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Public Health Surveillance Standards Project Overview for HL7 May2006WGm Helen Stevens Love – Project Manager

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1 Public Health Surveillance Standards Project Overview for HL7 May2006WGm Helen Stevens Love – Project Manager helen.stevens@gpinformatics.com

2 2 Presentation Objectives Provide overview of the Canadian Public Health Surveillance Program Outline the objectives and deliverables of the PHS Standards Project Inform and Secure support for project objectives

3 3 Canadian Public Health Surveillance Program The Public Health Surveillance program will accelerate the implementation of health surveillance systems in each of Canadas public health jurisdictions. These systems track communicable disease cases to allow public health monitoring of the treatment patients receive, manage information related to immunization, and support the detection of suspected outbreaks as early and accurately as possible. Timely and accurate detection of individual cases and emerging outbreaks is crucial to mounting an effective response, to safeguard public health and safety. More than JUST Public Health Reporting – it is Public Health Management Strong public, political, organizational and financial support for this program!

4 4 Expected Benefits Engagement of pan-Canadian stakeholders in the definition and approval of PH Solution standards. Standards-based integration between the PH Solution components, to support the jurisdictional substitution of components when required; Standards-based integration between PH Solution and EHR components, to support: rapid deployment of PH Solution in jurisdictions in the near term; PHS/EHR interoperability in the medium to long term Standard Terminologies that will enable the exchange of discrete clinical data improving the care or patients and the epidemiological analysis of public health information Reduced barriers to deployment of PHS Solution in whole or in part for jurisdictions; Accelerated adoption of HL7 V3 standards within the PH software industry, and subsequent savings in not having to develop/maintain regional standards;

5 5 PHS Project Context Solution Development (2006) Standards Scoping (complete) Standards Development (this project) Implementation Procurement/Design (in progress) Solution Requirements Design Requirements & Architecture JSRFP Joint Solution Procurement Process Solution Selection Existing Standards Assessment Standards Inventory A/A/D Analysis Standards Phase 2 Definition Standards Selection Decision International SDO Process Review/Revise/ Resubmit Canadian SDO Process Approval SCP Solution Development Solution Design Jurisdictional Implementations Jurisdictional Implementations Jurisdictional Implementations Jurisdictional Implementations Adapt/Develop Standards Reference Implementation

6 6 Standards Project Timeline & Deliverables Phase 0/1 Start Standards Inventory Establish pCSG Phase 2 Plan Phase 0/1 Complete Phase 2 Start pCSG Kickoff Core Team recruitment Launch SDO activities Draft Requirements & Standards 09/0511/05 Final Draft Standards & Terminologies International Balloting Implementable Standards Available 1/0604/0609/0601/0711/06

7 7 Project Organizational Approach Infoway Standards Director (Julie Richards) Infoway Program Director (Tim Beasley) Infoway Project Manager (Helen Stevens) PHS pCSG PHS Standards Development Team PHS Nursing SME PHS Epidemiology SME HL7 Facilitator HL7 Modeller HL7 Designer Messaging Analyst Terminology Expert Representatives from Steering Committee PHS Work Group PHS Pan-Canadian Steering Committee PHS Working Group PHS pCSG Standards Steering Committee Standards Advisory Committee Change & Evaluation Specialist Solution Architecture Group Program Director Communication Specialist Project Coordinator / Secretariat Information Management Technology Specialist PHS Standards Support Team

8 8 PHS Development Team NameRoleE-Mail Helen Stevens LoveProject Managerhstevens@infoway.ca Lisa Zetes-ZenattaClinical SME (Epidemiologist)lisa.zetes-zanatta@bccdc.ca Aurelia PereiraClinical SME (Public Health Nurse)aupereira@sympatico.ca Michael van CampenFacilitatorMichael.vancapen@gpinformatics.co m Robert (Bob) GrantHL7 Modeller (Static Model)Robert.B.Grant@gov.bc.ca Patrick LloydHL7 Modeller supportPatrick.lloyd@gpinformatics.com Joginder MadraHL7 Designer (Publishing)Joginder.madra@gpinformatics.com Christine BesterMessaging Analyst (Dynamic Model) Christine.bester@gpinformatics.com Carol MolderTerminology Expert (Vocabulary) cmulder.infoaccess@on.aibn.com Hannah CracowerProject Coordinator / Secretariathcracower@infoway.ca Nancy StewartChange & Evaluation Specialistnstewart@infowy.ca

9 9 PHS Solution Scope The project will deliver stable HL7 V3 messaging standards to support exchange between PHS Solution Components, and between the PHS Solution and jurisdiction-specific components; and Terminologies to support integrated operation among Solution components; Functional Components: 1.Communicable Disease Case Management 2.Outbreak Management 3.Alerts Management 4.Immunization Management Service Delivery Immunization Registry 5.Inventory Management (Materials & Vaccine) 6.Work Management (Scheduling & allocation) Terminology Registry based on HL7 Common Terminology Services standards Disease Registry Jurisdictions reserve the right to substitute any of the 6 functional components using standards based messaging

10 10 Message Scope

11 11 Deliverable: Terminology Strategy Identification of key terminologies and terminology gaps based on analysis of requirements and Domain Analysis Model. HL7 V3 messaging accommodates requirement to manage semantic interoperability even when different encoding strategies are used for initially recording information. Vocabulary Domain represents the definition of the set of concepts (e.g. administrative gender) Specific coded values drawn from one or more identified coding systems are selected to represent the defined concepts (e.g. M= Male). Value Sets are used to validate message instances to ensure the intended semantics are retained by the receiving system. Public Health information topics overlap with other domains Project will work to harmonize terminologies (e.g. immunizations, allergies and adverse reactions, vaccines, and disease definitions). Domain Analysis Model (and Domain Information Model) will help identify specific data fields and the associated Vocabulary Domains As specific messages are designed, the Vocabulary Domains will be associated with specific value sets that identify which subset of codes from which coding schemes are to be used when transmitting message instances.

12 12 Deliverable: Message Flow Analysis Description of the business transactions required to support the Solution Description of the primary system functions within and communicating with the solution Identification of the transaction sets required by the solution Mapping of the flow of the transactions sets between the system functions

13 13 Message Standard Selection Priorities In order of preference: 1.Adopt Canadian HL7 3.x Standard 2.Adapt Canadian HL7 3.x Standards 3.Adopt HL7 International 3.x Standards 4.Adapt HL7 International 3.x Standards 5.Develop HL7 3.x Standards Use HL7 2.x as starting point where appropriate Only if supported already by external sender/receiver and required by the PHS Solution Design requirements: 1.Adopt non-HL7 Standard (e.g. CAP PHIN) 2.Adapt non-HL7 Standard Adopt Adapt Develop

14 14 Deliverable: HL7 Proposals Patient Administration TC: PRPA New Transaction: Population Candidate Query/Response Pharmacy SIG: POME Existing Transaction Adaptation: Drug Product Detail Query/Response Diagnostic Imaging SIG: POII New Topic: Order Management Scheduling & Logistics TC: POSC New Topic and Message Proposal: Materials and Vaccine Management Immunization Project: POIZ Existing Topic Adaptation: Immunization Administration

15 15 Deliverable: HL7 Proposals continued Patient Care TC: REPC Existing Transaction Adaptation: Adverse Event Existing Transaction Adaptation: Care Record Query/Response Existing Transaction Adaptation: Case Record Query/Response Existing Transaction Adaptation: Case Transfer Request New Topic: Care Plan Public Health and Emergency Response: PORR New Topic: Outbreak Management New Topic: Case Management Existing Transaction Adaptation: Product Defect Report New Topic: Disease Knowledge Base

16 16 PRPA: Patient Administration TC New Transaction: Population Candidate Query/Response Definition: Query to retrieve aggregate client information based on location, age group, or other parameters. This differs from the existing Find Candidates query in that the response should only contain aggregate information and not lists of candidates. Proposal: Develop a new Population Candidate query that will be similar to the existing Find Candidates Query interaction. The response to the query will be constrained to include only aggregate level information. The project is requesting that the committee consider this message for Committee Normative balloting in Sept2006 ballot cycle.

17 17 PRPA: Population Candidate Query Storyboard Eli Coli, epidemiologist, has been asked to track the immunization coverage rates in the downtown east side for Hepatitis B following an outbreak at a school in a neighbouring jurisdiction. Eli submits a query to the Client Registry to determine the number of residents in the jurisdiction within the appropriate age parameters [Population Candidate Query/Response]. She receives a response indicating that there are 400 clients that match a residential address in the area of interest and are of the appropriate age. Eli uses 400 as the denominator in her analysis and establishes that the immunization coverage shows an unacceptably low coverage rate. She recommends to Medical officer of Health that an immunization campaign be initiated in the area. Nancy Nightingale, a Public Health Nurse plans a Hepatitis B clinic for the grade five and nine students residing in the downtown east side of Anytown. Nurse Nightingale has been provided with the postal codes that are included in the downtown east side and she uses these codes to query the Jurisdictional Client Registry for all matches based on postal code and client age specifically asking for a list of the names, identifiers and ages of any matching candidates [Find Candidates Query/Response]. She receives a response listing the 400 client matches with the requested information and uses the response to trigger a series of queries to the PHS Systems immunization registry to check the immunization records of the clients and to plan the immunization campaign.

18 18 POME: Pharmacy SIG, Order/Observation TC Existing Transaction Adaptation: Drug Product Detail Query/Response Definition: Query that provides all available information about a vaccine product based on bar code or other identification key parameters. Proposal: Constrain the universal HL7 Drug Product Detail Query message for pan-Canadian use. There may be changes to the universal model pending final requirements targeted summer 2006. The project is requesting that the committee consider any changes to support the use of the message for this purpose for Committee Normative balloting in Sept2006 ballot cycle.

19 19 POME: Drug Product Detail Query Storyboard The Vaccine Identification Database System is a single source of comprehensive information on all vaccines approved for use in Canada. It is accessible real-time through existing electronic registries and via the internet and synchronized with vaccine product data stored in Health Canadas Drug Product Database During a community influenza immunization clinic, Nurse Nancy encounters an individual with a serious allergy to Neomycin. Nancy has access to two types of influenza vaccine. Using the vaccine vial bar code, she queries the Vaccine Identification Database System (VIDS) and discovers that one of the two available vaccines contains Neomycin. Based on this query, she administered the vaccine without Neomycin. [Vaccine Detail Query/Response]

20 20 POII: Diagnostic Imaging SIG, Orders/Observation TC New Topic: Order Management Description: Develop the POII Domain with an Order Management Topic consisting of a DI Candidate and Detail Query/Response and DI Order Request message sets. The messages will be developed based on the common order and observation patterns established by HL7 and will be appropriately constrained to the DI business requirements. This proposal includes providing the resources necessary to define the new domain for Diagnostic Imaging including managing the publication process in support of the committees objectives. Committee assistance is requested in contacting other projects doing similar development work so that we can explore opportunities for joint development of new specifications The project is requesting that the committee consider this topic for Committee Normative balloting in Sept2006 ballot cycle.

21 21 POII: Order Management Topic Storyboard Neville Nuclear, has a history of TB; yesterday he was admitted to hospital with a number of symptoms, including a cough and bloody sputum. During his infectious period, he remained at home with his wife. Mrs. Nuclear is records as a case contact on the Public Health Solution (PHS) and appropriate laboratory testing is ordered. Sputum results show that she is also positive for TB disease. During the initial assessment, Mrs. Nuclear states that she has previously undergone chest x-rays, to rule out pneumonia. Nurse Nightingale submits a query to the Diagnostic Imaging system to identify any chest x-rays that are on file for Mrs. Nuclear and taken within the past ten years. The response includes a list of seven previous chest x-rays that were performed over the past ten years, the most recent being two years ago [Diagnostic Imaging Candidate Query/Response]. Nurse Nightingale submits a second query for the details, including the images and radiologist report for the most recently performed chest x-ray [Diagnostic Imaging Detail Query/Response]. The 2-year-old chest x-ray showed no signs of damage from TB. Nurse Nightingale decides that Mrs. Nuclear will require another chest x-ray, to determine if the TB has now affected her lungs. A request is made to the diagnostic imaging services. [Diagnostic Imaging Order Request] A few days after her chest x-ray, Nightingale receives a telephone notification that the Order Request is complete. She then queries for diagnostic imaging system for the results. The system responds by providing the images and radiologist reports related to the chest x-ray order [Diagnostic Imaging Detail Query/Response].

22 22 POSC: Scheduling/Logistics TC New Topic and Message Proposal: Materials and Vaccine Management Description: Messaging to support the management of Materials and Vaccine Inventory. Proposal: Develop all new messages and associated artefacts under the topic of Materials and Vaccine Management. Project will assign the appropriate resources to assist in this work item. The project is requesting that the committee consider this topic for Committee Normative balloting in Sept2006 ballot cycle.

23 23 POSC: Materials and Vaccine Management Storyboard An outbreak of Influenza has just been reported in an adjacent town, creating an increased demand for flu vaccine within that region. Using the PHS Inventory system the Jurisdictional Pharmacy (JDP) is able to review regional public health influenza vaccine inventory levels [Materials and Vaccine Availability Query/Response]. The JDP requests that Sally ship a 3rd of the most recently received influenza vaccine shipment to the region experiencing the Influenza outbreak. The JDP advises that it will attempt to replace this diverted amount, once new flu vaccine shipments arrive from the manufacturer [Materials/Vaccine Inventory Transfer Request]. The public health unit runs annual community flu clinics, these clinics have historically immunized approx. 25,000 people. In preparation for a large clinic, Sally checks her local inventory levels and determines that she will require additional supplies. She submits a reservation request for the required amounts of vaccine and the corresponding supplies (i.e. syringes, alcohol swabs) to the JDP. The JDP responds that the reservation has been accepted and the supplies held so they will not be sent to other health units [Materials and Vaccine Reservation Request]. Once Sally has confirmed the logistics for the flu clinic and has arranged for appropriate local storage facilities – she submits a request to the JDP to ship the reserved supplies [Materials and Vaccine Allocation Request].

24 24 POSC: Materials and Vaccine Management Storyboard Sally encounters even more problems. Vaccine inventories must be maintained between 2ºC-8ºC in order to remain viable. Anytown has just experienced a lengthy power outage, affecting virtually every vaccine holding fridge in the region. Unfortunately some of the spoilt vaccines were subsequently shipped to family practice clinics. Sally was the first to notice the cold chain failure(s). She sends an Alert to the jurisdictional pharmacy, forewarning that other regions may potentially be affected [Alert Notification]. An alert is also sent to all the healthcare providers who may have received the spoilt vaccines. Health care providers are required to return all unusable vaccines to public health for removal from inventory. Upon receipt of the spoilt vaccine returns, Sally scans the returned vials. PHS captures the name of the site returning the vaccine, the product information and number of doses being returned and updates the JDP for them to adjust their inventory levels and reissue vaccines [Vaccine Inventory Update Request]. The JDP receives a notification from the Vaccine supplier that a contamination occurred in the manufacture of the the Hepatitis B vaccine that was recently shipped to the JDP. The JDP has distributed some of the vaccine to the Public Health units and issues a notification to the health units to remove the vaccine from inventory and return it to the JDP [Immunization Vaccine Recall Notification]

25 25 POIZ: Immunization Project Existing Topic Adaptation: Immunization Administration Description: Develop messaging to support the management of immunization events. Proposal: In addition to constraining the universal HL7 Immunization Administration topic messages ; the project proposes to add a transaction to support population queries and more narrowly define some queries. The project is requesting that the committee consider this topic for Committee Normative balloting in Sept2006 ballot cycle.

26 26 POIZ: Immunization Management Storyboard Nurse Nightingale works at an immunization clinic. The following activities occur during the course of a typical day. Martha Mum and her child have just moved from another town. Mum has no record of her childs immunizations. Nurse Nightingale queries the Immunization Registry and returns the childs immunization history, as was recorded by previous health units and/or health care providers [Immunization Record Detail Query/Response]. She reviews the childs immunization history and determines that additional immunizations are required, in order to make the child compliant with the current jurisdictional immunization schedule. She administers the required immunizations making a record in the immunization Management system and a message is sent to the Immunization Registry to record the immunization details [Immunization Event Record Request]. Neville Nuclear is planning a trip to Africa and would like to get a vaccination record listing the details of his Hepatitis A vaccination that he had six months ago at the public health travel clinic. Nightingale queries the Immunization Registry for the specific vaccination and date to retrieve the details of the vaccination event and prints a travel vaccination report for Mr. Nuclear. [Immunization Event Detail Query/Response]

27 27 POIZ: Immunization Management Storyboard Cont. Nurse Nightingale receives an alert of a hepatitis B outbreak within her jurisdiction. She runs a query of the Immunization Registry to identify individuals who are not fully immunized against hepatitis B. The registry responds with a list of all eligible immunization candidates, who live within her jurisdiction [Immunization Candidate Query/Response]. Nurse Nightingale follows up with the immunization candidates and where appropriate administers the vaccinations, making a record in the immunization Management system, and a message is sent to the Immunization Registry to record the immunization details [Immunization Event Record Request]. Some individuals have chosen to receive the hepatitis B vaccine through their family doctor. Physicians record these immunizations using various forms of software. There is a policy that requires doctors to report the immunization information via message from their clinical management system to the PHS. [Immunization Event Record Request] Nurse Nightingale queries the Public Health Solution to determine where each individual received the vaccine. The response indicates that all three individuals were immunized at the same physician office. [Immunization Event Detail Query/Response]

28 Patient Care Technical Committee REPC Domain

29 29 REPC: Patient Care Technical Committee The project is requesting the development of the following new Topic area as well as the adaptation of an existing message to meet a new requirement: Existing Transaction Adaptation: Adverse Event Existing Transaction Adaptation: Care Record Query/Response Existing Transaction Adaptation: Case Record Query/Response Existing Transaction Adaptation: Case Transfer Request New Topic: Care Plan

30 30 REPC: Patient Care TC The project is requesting the committees approval for the adaptation of the existing committee content to meet the requirements of the pan- Canadian Public Health Surveillance project and the development of a new Topic based on existing domain content for Care Plan: Existing Transaction(s) Adaptation: Adverse Event Existing Transaction(s) Adaptation: Care Record Existing Transaction Adaptation: Case Existing Transaction Adaptation: Care Transfer Request to Case Transfer Request New Topic: Care Plan

31 31 REPC: Adverse Event The Project has a requirement to request the recording of an adverse event in an immunization management system. The project proposes to adapt the Record Adverse Reaction Request (REPC_IN000004UV) and associated messages The Project has a requirement to report an adverse event following an immunization administration. The project proposes to adapt the Reportable Adverse Reaction Notification (REPC_IN000037UV) The Project has a requirement to message case update data following notification of an Immunization Adverse Event. The project proposes to adapt the existing HL7 Update adverse reaction notification (REPC_IN000007UV) Adaptations will be done to reflect pan-Canadian requirements but will be generalized to apply internationally. Project requests that Adverse Event transactions be organized together in a topic and be harmonized with relevant models in other committees Project requests committee consider submitting for committee balloting in Sept 2006 ballot cycle. Currently all three messages are in Draft ballot

32 32 REPC: Adverse Event Storyboard Dr. Seven reports a VAAE to the Immunization Registry at his local public health authority. The information recorded includes; allergies, demographic information, vaccine name, lot number, manufacturer, expiry date, time vaccine was administered, complete description of symptoms, time of symptom onset, duration of symptoms, correlative/causative factors and patient outcome [Immunization Adverse Event Request]. Nurse Nightingale at the public health authority initiates the VAAE investigative process. Nurse Nightingale submits her findings to the Medical Officer of Health (MOH), for review. Investigative findings and MOH recommendations are later entered as notes in the patient's record. A notification is sent to the Vaccine Surveillance database at the national Public Health Agency (PHA). [Immunization Adverse Event Notification]

33 33 REPC: Adverse Event Storyboard Continued Within PHA, a multidisciplinary advisory group assists with the evaluation of all cases. The specific mandate of this group is to review, in a systematic fashion, all serious VAAE reports. They review the case submitted by Nurse Nightingale. The advisory group queries their Vaccine Surveillance database and discovers that six other people, located throughout the province, had similar VAAE experiences during the past two weeks. They also discover that four of these six cases had recorded allergies to latex. The advisory group contacts the manufacturer and learns that the manufacturer has recently changed production facilities. The new vaccine vial stopper contains a small amount of latex. Some health care providers had failed to notice this change. A national alert is sent from PHA to all public health units, requesting that staff use only the single dose (latex free) syringes, instead of vials, when immunizing individuals with a potential latex allergy [Alert Notification]. PHA forwards all VAAE reports to the federal Depart of Health, for compilation at the national level. After PHA reviews and evaluates these cases, all textual comments from the notes field are translated into a standard coding scheme. PHA sends a message to Nurse Nightingale containing the re-coded data from her original VAAE report. [Immunization Adverse Event Update] This information is incorporated into the patient record in the health authorities tracking system.

34 34 REPC: Care Record The Project has a requirement to support case queries against an EHR based on symptomology, results or diagnosis etc. The project proposes to adapt the Find Care Record Candidate Query/Response messages (QUPC_IN041100UV & QUPC_IN041200UV) The Project has a requirement to retrieve detailed care records from an EHR. The project proposes to adapt the Get Care Record Query/Response messages (QUPC_IN040100UV & QUPC_IN040200UV). The project does not anticipate significant changes to these transactions for pan-Canadian use in this context; however wider search capabilities to support of case/care records than is currently supported in the message definition may be necessary. Project is requesting committee concurrence with the use of the transactions and support in developing additional documentation and resolving any issues that may arise in their implementation. Currently all three messages are in DSTU.

35 35 REPC: Care Record Storyboard Public Health receives a report of Legionnaire's disease. Nurse Nightingale, a public health nurse, queries the Jurisdictional EHR for anyone showing signs or symptoms of the disease. She identifies two recent hospital admissions with fever, abdominal pain, and other highly-correlated symptoms. [Find Care Record Candidate Query/Response] Public health case investigators submit additional queries for detailed information on the identified cases [Get Care Record Detail Query/Response]. Mr. Nuclear, one of the potential smallpox cases, has become unresponsive; no family/friends are available to provide a medical history. The public Health investigator and health care providers submit a query to the EHR to obtain Mr. Nuclears medical history. It is discovered that Mr. Nuclear has a number of co-existing medical conditions, making him even more susceptible to the smallpox virus. This information is used to determine the appropriate use of trial antiviral medications and/or antibiotics. [Get Care Record Detail Query/Response] Public Health in Anytown has had three more reported cases of e-coli, queries the EHR and identifies an additional two recent hospital admissions with similar symptoms [Find Care Record Candidate Query/Response]. Public health case investigators are sent to the hospital to initiate contact tracing procedures. An alert is sent to all health care providers, outlining new monitoring, reporting and treatment guidelines.

36 36 REPC: Existing Message Adaptation: Case Record Query/Response The Project has a requirement for a query against a public health case management system to identify cases based upon a variety of criteria. The project proposes to adapt the Find Care Record Candidate Query/Response messages (QUPC_IN041100UV & QUPC_IN041200UV) The Project has a requirement to develop a query for detailed case information available from a Public Health case management system. The project proposes to adapt the Get Care Record Query/Response messages (QUPC_IN040100UV & QUPC_IN040200UV). The project is seeking committee agreement that the same interactions are appropriate for use against two different target systems: an EHR external to Public Health application (previous use case) and against a Public Health case management system (this use case). The project does not anticipate significant changes to these transactions for pan- Canadian use in this context; however wider search capabilities to support of case records than is currently supported in the message definition may be necessary. Project is requesting committee concurrence with the use of the transactions and support in their adaptation for use with Case vs Care Record. Currently all three messages are in DSTU.

37 37 REPC: Case Management Storyboard Annie Nuclear has just been admitted to Greenville hospital as a suspected meningococcal meningitis (MM) case. Dr. Admit issues an investigation request to the local public health unit [PORR: Investigation Request]. Nurse Nightingale begins case management activities, which include managing the case (client), managing the case contacts, identifying exposure settings and supply ordering. Nurse Nightingale sends a message to Greenville hospital to issue isolation and treatment protocols [Care Plan Request]. Laboratory confirmation of MM has just been received. Annies case is updated in the Public Health case management system from a suspect case to a confirmed case of MM. Nightingale queries the Jurisdictional public health case management system, and determines that two days previously, Blueville health unit also had a confirmed MM case, involving a university aged individual [Case Candidate Query/Response]. Nightingale submits a detailed query to retrieve details of the case, including exposures and contacts to determine if there is a link to Annies case [Case Detail Query/Response].

38 38 REPC: Case Management Storyboard Continued Nightingale learns that Annie plays on her universitys soccer team and often shares a water bottle with her teammates. Nightingale lists the university as a potential exposure setting. The names of all students on Annies soccer team (who drank from the same bottle) are recorded on the PHS as case contacts on Annies case. Annie informs Nightingale, that she had shared the teams water bottle with Joanna, a member of the opposing team from Blueville. Nurse Nightingale adds Joanna's contact information to Annies case and sends a message to Bluevilles health unit with Annies case information, including her updated contact list [Case Update Notification]. Bluevilles health unit adds this exposure setting to their confirmed MM case, adding Joanna as a suspected contact. Nightingale queries Bellevilles MM case, she learns that the laboratory results show a similar serotype. She performs a query to determine how many of Bluevilles case contacts went on to become symptomatic. [Case Detail Query/Response] Annie Nuclear is being discharged from hospital. A message is sent to Greenville public health unit, informing Nightingale of the discharge date and requesting that the Greenville Public Health Unit assume management of Annies case [Case Transfer Request]. Greenville Public Health accepts the case transfer request and assumes primary responsibility for Annies case management.

39 39 REPC: Existing transaction Adaptation: Care/Case Transfer Request The Project has a requirement to support the transfer of details of a specific public health case, including all relevant case information, exposures and contacts. The project is proposing to adapt the Care Transfer Request (REPC_IN002120) message (and variants) to support additional interactions (abort) as well as extend the static model to support exposures and case contacts. Project is requesting committee concurrence with the use of the transactions and support in their adaptation to support Case requirements. Currently all three messages are in DSTU.

40 40 REPC: Case Transfer Storyboard Neville Nuclear has an active case of TB which is being managed by Nurse Nightingale in Public Health Region East. Neville will be moving to a neighbouring town in Pubic Health Region North next month. It is public health policy to transfer active cases of TB when a patient moves to another jurisdiction. Nurse Nightingale sends a case transfer request message including all of Neville Nuclear's case, exposure and contact information to Pubic Health Region North. This effectively transfers ownership of the case to the new jurisdiction [Case Transfer Request]. Public Health Region North responds, indicating that they will assume responsibility for Neville's case.

41 41 REPC: New Topic - Care Plan The Canadian Public Health Surveillance has a requirement for messages to support exchange of care plan information between public health and other care providers. The project is proposing to develop new messages for use in Canada and for submission to HL7 for inclusion in the REPC domain. The topic will contain the following transactions: Care Plan Request Care Plan Notification

42 42 REPC: Care Plan Storyboard Mr. Neville Nuclear immigrated to Canada twelve months ago. Based on pre- immigration medical examinations, he was diagnosed with a latent TB infection. Upon arrival, he complied with immigration rules by reporting to Nurse Nightingale at his local public health unit. Neville identifies Doctor Seven as his family doctor and tells Nancy at his next check-up visit. Nancy sends a notification to Doctor Seven, indicating that Neville is currently under medical surveillance by Public Health and includes relevant information regarding the medical surveillance requirements and treatment protocols being applied to Nevilles case along with results from recent client encounters. [Care Plan Notification] […content cut…] Nightingale visits Neville in the hospital and initiates contact tracing procedures. During his infectious period, he remained at home with his wife. Nancy records the wife as a case contact on the Public Health Solution. A referral is made to the wifes family physician, informing him of this recent exposure. Using Public Health protocols, Nancy sends the physician a list of assessment, treatment and reporting requirements for the wife. [Care Plan Request]

43 Public Health & Emergency Response SIG PORR Domain

44 44 PORR: Public Health & Emergency Response The project is requesting the development of the following three new Topic areas as well as the adaptation of an existing message to meet a new requirement. New Topic: Outbreak Management New Topic: Case Management Existing Transaction Adaptation: Product Defect Report New Topic: Disease Knowledge Base

45 45 PORR: Outbreak Management Storyboard Neville Nuclear has just returned from a trip to Anytown. He arrives in the emergency room with an acute case of stomach upset, vomiting and diarrhoea of a very dark color potentially indicating bleeding Lab specimens are taken and submitted for testing. In the mean time, the doctor suspects a diagnosis of E.coli. The Doctor submits a nation wide query to the Public Health Surveillance system, to determine if an E.coli outbreak has been identified. A response is received from the Public Health Surveillance system with aggregate data indicating three confirmed cases of E.coli in Anytown. [Outbreak Candidate Query/Response] Based on these findings, the doctor reports Mr. Nuclear as a suspect case to Public Health along with a request for further investigation by the local public health unit [Investigation Request]. Both his care providers and the public health investigators initiate precautionary interventions, and food and water histories are taken.

46 46 PORR: Outbreak Management Storyboard continued E.coli case classifications range from confirmed, probable or suspect; Mr. Nuclears case status is upgraded to confirmed in the Outbreak Management system. A Notification of the status change is sent to appropriate care providers and systems. This update ensures that the Public Health Integrated Solution remains current and able to provide accurate real time national outbreak status reports. [Outbreak Update Notification] There are many types of E.coli. The doctor submits an outbreak detail query to the Public Health Outbreak Management system, to identify the laboratory details assigned to the current E.coli outbreak. Specifically, the doctor wants to determine if the existing outbreak case definition is for 0157. [Outbreak Detail Query/Response] Public Health in Anytown has had three more reported cases so the Public Health case investigators query the EHR and identifies an additional two recent hospital admissions with similar symptoms [Get Care Record Candidate Query/Response]. Public health case investigators are sent to the hospital to initiate contact tracing procedures. An alert is sent to all health care providers, outlining new monitoring, reporting and treatment guidelines. Mr. Nuclear has become quite ill and no family/friends are available to provide a medical history. Public Health Investigator submits a query to the EHR to obtain his medical history [EHR Detail Query/Response]. It is discovered that Mr. Nuclear has a number of co-existing medical conditions, making him even more susceptible to the E.coli virus. This information is used to determine the appropriate use of medications and/or antibiotics.

47 47 PORR : Case Management Storyboard Mr. Neville Nuclear immigrated to Canada twelve months ago. Based on pre-immigration medical examinations, he was diagnosed with a latent TB infection. Upon arrival, he complied with immigration rules by reporting to Nurse Nightingale at his local public health unit. Neville identifies Doctor Seven as his family doctor and tells Nancy at his next checkup visit. Nancy sends a notification to Doctor Seven, indicating that Neville is currently under medical surveillance by Public Health and includes relevant information regarding the medical surveillance requirements and treatment protocols being applied to Nevilles case along with results from recent client encounters. [Care Plan Notification] Neville has remained stable and under medical surveillance since his arrival to Canada. However, yesterday he was admitted to hospital with a number of symptoms, including a cough and bloody sputum. The laboratory results confirm that Neville is positive for active TB disease. Dr. Admit notifies the public health department, to initiate contact tracing activities. [Investigation Request] Laboratory tests indicating that Neville is positive for TB disease have been forwarded to Nurse Nightingale and recorded on the Public Health case management system. Nevilles case has been updated from latent TB infection to active TB disease. Nurse Nightingale receives the investigation request from Dr. Admit and queries Nevilles medical record to review previous test results and assessments. All previous test results and assessments have been stable. [Case Detail Query/Response] Nightingale needs to determine if Neville is part of a larger TB outbreak. She queries the Public Health Surveillance application for a list of all active TB cases within Anytown. The system responds by producing a list of names, including demographic information. [Case Candidate Query/Response]. No link is found between the listed active TB cases and Neville.

48 48 PORR : Case Management Storyboard #2 Annie Nuclear has just been admitted to Greenville hospital as a suspect meningococcal meningitis (MM) case. Dr. Admit issues an investigation request to the local public health unit [Investigation Request]. Nurse Nightingale begins case management activities, which include managing the case (client), managing the case contacts, identifying exposure settings and supply ordering. Nurse Nightingale sends a message to Greenville hospital to issue isolation and treatment protocols. [Care Plan Request]. Laboratory confirmation of MM has just been received. Annies case is updated in the Public Health case management system from a suspect case to a confirmed case of MM. Nightingale queries the Jurisdictional public health case management system, and determines that two days previously, Blueville health unit also had a confirmed MM case, involving a university aged individual. [Case Candidate Query/Response]. Nightingale submits a detailed query to retrieve details of the case, including exposures and contacts to determine if there is a link to Annies case [Case Detail Query/Response]. Nightingale learns that Annie plays on her universitys soccer team and often shares a water bottle with her teammates. Nightingale lists the university as a potential exposure setting. The names of all students on Annies soccer team (who drank from the same bottle) are recorded on the PHS as case contacts on Annies case. Annie informs Nightingale, that she had shared the teams water bottle with Joanna, a member of the opposing team from Blueville. Nurse Nightingale adds Joanna's contact information to Annies case and sends a message to Bluevilles health unit with Annies case information, including her updated contact list. [Case Update Notification]. Bluevilles health unit adds this exposure setting to their confirmed MM case, adding Joanna as a suspected contact.

49 49 PORR : Product Defect Report Storyboard Nurse Nightingale learns that three individuals (who were fully immunized against hepatitis B) become ill with hepatitis B disease. These disease occurrences are recorded on the Immunization Registry and a notification is sent to the the EHR and appropriate regulatory agency, indicating a vaccine failure may have occurred thus triggering an investigation [Immunization Vaccine Failure Notification].

50 50 PORR: Disease Knowledge Base Public Health is information intensive consequently specific Dictionaries, registries and/or knowledge bases will be used to support work activities and ensure access to reliable information. Disease Knowledge Base contains information regarding diseases including symptomology, treatment protocols, isolation/precaution protocols and other information relevant to disease detection and treatment. Maintained by the Public Health Surveillance government agencies and is the source of truth for information on Diseases. Accessed by Public Health workers, investigators, epidemiologists as well as healthcare providers external to public health. Updates to the Disease Knowledge Base may be issues on a regularly scheduled/managed base; however, during an outbreak situation updates to the Disease Knowledge Base are made quickly, by appropriately authorized channels, to ensure that current information is available to healthcare providers.

51 51 PORR: Disease Knowledge Base Storyboard A committee from the International Health Organization (IHO) has surveyed worldwide tuberculosis (TB) laboratories and has discovered a new and more serious form of TB. Committee members name this new illness Vast Drug-Resistant (VDR) TB. A formal definition for VDR-TB is established through the IHO. The Public Health Solution receives a notification from the IHO; this message includes the disease definition and disease characteristics. [Disease Update Notification] Across the world in Canada, patient Neville Nuclear arrives at the emergency room with a number of symptoms, including a cough with bloody sputum. Doctor Adam Admit suspects either tuberculoses (TB) or pneumonia. Doctor Admit uses the disease Knowledge Base and queries TB; a list of associated signs and symptoms is retrieved. He then queries pneumonia; another list of associated signs and symptoms is retrieved. Query results indicate a closer match to TB. He decides to pursue an investigation for TB. [Disease Detail Query/Response] The laboratory findings are reviewed; test results come back positive for TB. However, it appears that the patients specimen was resistant to both first line and second line TB medications. This outcome is highly unusual; Doctor Admit has never encountered such a case. He queries the disease Knowledge Base by recording the disease characteristics and laboratory findings [Disease Candidate Query]. He discovers that Nevilles assessment and laboratory findings are consistent with VDR-TB. Appropriate communications, treatments and interventions are initiated.

52 52 Questions / Comments Helen Stevens Love Project Manager, Health Surveillance Canada Health Infoway/Inforoute Sante du Canada 1959 Hampshire Road, Oak Bay, Victoria, B.C. V8R 5T9 Land: (250) 598-0312, Mobile: (250) 888-5824 helen.stevens@gpinformatics.com www.canadahealthinfoway.ca


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