Public Health Registries – Integration of Health Public Health Registries – Integration of Health Data Sources with Immunization &Data Sources with Immunization &

Disease Reporting SystemsDisease Reporting Systems

Todd Watkins, STC

Baseball Sayings: A Metaphor for PH Data Baseball Sayings: A Metaphor for PH Data StandardsStandards

Yogi Berra

“This is like déjà vu all over again”“You can observe a lot by just watching”“I knew I was going to take the wrong train, so I left early”“Baseball is 90% mental, the other half is physical”“A nickel isn’t worth a dime today”“If you come to a fork in the road – take it”

Baseball Sayings: A Metaphor for PH Data Baseball Sayings: A Metaphor for PH Data StandardsStandards

Casey Stengel

“All right – everyone line up alphabetically according to your height”“Finding good players is easy. Getting them to play as a team is another story”“Managing is getting paid for home runs that other people hit”

Warren Spahn

“I finally became a good pitcher when I quit trying to make hitters miss, and started making them hit”

Business Case for PH Data StandardsBusiness Case for PH Data Standards

Standards

S&L(implementer)

Feds(creator)

HealthcareProviders

(utilizer)Consumers(beneficiary)

HIT in the Presence of Standards

Results in… Allowing… Cost effective Analytics Efficient Predictive Analysis Streamlined Outcome-based

Solutions Reconciled Proactive IT Apps

S&L

Feds

HealthcareProviders

Consumers

Integration& Mapping

HIT in the Absence of Standards

Results in… Expensive Inefficient Redundant Not Reconciled

Integration& Mapping

Integration& Mapping

Integration& Mapping

Policies andPolicies andProceduresProcedures

TechnologyTechnology

MedicalMedical

Fed

Fed

Fed

State

State

State

Standards Environment For Public HealthStandards Environment For Public Health

NHIIPHINCDC Reportable Diseases…

ICD-10SNOMEDLOINC…

HL7 RIMNEDSS LDMPHIN MessagingebXML…

Industry

Local

Local

Local

State Reportable Diseases…

NBS or AlternativeDB Interoperability Standards…

Best PracticesLicensure…

Collaboration Protocols w/ Third Parties…

RDBMS for local data collection effortsOO-application design principles…

Best PracticesLicensure…

EMR/EHR HIE

Stand-alone “legacy” electronic systems – birth of registries

Paper based

Personal Health Record

now 2015

Health and welfare of Population

Implementation of standards

Effective utilization of standards

Introduction of standards

Changing Environment of HIE / HITChanging Environment of HIE / HIT

Data Exchange / Usage MetricsData Exchange / Usage Metrics

Total Users

Total PatientsTotal Shot Records

Total Electronic

Links

Total % Growth in

Users

Total % Growth in Patients

Total % Growth in

Shots

1,640 710,418 2,849,262 21 50% 489% 135%8,124 3,596,289 38,036,636 101 -7% 10% 23%6,060 533,253 6,191,824 17 8% 7% 3%8,367 2,977,292 23,816,929 0% 0% 0%16,013 2,702,643 31,918,612 65 19% 5% 2%4,838 1,089,848 4,296,387 20% 9% 38%4,246 1,399,263 11,882,812 5 0% 1% 1%3,448 1,032,977 16,154 0 N/A N/A N/A17,138 5,900,932 42,260,076 177 2% 13% 28%2,347 1,012,701 6,722,570 84 37% 4% 3%1,221 414,178 3,700,445 5 45% 4% 3%

73,442 21,369,794 171,691,707 475 15% 17% 15%

IIS’ are “HIE Ready”: Registries TimelineIIS’ are “HIE Ready”: Registries Timeline

Characteristic

1980 – 1989 1990 – 1999 2000 – 2009 2010 – 2019

Technical

From•Green Screen•Centralized

To•Client Server•Distributed

From•Client Server•Distributed

To•Web-based•Distributed

•Web-based•MPI•Visualization

•User-driven•Central HIE•Health Portal•Dashboard•Predictive Analysis

Programmatic

•Ownership•Opt In / Out•Forecasting•Adverse Events•Consent•Data Integrity•Reporting

•De-dupe•Expand User Base

•School Nurses•Providers

•Data Sources•Vital Records•PMS

•Integration•Vaccine Mgmt•Mass Imms•Event Mgmt

•Anthrax•Katrina•Avian Flu•H1N1

•Role in HIE•Role in PHR•Consumer Module•Outcomes

Business Models

•Home grown•State-funded

•Work-for-hire•GOTS•COTS•CDC-funded

•COTS•Public Domain•ASP•CDC-funded•State-funded

•Open Source•Subscription•$/Record•Alternate funding

Public Health: Today’s EnvironmentPublic Health: Today’s Environment

Introduction of Standards

App

licat

ion

Assessments &Evaluation

MethodologyStandards

DataDefinitionsStandards

ReportingStandards

DuplicateIdentification

AutomatedAlert &

Notification

SimulatedModels

Infra-

DesignStandards(PHCDM)

QualityControl

Standards

ElectronicExport

Standards(HL7)

LeadScreening

New BornScreening

Pre-NatalHealthCare

HIV/STD

TBRegistry

WCHService

RuleBasedTools

Visualization/IntegratedMapping

(GIS)

ThreeTiered

ReportingTools

Inlin

e

Geoc

odin

gst

ruct

ure

Stan

dard

sSt

atistic

al

Tool

s

Reco

rd

Mer

ging

Dev

elop

men

t

Stan

dard

s

Dat

abas

e/GUI

Secu

rity

&

Stan

dard

s

Confi

dent

ialit

y

Disea

se

Repo

rtin

g

(Bas

e Sy

s.)

EBC

VR&

SIIS

Stand-Alone Solutions

Focused on Data Collection

Leads to Silos of Information

DesignStandards(PHCDM)

InfrastructureStandards

Assessments &Evaluation

MethodologyStandards

ThreeTiered

ReportingTools

StatisticalTools

ElectronicExport

Standards(HL7)

QualityControl

Standards

Security &Confidentiality

Standards

DataDefinitionsStandards

ApplicationDevelopment

StandardsDatabase/ GUI

ReportingStandards

RecordMerging

DuplicateIdentification

RuleBasedTools

AutomatedAlert &

Notification

InlineGeocoding

Simulation/Modeling

Visualization/

HIV

/

New B

orn

Scre

enin

gSe

rvice

TBRe

gist

ry

SIIS

Pre-

Nat

alCa

re

Hea

lth

Lead

Scre

enin

g

Reu

sabl

e To

ols

Standards

App

licat

ions

Mapping(GIS)

Integrated

STD

WCH

Disea

se

Repo

rtin

g

(Bas

e Sy

s.)

EBC

VR&

Effective Utilization of Standards

Free flowing informationHighly secured / protected

Rapid Application Development

Focused on outcomes

Public Health: Today’s Goal – HIEPublic Health: Today’s Goal – HIE

Registries for Public Health Care ManagementRegistries for Public Health Care Management

2003 Hurricane Katrina support included linking all U.S. states to Louisiana immunization registry – saved > $15M in vaccines

2008 Integrating Immunization tracking system in Louisiana with EOC to support resource allocation and Patient Care Management

Integration Examples – Currently in EffectIntegration Examples – Currently in Effect

Todd Watkins, STC

Immunization Registries and Vital RecordsImmunization Registries and Vital Records

Birth data from VR forms basis for IIS demographic recordCDC-defined Immunization Registry Data Standards for demographics supports seamless creation of a new recordData transferred through pre-defined standard formats requiring translation tools to facilitateNew exchanges are sent via standardized HL7 messages (no need for translation)

3. State Immunization Registry System

2. Electronic Exchange (HL7)

1. State Vital Records System

4. Pre-populated

patient demographics

Vital Records are the “bookends” for Health Information Exchange, with the

first exchange being to IIS.

Immunization Registries and Vital Records Systems are Population-based

Immunization Registries and EMRsImmunization Registries and EMRs

Example 1: Providers Populating SIISDirect data entry into SIIS (Not preferred by providers)Translation of EMR/PMS data to SIIS (Requires a translation tool / mapping)Submit Immunization Encounters via HL7 (Preferred)

HL7 provides extensive code table mapping and observation definition functionalityAble to define and manipulate observation definitions makes it very adaptableAble to communicate with different dialects of HL7 messages

Provider Feedback is Key!

Example 2: I.H.S. RPMS BYIM applicationAn HL7 Bridge tool is used to automate file transfers removing the need to manually transmit HL7 filesThe Bridge is installed at the local IHS site and configured to constantly inspect the export and import directories where BYIM saves and reads the HL7 filesWhen BYIM exports a new file, the HL7 Bridge sends it securely to SIIS and waits to receive a response fileThe response file contains updates to be imported into RPMS. The HL7 Bridge saves this file in the import directory for BYIM to process.

How Electronic Medical RecordsHelps Immunization Registries

Provider

EMR

DTT

HL7

Direct Data Entry

Provider Feedback

Immunization Registries and EMRs (RPMS)Immunization Registries and EMRs (RPMS)

SIIS InternetHL7 Bridge

State HL7 Imm. Data

Site HL7 Imm. Data Export

Site HL7 Imm. Data Export

State HL7 Imm. Data

HTTPSSecure Connection

State Immunization Data

Site Immunization Data

RPMS

IZDE

IZIM

IZAD

RPMS Database

Immunization Data Hold Area

IHS RPMS Data Flow – Bi-directional Exchange:

Disease Surveillance and Electronic Lab ReportsDisease Surveillance and Electronic Lab Reports

HL7 Messages processed as new patients, cases, or new lab reports for existing casesLab Report data transferred from the lab to the Public Health Department using CDC’s PHIN MS to ensure secure transfer of data – other methods may also be usedLab Tests and Test Results are stored in LOINC / SNOMED nomenclature

ELR Processing in a ELR Processing in a Disease Surveillance SystemDisease Surveillance System

ReceiverReceiver Disease SurveillanceDisease Surveillance

TranslationTranslation

Disease Surveillance and CDC NETSSDisease Surveillance and CDC NETSS

Begin with base of NETSS-reportable disease conditions. NETSS Core data exported to CDC weekly.TB and Varicella will be sent using the CDC HL7 v2.5 case definition beginning December 2009. Messaging standards for other diseases will be forthcoming from CDC. Slowly converting from NETSS to NEDSS messaging standards.As the CDC publishes defined standards, Disease Surveillance Systems must be updated to replace the NETSS reporting to the CDC as HL7 messages.

NETSS Processing in a Disease Surveillance SystemNETSS Processing in a Disease Surveillance System

Disease Disease SurveillanceSurveillance

Immunization Registries and Disease SurveillanceImmunization Registries and Disease Surveillance

Disease Surveillance System Interface with Immunization RegistryDisease Surveillance System Interface with Immunization Registry

Example: Ability to query an immunization registry that supports HL7 queries. Users can identify a patient’s vaccination history – dates, manufacturers, lot numbers --to assist in case investigation.Example: Immunization Registry as source for provider, occupation, household members, and other demographicsExample: Disease Surveillance / Immunization Registry interface can aid aggregate reporting of cases to third parties (e.g. CDC and pandemic influenza)

Disease Disease SurveillanceSurveillance

The Value of StandardsThe Value of Standards

Decreased costs

Software easier to maintain – E.g. HL7 standard:Data exchange in both real-time and batchsystems.   Divides the one record into separate“messages.” A National Standard for Registry(PH) communication (CIRSET)

Easier interpretation – E.g. LOINC/SNOMED:Standard test and results codes allows common understanding to index, store, retrieve, andaggregate data across various labs, jurisdictions, etc.

Standards can be leveraged across multiple public health programs – IT support can be leveraged, too – E.g. CDC Implementation Guide for Immunization Data Transactions v2.2, June 2006

Promotes growth in data exchange between systems, including unanticipated future data exchanges between programs.

The Value of Standards – Example: State-to-State The Value of Standards – Example: State-to-State SIISSIIS

“Out of State” SIIS “Home State” SIIS

· Username· Date, Time· Search Criteria

· Core Patient Demographics

· Vaccine, Date· Multiple Matches

6

5

7

1

2

User Enrolls in “Out of State” SIIS

“Home State” SIIS creates state account

AuditLog

· Username· Date, Time· Match: Exact, No,

Multiple· # of Multiple· Patient ID

State to State Pilot Process

User Agreement Acceptance

3

4

· State Account· Username

Integration Examples – Underway / FutureIntegration Examples – Underway / Future

Todd Watkins, STC

Immunization Registries and EMRs (MMIS)Immunization Registries and EMRs (MMIS)

State Immunization Information System State MMIS

Medicaid Eligible Patient Demographics,Immunization Histories and Assessment

Tools

Medicaid Prevention Programs

Supplemental Patient Care

DataElectronic Exchange

PatientPatient

An MMIS – IR Datamart (+)

The Medicaid Medical Record as an EMR Example:

EPSDT Medical Records

Decrease costs Increase accuracy of information Integrate data for use across other PH programs – treatment & prevention

State Immunization Information

System

Request for record

HL7Request

Record Locator

ExchangeTool

Forecaster

Deduplication

Record

No Record or Need More to Identify

HealthData Bank

STC’s IIS Electronic Exchange

Consumer Request

Authentication

HIE Proof of Concept:HIE Proof of Concept:Patient Requesting Immunization Records from a State Immunization RegistryPatient Requesting Immunization Records from a State Immunization Registry

ImmunizationRecordCapture – Proprietary and Confidential Business Information Copyright 2008 Scientific Technologies Corporation