Chicago and Illinois – Integration Through Collaboration · • Replication activity bi-weekly – sharing data with central registry Quarterly training for new TOTS users 36 Computer

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Chicago and Illinois –Integration Through

CollaborationA Model for Building Sustainable Registry

Services

Illinois - Chicago Immunization Collaboration (“I-CIC for ICARE”)

I-CIC

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I-CIC Plenary Participants

AALLLLIIAANNCCEE Of Chicago Community Health Services, LLC

Chicago Area Immunization Campaign

Chicago Department of Public Health

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Agenda1. Vision, People and Process (Brian Bragg)

2. Implementation and Technology (Alex Lippitt)

3. PanelKey Pieces of the Puzzle (Alex Lippitt)

The TOTS / ICARE Registry (Karen Austin)

The City of Chicago (Maribel Chavez-Torres)

View From the Provider…Software Solution, That is(Mark Leavitt)

4. Wrap-up-Next Steps: We Need You (Alex Lippitt)

5. Discussion (Allan Lieberthal)

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Immunization Focused Coalition

State DPH/DHS

City/Local DPH

Software Vendors

Public sector providers

National -CDC/CIRSET/AIRA

Private sector providers

Professional Organizations

Chicago Area Immunization Campaign

Brian Bragg, BAProject Director

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Immunization Registry Services and Integration

Immunization Registry

Clinical Practice By Patient•Complete History•Contraindications and immunities•Schedules: standard and projected

Clinical Operations – Practice guidelines,Vaccine inventory managementClinical Management – CASA, HEDIS, VAERS, etc. ReportingPatient and Patient Services – School and other records, multimedia reminder/recall

‘Healthcare Home’ eHR

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Illinois Registry Workgroup FindingsProvider Focus Groups’ Findings:

- is effective in helping practice improve immunization rates,

- will help reduce over-immunization of children, and,

- will help provide more accurateinventory management

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Illinois Registry Workgroup Findings

Strong qualitative sentiment expressed for mandatory registry participation by providersDatabase will include generally reliable complete immunization records.

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Reaching Tipping Point in Registry Usage

Registry Technology and Utilization State Public

Health

Hospital andAmbulatoryNetwork ProvidersSmall Providers -With Systems

Small Providers -With Office ToolsOnly

Mixed

Managed care can be any option but State Public Health

Mixed category includes: 1) people in different sectors2) people in same sector, with different providers

90% of people covered in Registry currently – only children: nationally, the foundation of the “43%” – other “private” sectors are key for growth.

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Barriers: Mandatory Usage Legislative Initiative

Time – The time it takes to input data into the system (double entry)

Data – Is the data complete? Is the data accurate?

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The Integration Issue

BirthRegistry

Not in Illinois –Registry Not Sanctioned

Illinois ImmunizationRegistry

(not yet mandated)


Only for immunizations covered with individual consents for each provider – in Illinois

Only a Dream For Now in USA –Siloed and Fragmented

Other ImmunizationRegistries

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SolutionIntegration of the registry with a practice management/billing system (PMS) and/or Electronic Health Record System (EHRS)

Saves time – no double entryIntegration would allow the correct data to be completely and accurately loaded onto the registryRegistry data could be trusted

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Important Take-home Messages

Build Coalition Across CommunitiesBuild Coalition Among OrganizationsUse Experience and Best Practices to Guide Immunization RequirementsUse Current Standards as BaselineBuild Plan For Short, Mid and Long TermFocus on Technology Neutral SolutionsKeep Eye on Big Picture But Dot the Is

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Immunization Focused Coalition State

DPH/DHS

City/Local DPH

Software Vendors





Alex Lippitt, MBACIO

AALLLLIIAANNCCEE Of Chicago Community Health Services, LLC

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Immunization Encounter and Follow-up: Ideal Flow

Intake and Registration

Encounter-Nursing

Encounter-Provider Checkout

PMS EHRS EHRS /PMS

ICARE Immunization Registry

•Access, update history•Record historical

immunizations•Schedule immunization(s)

•Provide complete history•Provide clinical guidelines

•Record immunizations

Immunization tickler work in process data from

reminder/ recall flow

• Capture encounter immunization records

•Print forms – school, etc.•Schedule next immunization(s)

•Set up reminder/recall plan•Update vaccine inventory records•Update CASA, VAERS dataReminder/recall execution

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New NVAC StandardsPublished in Pediatrics - October 2003 issue. Provider Registry Electronic Interface efforts critical to meeting these standards:

6 of the 17 standards rely on integration efforts for success: ex • “12. Vaccination records for patients are

accurate, complete and easily accessible.”

8 more of the 17 standards are directly addressed

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2004 Timeline – Proof of Concept4th Qtr 03 1st Qtr 04 2nd Qtr 04 3rd Qtr 04 4th Qtr 04 Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec

Startup Phase

Organize: Resource, Complete Agreements

Benchmark / Design Pilot / Implement Web Version

Pilot Implement Phase

Pilot 1 – PMS interface

Conduct pilot

Package and Disseminate

PMS Interface / Add Vendors

Pilot 2 - EHRS Interface

Small Provider Interface Design and Agreement

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Illinois Immunization Program1. Elimination of double entry and

integration into EHRS and PMS workflow with….

2. Clinical benefits and no more burdens for clinicians

3. Tipping point – clinical trust, use of registry

4. Enough support for Illinois to become opt-out state

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Big Tent Solutions for markets currently not covered (levels):

A. Hospitals and Ambulatory Networks

B. Providers With Billing, PMS, EHRS - Minimum Data Set HL7 Transaction

C. Smaller Providers With Simple Tools (Microsoft Office, etc.) -HL7/XML/SOAP Flat File

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PMS/EHRSSmall PMS, Homegrown

Billing

Illinois TOTS/ICARE Registry Load -Late 2004 and Beyond

State Public Health

TOTS/ICARE/DPH

Small Providers

Hospitals and

Ambulatory Networks

CIRSET L 2, 3CIRSET L 1

TOTS Dial-up Web Access

Manual double entry

KeyExisting ElectronicProjected 2004 ElectronicFutureProjected 2004 ManualCurrent Manual NEW

Medicaid Global (Chicago, Cook County) WIC Case Mgmt

Cornerstone/DHS

Real timeMonthly Batch Weekly Batch

Some entry is double entry –behavioral services (ex: WIC)

NEW

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2004 Long-term Key Deliverables -National

First Year GoalsFour large market share vendor commitmentsPMS interface and implementation toolkitEHRS interface and implementation toolkit

CDC/CIRSET/AIRA Standards SnowballKnowledge Base– National resource, linking existing knowledge and peopleImplementation Guide ExpansionExtension of PROW concept – Levels, etc.

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Building on Provider and Electronic Integration History

Public

PMS–1 way

EHRS

Various States –WIC, Medicaid, etc.

Illinois – Multiple

Utah –Intermountain Health

Michigan – MDServe

Houston-Harris County Registry

– GE Logician

Wisconsin - Epic

West VA –Medical Manager

2 wayIndiana-Marion County

County Registry– QS Tech Insight

Illinois – Multiple

1990s Now in Test In Development

Georgia – Multiple

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Agenda

1. Vision, People and Process (Brian Bragg)





View From the Provider….Software Solution, That is (Mark Leavitt)



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Puzzle Pieces – Required to Get to Immunization Integration and Opt-OutImmunization Focused Coalition –Listening, Legislative Initiatives, Outreach, High energy cheerleading, IT/Clinical Integration, bringing together other puzzle pieces

State DPH/DHS – Strong standards-compliant registry with close working relationships with WIC/Medicaid

City/Local DPH – Key part of state plan, builds local coalitions

Software Vendors –Part of solution team; see win/win and united, organized, standards oriented environment

Public sector providers – Strong business case for leveraging of complete records to reach disparities populations and serve patients more efficiently and effectively

CDC/CIRSET/AIRA – Active and visible support and facilitation

Private sector providers – Similar to public sector but with more emphasis on cost reduction

Professional Organizations – Reflects interests of specialties and professions; especially local and state chapters of AAP, AAFP, AMA, ANA, AAPA

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Project StructureIllinois Steering Group

Chicago DPH (funder)•Illinois DPH - TOTS – ICARE (sponsoring registry and funder)

•Chicago Area Immunization Campaign (CAIC)–•Immunization Registry Workgroup

•American Academy of Pediatrics (AAP)– National Office and Illinois Chapter

•Illinois Maternal and Child Health Coalition•Alliance of Chicago Community Health Services (Alliance)

Program Office•Brian Bragg (CAIC)

•Alex Lippitt (Alliance)•Project Leader / Analyst (Alliance)

SMEs(Subject Matter Experts),

ReviewersContributors

NationalAdvisory Group

•CDC NIP•BPHC•AIRA

•CIRSET•CIRSET Vendor, Standards

Workgroup

Quality and Compliance Review Team

•TBD

Site Team •EHRS / PMS Vendor Team

IDPH Registry Team

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Cerner Webcast– October 03, 2003

Public Health•CDC – Atlanta•IDPH•CDPH•Cook County DPH

Outcomes•Cerner Design•Clinical Follow-up•Technical Follow-up•Cerner to CIRSET•HIPAA Compliance•Knowledge Base

Managed Care•Humana•United Health Care•Harmony•BCBS – Illinois *

Professional Organizations•AAP - National•AAP - Illinois•AMA

Providers•Alliance•Cook County•Advocate *•Northwestern PPG *

Immunization Focused Coalition•Chicago Area Immunization Coalition (CAIC)•Alliance

Registry Organizations•AIRA•CIRSET

States and Regions•Illinois•New York City•Massachusetts•Utah

Key – Presenters, * = not present, but will be in follow-up

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Implementation Approach – Key PrinciplesBuild on others work – start from knowledge baseBuild under clinical directionWork from scenario and event base

People, process and technologyTest, train, test, train

Implement in digestible chunksBuild for replicationDefine and benchmark key metrics early – build business caseMarry data and event handling quality requirements to solutionsIn the end – add to knowledge base, standards and critical mass …..

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State DPH/DHS

City/Local DPH

Software Vendors





Karen Austin, BA, HSAImmunization Registry Administrator

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1. Manual 2. Fax/Phone 3. Dialup 4. Web 5. Integration

Ability to check registry and add data at 1 dedicated workstation per site with dialup by modem

•Ability to access registry wherever there is Internet connection

•HIPAA compliant security

Integration into clinical flow – no separate application

Illinois Immunization Program –Technology Evolution

1999 –Present

2003 - Futureup to 1999 2004 - Future

Fax and voice response –ability to transmit data to registry

1999 –Present

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Where We Are… and Where We Are Going

Future registryWeb-based applicationComprehensiveDedicated to exchanging immunization information electronically

Current registrySoftware programInstalled on PC at provider siteDependent on provider to share data through modem connection

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Developed internally at IDPHPrivate provider focus

250+ private provider sitesDatabase contains 100% of the public immunization information

386 WIC/Immunization clinics• Linkage with WIC/IMM system (Cornerstone)

Over 800,000 participants 4 months – 5 years at least 2 immunizations, 74% of eligible participants in the Illinois geopolitical area

TOTS – Tracking Our Toddlers Shots

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Continued collaborationHL7 complianceDatabase qualityTechnical & program support

Ongoing Efforts

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Dedicated experienced staffProven functional programDedicated usersSignificant interest in Web-based registry by health care providersStrong collaborative relationships with immunization champions

Successes Celebrated

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State DPH/DHS

City/LocalDPH

Software Vendors





Maribel Chavez-Torres, MPHImmunization Program Director

Chicago Department of Public Health

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Chicago Registry Initiatives

Computer Distribution ProjectDownload of Global DataFund Partner Agencies

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Computer Distribution ProjectStarted in January 2002Purchased 100 computers and printers Process

ApplicationLinkage Agreement signed by CDPH & Provider OfficeForward TOTS application to IDPHInstallation of equipmentQuality control

• Replication activity bi-weekly – sharing data with central registryQuarterly training for new TOTS users

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Computer Distribution Project

Chicago TOTS Users

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95

135

0

20

40

60

80

100

120

140

Dec. 01 Dec. 02 Sep. 03

Dec. 01Dec. 02Sep. 03

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Computer Distribution Project

“Challenges”Practice staff

• Lack of basic computer skills• Staff turnover

Maintenance of equipment• Unexpected equipment problems

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Download of Global Data

Global = CDPH billing system (Medicaid – non billed and others)

Public Health ClinicsImmunization Walk-in ClinicsCommunity Immunization ClinicsCareVan

3,332 complete participant records downloadedBi-weekly (every two weeks)

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Working with Community Partners

Fund Partner Agencies7 Delegate Agencies

Registry activitiesCAICAlliance of ChicagoProvider EducationHospital-based Hepatitis B project

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State DPH/DHS

City/Local DPH

Software Vendors





Mark Leavitt, MD, PhDVice President – Clinical Initiatives

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Introduction

Current Use/Penetration of EHRsState of the Art in EHREHR/Immunization Registry Relationships: Keys to SuccessEHR/Immunization Registry Interactions:

BasicIntermediateAdvanced

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Current Use and Penetration of EHRs

Advanced EHR: 5%

Basic EHR: 17%

No EHR: 78%

Advanced EHR: 1%

Basic EHR: 19%Installing: 37%

Planning: 23%No plans: 20%

Acute Care: 1% - 57% of hospitals

Ambulatory Care: 5% - 22% of offices

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State of the Art in EHR:From Basic to Advanced

Stores encounter notes as textMaintains summary: problems, meds, allergiesManages internal workflows and messagesStructured capture of observations & proceduresProvides decision support, alerts, remindersAccepts HL7 data from external sourcesExports HL7 data to repositories and registriesLinks to external knowledge resourcesPopulation-based reporting and management

= critical capabilities for immunization mgmt

Bas

icAdva

nce

d

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EHR/Immunization Registry Relationships: Keys to Success

EHR/Registry interaction must......add value--not costs--for the provider...be implementable and supportable with minimal technical resources...simplify workflow--not add steps...deal with privacy and data ownership concerns...reduce--not increase--risk/liability

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EHR/Registry Interaction:Basic Level

Basic EHR

Registry(web interface)

Registration or pt summary

screen

Patientlook-upscreen

Help fill in reg data?

Vaccinationstatus

report screen

New vaccinationdata entry

screenReturn free text:

vaccination status and new vaccinationdocumentation

Encounternote entry

screen

Complete theencounter note

Low-tech interactions: screen scraping,

keystroke emulation, clipboard copy/paste

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EHR/Registry Interaction:Intermediate Level

Intermediate EHR

Registry(Web Interface)

Patient ClinicalSummary

Response: a few seconds!

RegistryDatabaseEncounter

Capture Form

Encounternote

documentation


HTTP / XML interactions

Vacc Status Window

Pt Request/Vacc Status Window

RegistryWebAPI

Vacc Proc Window

Vacc Update Window

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Conceptual Interaction: Logician EHR and iCare

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EHR/Registry Interaction:Advanced Level

Advanced EHR

Registry(HL7 Interface)

Immunizationview or

flow sheet

Response: a few seconds!

VXQ Vaccination Query

RegistryDatabase

andSecure

NetworkInterfaces

Vaccinationprocedure

capture screen

Encounternote

documentation


HL7 messages

Refresh

VXR Vaccination Record

VXU Update toVaccination

Record

AcknowledgementSend

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Agenda

1. Vision, People and Process (Brian Bragg)





View From the Provider….Software Solution, That is (Mark Leavitt)



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www.eproject.com – Vendor Workgroup, Standards Workgroup

•Knowledge Base – case studies, standards, links, etc.

•Connection Base Directory of Registries, Vendors, success stories, etc.

•Help! – SMEs answer

•Toolkits – Solution Models

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Connecting With Us –Building the Web

Access to CIRSET Standards and Vendor Workgroup RepositorieseMail

[email protected]@[email protected]

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Other Connect Plenary Sessions That “Connect”

Past…MondayA6 Challenges and Successes of HL7 ConnectionsB8 Practical Connections with the HL7 Standard

1:30 – 3:00 PM TodayC5 The Indian Health Service HL7 Data Exchange Project: Lessons LearnedC9 The Future is Now: Emerging Technologies

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Attachments

Slides “retired from presentation” but which may be used elsewhere

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CAIC Mission StatementThe CAIC is a diverse community-focused

coalition of public and private partners whose goal is to improve children’s health by increasing immunization rates in the Chicagoland area with a particular focus on completion of the primary series by age two.

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CAIC Structure

Provider Education Public Awareness Immunization Registry

CAIC Steering Committee

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Alliance Immunization Program – Two Thrusts

Ongoing Implementation – All Members

Registry data entryReminder recall

TrainingShift to web application embedded in clinical flow

Long-term1. Elimination of double

entry - integration into EHRS and PMS workflow

2. Tipping point –clinical trust, use of registry

3. Illinois will become opt-out state

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Important Take-home messagesBuild Deep and WideUse Team Models to Focus StrengthsIntegrate Knowledge To Integrate SolutionsBuild on Past SuccessIdentify The Challenges Early

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Knowledge Base Build – We Need You

Knowledge Base Beginning – National resource, linking existing knowledgeRegistry directory – standards and interfaceVendor directory – standards and interface, clientsProvider/Registry interface directory – existing, under development, failedOther resources – people, organizations, technical, FAQs, conversation threadsData quality methods, tools and evaluation criteriaStandards, regulatory Model agreements, contractsLinksImplementation toolkits…

Implementation Toolkits – by vendor interface typeExisting toolkits Readiness and QA checklistsWork plan and resource estimatorsBusiness case modelSystem test plan, conditions and sample data for modification

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Knowledge Base Input

AIRA Abstracts – inventory of articles covering Immunization Registry Business Case (Excel file)SPECIAL ARTICLE – “Standards for Child and Adolescent Immunization Practices”, National Vaccine Advisory Committee (NVAC), Pediatrics Vol. 112 No.4 October 2003

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Software Company Representative – GE

What do we in the immunization / registry community need to do to make an immunization interface and support functionality viable for EHRS software companies?What should the interface look like in the future – web services, HL7? And where should functionality be distributed between the EHRS, registry, and personal health record management systems?

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Immunization in Perspective –Support for EHRS


Individual Procedures and Consults – Hospitals, Specialty Clinics, Labs

Population and Holistic Individual Disease Management and Evidence Based Medicine –Registries, Data Warehouses, Measurement Sets, Clinical Practice Guidelines, Formularies (ex: Diabetes, AIDS, Immunization, NEDSS), Timed Interventions

Patient Health Record Management – Subjective input, record keeping, Portals

Other Healthcare Home Integration – Beep, beep….on a planet far, far awayKey – Alliance Focus Areas

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Addresses New NVAC StandardsStandards for Child and Adolescent Immunization Practices – National Vaccine Advisory Committee

Standards basically apply to adult immunizations as well

17 standards published in the October 2003 issue of Pediatrics. First revision since 1992. Our integration efforts impact these in various ways:

6 standards rely on it for success 6 standards rely on it for success 1.1. 12. Vaccination records for patients are 12. Vaccination records for patients are

accurate, complete and easily accessibleaccurate, complete and easily accessible –Integration across locations, History

8 more are directly addressedThe last 3 are not directly addressed

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Addresses New NVAC Standards – Availability of Vaccines1. Vaccination services are readily

available2. Vaccinations are coordinated with other

health care services and provided in a medical home when possible – EHRS, PMS, Registry Integration

3. Barriers to vaccination are identified and minimized – scheduling, guidelines

4. Patient costs are minimized - efficiency

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Addresses New NVAC Standards –Assessment of Vaccination Status

5.5. Health care professionals review the Health care professionals review the vaccination and health status of patients vaccination and health status of patients at every encounter to determine which at every encounter to determine which vaccines are indicatedvaccines are indicated – History, Schedule

6. Health care professionals assess for and follow only medically accepted contraindications – Clinical Guidelines, Entry Validation and Cross-validation

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Addresses New NVAC Standards –Effective Communication About Vaccine Benefits and Risks

7. Parents/guardians are educated about the benefits and risks of vaccination in a culturally appropriate manner and in easy-to-understand language – Registry and EHRS FAQ, CBT, Knowledge Base

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Addresses New NVAC Standards – Proper Storage and Administration of Vaccines and Documentation of Vaccines8. Health care professionals follow appropriate procedures for

vaccine storage and handling.9. Up-to-date, written vaccination protocols are accessible at all

locations where vaccines are administered – VIS tracking and electronic forms tied to procedures automatically generated

10. People who administer vaccines and staff who manage or support vaccine administration are knowledgeable and receiving ongoing administration – EHRS and Registry CBT, FQA, Knowledge Base functions

11.11. Health care professionals simultaneously administer as many Health care professionals simultaneously administer as many indicated vaccine doses as possibleindicated vaccine doses as possible – History, Schedule

12.12. Vaccination records for patients are accurate, complete and Vaccination records for patients are accurate, complete and easily accessibleeasily accessible – Integration across locations, History

13.13. Health care professionals report adverse events after Health care professionals report adverse events after vaccination promptly and accurately to VAERS and are aware vaccination promptly and accurately to VAERS and are aware of a separate program, the Vaccine Injury Compensation of a separate program, the Vaccine Injury Compensation Program (VICP)Program (VICP) – Built in prompting and functionality in registry

14. All personnel who have contact with patients are appropriately vaccinated

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Addresses New NVAC Standards –Implementation of Strategies to Improve Vaccination Coverage

15.15. Systems are used to remind parents / Systems are used to remind parents / guardians, patients and health care guardians, patients and health care professionals when vaccinations are due and professionals when vaccinations are due and recall those who are overduerecall those who are overdue –reminder/recall facilities in PMS, EHRS and Registry

16.16. OfficeOffice-- or clinicor clinic--based patient record reviews based patient record reviews and vaccination coverage assessments are and vaccination coverage assessments are performed annuallyperformed annually – auto generation of CASA and HEDIS reporting, EHRS patient record validation capabilities.

17. Health care professionals practice community-based procedures – Integration with WIC, Case Management and other

Chicago and Illinois – Integration Through Collaboration · • Replication activity bi-weekly – sharing data with central registry Quarterly training for new TOTS users 36 Computer

Documents