1. National Immunization Conference
Management of Moved or Gone Elsewhere (MOGE) and other Patient Immunization Statuses in Immunization Information Systems
National Immunization Conference
March 9th, 2006, Atlanta, GA
Good morning!
I’m excited to be hear and present a very important and new effort for Immunization information systems. I’m going to give some specific results on a operational improvement project that first examined patient status (MOGE) and is overlap with RR and coverage assessment.

2. Presentation Collaborators
Presenter: Warren Williams, MPH - Team Lead, National Immunization Program (404)
David Lyalin, PhD - Business Analyst, Northrop Grumman Co./ David Lyalin Consulting, Inc
Therese Hoyle - Michigan Childhood Immunization Coordinator, Michigan Department of Community Health
Katie Reed, MBA -Vice President, Partners In Health Systems LLC
Kim Salisbury-Keith, MBA - Development Manager, Rhode Island Department of Health
Angel Aponte, Computer Specialist, NYC Department of Health and Mental Hygiene
First a special thanks to the collaborators on this presentation.
The findings and conclusions in this report are those of the author(s) and do not necessarily represent the views of the funding agency

3. Background
The Modeling of Immunization Registry Operations Workgroup (MIROW) of American Immunization Registry Association has been formed to develop an IIS “Best Practice” guidebook for functionality.
Understand how modern business engineering techniques can be applied to analysis and development of IIS processes and standards
Define immunization statuses for a patient
Identify the impact of immunization statuses assignment on reminder-recall notifications and coverage
The Modeling of Immunization Registry Operations Workgroup (MIROW) was formed by the American Immunization Registry Association (AIRA) in partnership with Centers for Disease Control to develop a “Best Practice” guidebook for Immunization Information Systems (IIS).
This specific presentation is going to review several items.
-Provide and understanding
-Review the status definitions
-Document how the group identified the impact of status on items.

4. Background-Topic Selection
In April of 2005 AIRA conducted an assessment to get a sense what the operation topics. Results to open ended questions are often difficult to quantify but generally the trends fell into 11 “big buckets”
-Assessment conducted in April 2005
-49 responders
-More than 100 individual issues were submitted by responders
-Chart summarizes topics
-MSC considerations include:
---practical reality: such as cost, do-ability for initial go-round
-were other groups dealing with it?
-could it be scoped appropriately
So in summary the largest slices of the pie were not targeted for the first guidelines development but focusing in on MOGE/patient status we were able to chose a topic that we felt was both strategic and practical.

5. Why Patient Status is important?
As data sharing increases among IIS programs there is a need to use consistent and agreed upon terms and rules for their implementation
It affects immunization coverage assessments
Inappropriate classification of MOGE or other status may result in an inflated/deflated coverage measure
It affects reminder-recall notifications
Inactive patients may not need reminder notices
A patient immunization status is a ranking term used to describe a standing of the individual in reference to the level of immunization tracking activity at a provider or geographic jurisdiction level. Immunization status is directly related to the concept of responsibility for immunization of Patient/Individual.
Quality, Consistency, and Cost savings are some of the major reasons, this issue is important. For example, improving the integrity of data within and between the IIS is important. Additional factors include improving coverage assessment measures and cost savings by effectively targeting Reminder notifications.

6. Guidelines: Expected benefits
Encourage common practices for determining patient status
Promote consistent use of definitions and application of rules in IIS operations
Improving overall data quality and usefulness of IIS data
Serve as a technology-neutral requirements guideline for information technology projects
Foster collaboration and aid in communication among IIS professionals
Programmatic people understand how important their role is in understanding this model as it represents their process, decision points, business rules and other programmatic elements.  
These points and these documents describe technology neutral business decisions.   

7. Approach/Methods
Incremental, consensus-based recommendations development process
Two and a half days face-to-face meeting of SMEs
Extensive pre- and post- meeting work
Business Modeling / Engineering techniques
Joint Application Development facilitation techniques
Notation: UML – Unified Modeling Language
Tools: IBM-Rational Rose and Microsoft VISIO, Word processing tool-Microsoft Word

8. Methods –Pulling a guideline together
Discussing
Brainstorming
This is a visual schematic that helps to outline the steps in a business engineering strategies to bring subject mater experts to reach consensus and develop a practice guideline.
Reaching consensus

9. Results
Developed a concept that a patient status should be defined and maintained on provider and geographic jurisdiction levels
Defined patient statuses on both levels
Defined events, conditions, and business rules that lead to transition between these statuses
Developed decision tables between patient statuses and reminder/recall actions and coverage assessments
I’m going to spend the majority of the time discussing the results from the best practice guideline off the AIRA web site. However these were the highlighted results.
NOTE of issue: the group examined patient status at two different level the geographic jurisdiction level as well as the provider level. Provider level monitoring is important and routinely done at the registry and program level, however it was felt that patient status should be monitored at the geographic level, to help reduce the risk of patients falling through the cracks of immunization system

10. How to read status diagrams
BR10
BR11
BR15
BR12
BR17
BR47
BR14
BR13
BR36
BR16
Business Rule: how to assign this status
Patient Immunization Status
Business Rules: how to exit from this status
I’m going to review finding from the group and explain briefing what a status diagram is telling us
Each patient status is indicated by 3 status categories boxes A, Inactive, UNK; Several rules for going to status and rules for how to exit from the status. MOGE is a form of Inactive in the system but it is not the only form of inactivity.

11. Unknown status – Provider level
BR10
BR11
BR15
BR12
BR17
BR47
BR14
BR13
BR36
BR16
BR11: If patient provider information is received via electronic interface with no status, then the patient's provider status is set to unknown.
Don’t get into a def of the rule debate here.
For example this rule is a clarification of the rule that goes to get a patient into the Unknown status

12. Patient Immunization Status - Diagrams
Provider level
Geographic Jurisdiction level
BR10
BR11
BR15
BR12
BR17
BR47
BR14
BR13
BR36
BR16
BR25
BR26
BR22
BR23
BR15
BR27
BR14
BR24
Over the next 2 slides I’m going to highlight specific BR examples and their recommendations that relate to these diagrams.
Again note, these issues that the group examined patient status at two different level the geographic jurisdiction level as well as the provider level. This slide illustrates the rules at both views and the status involved at the geographic as well as provider level.

13. Business rules (a fragment)
Inactive - MOGE (Provider level)
How to assign this status
BR13: If a reminder recall notification has been returned with a forwarding address out of the immediate area, or
If a request to transfer a patient's medical records has been received, or
If a notification of intent to get immunizations elsewhere is received from the parent or guardian, or
If a patient has moved with no forwarding address, then the patient's status should be set to Inactive - MOGE.

14. Reminder-Recall Notification at the Geographic Jurisdiction level
CONDITIONS
Scenario A B C
Individual Status at the Geographical Jurisdiction level
Active
Inactive – MOGE,
Inactive – Permanently,
Unknown
Inactive - Lost to Follow-up
ACTIONS
Include in Geographical Jurisdiction Reminder Recall notification X
Exclude from Geographical Jurisdiction Reminder Recall notification (2)
Registry makes determination whether to include
X (1)
Next will review the groups decision impact tables on Reminder recall notifications and coverage assessments. Here is the one on RR.

15. Immunization Coverage Assessment at the Geographic Jurisdiction level
CONDITIONS
Scenario A
Scenario B
Patient Geographic Jurisdiction Status
Active,
Unknown,
Inactive -Lost to follow up(1)
Inactive -MOGE
Inactive -Permanently
ACTIONS
Include in Geographic Jurisdiction Immunization Coverage Assessment X
Exclude from Geographic Jurisdiction Immunization Coverage Assessment
This example was a debated issue during the meeting but in the end it was agreed that the best thing to do was include Active, Unknown, Inactive-lost to follow up in the jurisdictional coverage assessment. We really want the lost to follow up to be minimal. The group realized that it deflates coverage but otherwise people slip through the cracks.

16. Summary Assembled 16 experts participated in 2.5 day meetings
Formulated 23 agreed upon business rules that define patient statuses and transitions
Defined 6 patient statuses at the Provider level
Defined 5 patient statuses at the Geographic Jurisdiction level
Developed 2 status diagrams, 1 domain diagram, and 4 decision tables

17. Conclusions
The workgroup believes that the consistent use and implementation of these guidelines will help improve the collection of patient status information and help ensure that all patients are kept up to date with the current immunization schedule.
The first content chapter was created but also the modeling techniques served as a springboard to communicate peer recommendations and document the issue.

18. Session Evaluation Results
16 Subject Matter Experts that participated in the meeting answered the 10 questions questionnaire.
Average score is 3.78 (4 – highest/most positive, 1 – lowest/least favorable)
Most significant scores:
How satisfied are you with the emerging recommendations? – 3.86
How helpful were the business modeling techniques in discussing and documenting the MOGE issue and recommendations?
How likely would you take time to do this again for another topic/event? – 4.00

19. Other Qualitative Feedback On Resulting Document
“…Thanks again for this wonderful document. …suggested that it be the basis for our functional requirements for patient status-MOGE functions and logic going forward.”
“…congratulates the MIROW group on spending a considerable amount of time discussing MOGE and patient status for registries…the document is quite thorough albeit for the uninitiated in the format of the business management and business rules, reading it took a supreme amount of concentration!”
Sometimes qualitative (unstructured) comments are insightful to the reaction the community has. These are a few comments both positive and constructive that the group received.
There actually were several comments on the “denseness” of the document… as punishment or to address this issue...

20. Take Home Messages
Common approaches can be discovered and agreed upon in IIS operations
Operational guidelines exist for IIS topics-See AIRA web site
Translate guideline into practice
Business modeling initiative provides an efficient venue for collaboration and exchange of ideas among peers
More topics and guidelines need to be produced
The first chapter is not just a ‘content’ chapter but also theses models/documents are a way of communicated peer recommendations in technology neutral requirements and serve to present an understanding of the world we examined (Patient status: MOGE) which then becomes a tool to facilitate discussions between programmatic and technical experts.
We also feel these guidelines help translate the wealth of operational knowledge and experience that IIS professionals have into a way that others can use. Therefore continuing to promote leadership and capacity of IIS community to the rest of the HIT environment as other document get produced.

21. Acknowledgments
Subject Matter Experts: Angel Aponte, Jim Aspevig, Bill Brand,Frank Caniglia,Michael Flynn,Ruth Gubernick,Therese Hoyle,Janet Kelly,Tory Lorenz, Katie Reed, Kim Salisbury-Keith, Susan Salkowitz, Rob Savage, La Tonya Thomas, Ellen Wild, SME Reviewers: Don Blose, Amy Groom, Amy Kirsch
Steering Committee: Bill Brand, Barbara Canavan, Michael Flynn, Therese Hoyle, Janet Kelly, David Lyalin, Tom Moss*, Sue Salkowitz, Cindy Sutliff, Warren Williams*
A massive group effort was need to pull this off it involved a group of dedicated and passionate SME as well as steering committee which helped focus, plan and guide the topic.
Some MSC people played a duel role as SME also…double the pain!
THANKS!!!
* Committee co-chairs

22. Document Reference
American Immunization Registry Association Web Page see Publications and Related Links section
The document for reference is list on the AIRA web page at the following link
And as a closing point…

23. The MIROW Next Topic will be:
Vaccine Level De duplication
May 8-10, 2006
Stay tuned to AIRA Web Page: see Publications and Related Links Section
Existing Status document