1. The Immunization Provider’s Toolbox: Immunization Interfaces with State IIS Cecile Town, MPH IHS Immunization Program Division of Epidemiology & Disease Prevention July 24, 2012

2. Background Since 2006, the Indian Health Service (IHS) immunization data exchange initiative has worked with IHS, tribal and urban Indian health (ITU) RPMS sites to participate in immunization information systems (IIS) via ITU/IIS Health Level 7 (HL7) immunization interfaces. In 2009, the Centers for Medicare and Medicaid Services (CMS) established interoperability measures of Electronic Health Record (EHR) meaningful use that can be demonstrated by submission of electronic immunization data to IIS. The IHS Immunization Data Exchange process and software enhancements will support the ability of RPMS providers to attest for this MU measure.

3. Background Why we participate in IIS projects: IHS sites are independently operated and used at the local level, we need the IIS to exchange information. IHS sites need access to data from other non-IHS institutions.

4. What’s an Immunization Information System ? Also known as Immunization Registries, Immunization Information Systems (IIS) are confidential, population-based, computerized information systems They collect vaccination data about all children within a geographic area (usually statewide) Some registries also collect vaccine data for adults.

5. The IHS Data Exchange Initiative A bidirectional HL7 RPMS/IIS interface using: IHS Immunization Module (BI) IHS data exchange software (BYIM) Automated transport software Benefits of Interface: –Facilities continue to use the RPMS as their primary information source –Eliminates need for double data entry –Data can be pulled from the IIS directly into individual RPMS records –Interfacing allows RPMS providers to attest for related Meaningful Use measures

6. Background An immunization data exchange interface will link SIIS and RPMS systems in up to 34 states 12 Administrative Areas, ~260 RPMS instances Pacific Island and West Virginia RPMS users IHS Immunization Interface software: internal call letters BYIM National team develops software, primary participants in discovery process, handles HL7 & programming issues Area teams (clinical/IT) recruit provider sites, coordinate installations, meetings Local teams – primary operators of software, first link in troubleshooting with IIS

7. Background IHS sites are located in sovereign nations and operate under local control. Area and national IHS staff members technically assist many of these IHS sites. IHS sites may choose to operate independently and install their own EHR software. IHS sites connect directly and independently to IIS.

8. Objectives Review software enhancements in Immunization Interface Management (BYIM 2.0*3, 3.0) Discuss revised process for implementing new interfaces Discuss implications of Meaningful Use Stage 2 proposed rules on the immunization submission measure

9. IHS Data Exchange 2012

10. Software Enhancements: When we make changes Interfaces require that RPMS message submissions are compatible with IIS requirements. When a change is requested in BYIM, it must: Conform to CDC standards NOT clash or conflict with current practice, not otherwise specified by CDC standard Be feasible in terms of BI data collection

11. Development Priorities Align message to National Institute of Standards and Technology (NIST) EHR Certification specifications Achieve widespread interoperability in –Messaging (what the message says) –Transport (how the message is conveyed) Create a process that enhances RPMS user uptake

12. Software Updates: BYIM 2.0, patch 3 - The HL7 Message –Upgrading from v 2.3.1 to 2.5.1 –Sends 16 additional message elements –Release: August 2012 BYIM version 3.0 – The Transport -Maintains batch interfaces, allows additional real-time interactions -Web services capability increases interfaces in 38% of RPMS states -Release: October 2012

13. ENHANCED IMPLEMENTATION PROCESS Planning for Increased Uptake

14. Road Map Interfacing usually requires the cooperation of four independent entities: State or Local IIS Project Immunization Provider IIS Vendor EHR Vendor Good communication, adherence to national standards help this process work well.

15. HL7 2.3.1 Process

16. Why change the process? ONE MESSAGE: ITU clinics utilizing RPMS can use BYIM to demonstrate meaningful use by submitting test messages to state IIS MANY PARTNERS: Every IIS is free to adapt the CDC HL7 standard to meet local requirements according to: –local or state law and regulations –specific IIS needs or expectations. These differences make it very hard for a national organization, such as Indian Health Service, to create a standard interface with all IIS. These differences are hard to see at first and can only be determined after attempting to interface.

17. HL7 2.3.1 Process - Site

18. First Solution: IIS Profiling Project Create a system to automatically profile IIS to determine which kind of messages are acceptable and which are not.  Review IIS guide and develop a report template.  Establish test connections to real-time or batch interface.  Submit several hundred test messages to verify expected responses to known error conditions.  Develop unified profile representing IIS.

19. Local Engagement Pre-Deployment Testing Verify with IHS Standard Verify with NIST Certification Verify with IIS Directly Profile IIS Interface Test Interfaces with IIS (Real-time or Batch) RPMS 2.5.1 Development Engage IIS to connect local IHS site in progress... Engage local IHS site Install Software Create DQA Report CDC Specification IIS Specifications HL7 2.5.1 Process

20. IHS Data Exchange 2012

21. Second Solution: Data Quality Assurance  Identifies and summarizes data quality issues from the vantage point of a batch.  Based on requirements and information gathered in IIS profiling project.  DQA report can be emailed, contains no patient specific information.  IIS sites will go through data quality process before submitting initial data.

25. Local Engagement Pre-Deployment Testing Software Development Verify with IHS Standard Verify with NIST Certification Verify with IIS Directly Profile IIS Interface Establish Test Interface (Real-time or Batch) RPMS v2.5.1 Development Engage IIS to connect local IHS site SSM Development Engage local IHS site Install Software Create DQA Report CDC Specification Feedback IIS Specifications IIS

26. IIS - IHS Connecting Points  Receiving latest IIS HL7 specification and supporting materials.  Setup process for accepting and responding to review of development messages.  Provide real-time or batch interface for submitting test messages or files.  Coordinate during local deployment.

27. Third Solution: Simple Message Mover Open Source software that offers ability of BYIM to auto-message with more states Current Bridge – HTTPS –14 states SMM - HTTPS & web services compatible –23 states

28. Meaningful Use and Data Exchange

29. Meaningful Use Changes: Immunization Submissions MU Stage 1 1.Menu Set item 2. Failed Submission = PASS 3. Transport -ONC – not in scope -CMS – not in scope MU Stage 2 Proposed 1.Core item 2. PASS = ongoing submissions 3. Transport -ONC – not in scope -CMS – provider must adhere to PHA transport method

30. Meaningful Use Implications Stage 2 Proposed For ProvidersIHS Comments & BYIM Process Enhancements: CoreAll RPMS sites must implement Comment: Dependent on IIS and increased involvement by RPMS sites, Areas Ongoing Submission Site level practice in place, staff assigned Comment: Request to make onboarding process count for meeting the measure Enhancement: Profiler & Internal Data Quality Assurance will expedite PHA Defines Transport Creates a need for BYIM variability Comment: A standard has been defined but not recognized, request to leave this measure for Stage 3 Enhancement: Widely interoperable open source transport development

31. Summary 3 step verification process Interface profiling and documentation process – interactive vs. static Data quality assurance process – pre-deployment Streamlines interface on-boarding process for providers Aligns with NIST, HL7 and transport standards up front Will enable greater Meaningful Use attestation agency wide

32. Lessons Learned The release of the Meaningful Use Stage 2 rules will drive an increased interest in immunization interfaces. BYIM enhancements will support the ability of RPMS providers to attest for Meaningful Use. Technical capabilities must be implemented by personnel

33. Questions?

35. IHS Electronic Health Record Resource Patient Management System (RPMS) Utilized by all IHS and most tribal and urban Indian health facilities Open source product used outside of Indian health Includes immunization component –Clinical decision support (forecasting) –Coverage reports 3-27 month old, 2 year old, Adolescent, Influenza (all ages) report Based on vaccines administered –Reminder/recall lists and letters

36. Development Timelines Current version: BYIM 2.0*2 BYIM 2.0*3  Beta testing: late July 2012  Release: August 10, 2012 BYIM Version 3.0  Beta testing: mid-August, 2012  Release: mid September, 2012

37. Local Engagement Pre-Deployment Testing Software Development Verify with IHS Standard Verify with NIST Certification Verify with IIS Directly Profile IIS Interface Establish Test Interface (Real-time or Batch) RPMS v2.5.1 Development Engage IIS to connect local IHS site SSM Development Engage local IHS site Install Software Create DQA Report CDC Specification Feedback IIS Specifications

38. Open Source Partnering

39. IIS Profiling Project

40. Open Source Software  As a by-product of current work, a set of open source tools are available: HL7 Jump: very simple HL7 parser. Data Quality Assurance engine. Simple Message Mover. IIS Web Service support.  http://www.openimmunizationsoftware.org/

41. Summary  Putting in new three step testing process.  Systematically collecting IIS requirements.  Profiling IIS HL7 interfaces.  Adding Data Quality report to our pre- deployment process.  Create new simple message mover.  Upgrading to HL7 2.5.1.  Will support vaccination query.