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

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

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

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 + 400 pharmacies sending HL7 data through the web service; (189 provider sites are bi-directional)

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

Interoperability Standards HL7 2.5.1 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

[bi-directional demo]

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

Columbia presbyterian hospital * P < 0.05; ** P <0.01; *** P < .001; **** P < .0001 Stockwell, et al, 2010. http://cdc.confex.com/cdc/nic2010/recordingredirect.cgi/id/6746

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

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

Increase in adult data capture

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 HL7 2.5.1 format

increase in HL7 sites Start of MU (Jan)

shift in reporting method -Legend darker

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

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 e-mails 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

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

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

Director, EHR-IIS Interoperability Project Thank you! Amy Metroka Vikki Papadouka Angel Aponte Paul Schaeffer Contact Information Kristen Forney Director, EHR-IIS Interoperability Project kforney@health.nyc.gov 347-396-2578