error display and/or logging Error display and/or logging Immediate feedback on errors. Immediate feedback on errors. When to display? When to display? Potential to impact work flow. Potential to impact work flow. Missing data fields. Missing data fields. Some data necessary for reporting. Some data necessary for reporting. Utilization of IIS data returned. Utilization of IIS data returned. OBX and recommender ignored. OBX and recommender ignored. Slide 16

17. To protect the health and environment of all Kansans by promoting responsible choices. LL: EMR Functionality Observation VXU mechanism can create issues. VXU mechanism can create issues. Queue – inability to bypass or modify queue. Queue – inability to bypass or modify queue. Manual – backup to send unsent. Manual – backup to send unsent. Both – good to display last updated date. Both – good to display last updated date. Error Display. Error Display. Should display ACK|AR errors immediately. Should display ACK|AR errors immediately. Should log all errors for later referral. Should log all errors for later referral. Ability to match ACK error with VXU. Ability to match ACK error with VXU. Utilize OBX and Recommender data. Utilize OBX and Recommender data. Slide 17

18. To protect the health and environment of all Kansans by promoting responsible choices. LL: IIS Functionality Patient matching criteria Patient matching criteria Duplicate Vaccines only included same date same antigen check. Duplicate Vaccines only included same date same antigen check. Detect possible duplicates. Detect possible duplicates. Default date for birth dose of HepB. Default date for birth dose of HepB. EHR handling of duplicates may differ. EHR handling of duplicates may differ. Missing core data (e.g. county) Missing core data (e.g. county) Slide 18

19. To protect the health and environment of all Kansans by promoting responsible choices. LL: IIS Functionality Solution Patient Duplicates Patient Duplicates Tweaked matching algorithm to reduce duplicates. Tweaked matching algorithm to reduce duplicates. Vaccine Duplicates Vaccine Duplicates Created filter to look for 10 day window. Created filter to look for 10 day window. MMIS duplicates MMIS duplicates e.g. Hibtiter billed – ActHib administered e.g. Hibtiter billed – ActHib administered HepB – script removes default from Vital Import HepB – script removes default from Vital Import Identify core data set – taking into account long term reporting needs. Identify core data set – taking into account long term reporting needs. Slide 19

20. To protect the health and environment of all Kansans by promoting responsible choices.Recommendations Develop data quality policies and procedures Develop data quality policies and procedures Need to update as new data sources are added. Need to update as new data sources are added. Develop core set of data for long-term data use. Develop core set of data for long-term data use. Push HL7 bi-directional, real-time exchange Push HL7 bi-directional, real-time exchange Enforce bi-directional EHR exchange through CCHIT. Enforce bi-directional EHR exchange through CCHIT. Utilize Recovery/Reinvestment funding to develop bi-directional capability. Utilize Recovery/Reinvestment funding to develop bi-directional capability. Slide 20

21. To protect the health and environment of all Kansans by promoting responsible choices. Contact Information Mike McPherson KS IIS Interface Consultant Kansas Department of Health & Environment 785-296-1319 mmcpherson@kdheks.gov 785-296-1319 mmcpherson@kdheks.gov mmcpherson@kdheks.gov http://kdheks.gov/immunize/webiz.html