HL7 Immunization User Group First Meeting April 10, 2014.

HL7 Immunization User Group

First MeetingApril 10, 2014

Agenda

• Welcome• Presentation on IIS Interoperability Status Check• Organization Updates• Future Work Group Topics• Open Discussion• Next Meeting

Welcome

• Introducing co-chairs:• Kim Salisbury-Keith• Nathan Bunker

• Welcome to the HL7 community – Chuck Jaffe• HL7 was founded in 1987, and now has over 2,000 members.• Global authority for healthcare information interoperability and standards• Announced establishment of this User Group meeting on April 2

• Welcome to the AIRA community – Alison Chi• The American Immunization Registry Association (AIRA) is a membership

organization that promotes the use of Immunization Information Systems (IIS)

Group Charter and Purpose

• Provide support for implementers associated with:• Immunization Information System (IIS)• Electronic Health Record (EHR)

• Focus on the following topics:• Education and training on how to use HL7 messages• Share lessons learned• Ask questions• Provide feedback that the Public Health and Emergency Response (PHER)

work group and the AIRA Standards and Interoperability Steering Committee (SISC) can use to make further improvements to the immunization standards

Welcome

• Meeting Schedule• Second Thursday of every month• 2:00 PM Eastern / 11: AM Pacific

• User Group Membership• Members of HL7• Members of AIRA• Special HL7 User Group Membership

IIS InteroperabilityStatus Check

Independent Report byNathan Bunker

Dandelion Software & Research Inc.

Background

• Certified Electronic Health Record (EHR) systems must be able to demonstrate the ability to support seven (7) scenarios• Developed in the Summer of 2012 by NIST with cooperation from the

Immunization Information System (IIS) community

• EHR system vendors are now building support and upgrading systems• This certification process is good news for IIS• Status Check project is designed to verify if IIS are ready to work with

these soon to be upgraded EHR systems• Short CDC project conducted in spring of 2013.

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Status Check Participation

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RIDE DC

PARTICIPATED

WILLING

Status Check Process

1. Seven (7) NIST test messages were submitted to each IIS2. The results were reviewed to determine if each message was

accepted3. If a message was rejected, changes were made to the message, and

the process was repeated starting from step 14. After all messages are accepted, the changes made to the message

were documented and analyzed5. Any change made that was not anticipated by NIST certification was

labeled as a “local requirement” or in other words local constraint

Results Overall

• All IIS that participated supported the HL7 2.5.1 or HL7 2.3.1 standard• The IIS that didn’t participate are known to already have or will have

soon HL7 2.5.1 interfaces • IIS have shown great support for the HL7 community standard by

universally adopting it• There are minor local variations that must be considered by any EHR

system integrating with IIS across the US

Results

• The most common reasons for minor local variations are:• Local requirements for identifying the

sender of the message• Inability to correctly handle vaccination

refusals or history of disease• Rigid enforcement of minor technical

requirements based on local interpretations of current or previous standards

• Problems correctly accepting or ignoring certain types of vaccination information

Identifying the sender of the message• IIS have several different methods used for identifying and

authenticating the sender of the message:• Transport Layer • MSH-4 Sending Facility • MSH-4.2 Sending Facility – Universal Id • MSH-8 Security • RXA-11.4 Administered-at-Location Facility• Combinations of any of these fields

• Problem of identifying the sender is common to all IIS• IIS are solving this problem in different ways

Vaccination Refusals or History of Disease• Many IIS are not prepared to accept vaccination refusals or history of

disease (such as history of varicella)• IIS are not required to store either of these types of information, but

shouldn’t reject messages that contain them

• NIST requires EHR systems to be able to report this information• All IIS will potentially receive vaccination refusals and history of disease

information

• All IIS should ensure that HL7 interface can:• Accept or ignore RXA segments with a CVX code of 998 in RXA-5• Accept or ignore RXA segments with Completion Status of RE in RXA-20

Too Rigid Enforcement of HL7 Rules

• Rejection of messages for optional or required-but-may be empty fields that are generally not critical to IIS functions:• Rejecting message because RXA-4 Date/Time End of Administration field is

empty• Rejecting message because the ethnicity code was not recognized• Rejecting message because value in RXA-9.2 was not what was expected• Rejecting messages because the LOINC in OBX-3 was not recognized

• IIS should not reject entire message if:• Problem occurs in optional or required-but-may-be-empty fields• Does not severly impact quality of core data received

Certain Types of Vaccination Information• NIST requires EHR systems to report the following information in OBX

segments:• VIS type• VIS published date• VIS given date• VFC status for immunization

• Many IIS complained or rejected messages with these types of fields in them• IIS may warn sender that these fields were not accepted• IIS should not reject messages when these fields are present

Other Local Rules

• Some other local rules were identified:• Requiring insurance information (IN1 segment)• Requiring address (very common requirement)• Requiring consent on child and/or adult records• Requiring that the sender NOT submit SSN• Requiring vaccinations for new patient records

• Many of these requirements should be documented nationally for EHR system implementers

• Some of these requirements could be captured as comments or defined optional uses in the national guide

Recommendations

• Short Term for 2013• Create a companion document to the CDC Implementation Guide that details

known local requirements• IIS should provide EHR vendors with regular and ongoing access to the IIS test

system – In Process, IIS are working to improve and establish test systems• IIS should work towards reducing local requirements and aligning to the

national standard, particularly in areas that do not directly impact local IIS policies and project requirements – In Process, release 1.5 gives guidance to prevent rejection of messages for small issues

Recommendations

• Medium Term for 2013-2015• IIS community should discuss and harmonize standards for authenticating and

identifying submitters – In Process, SISC is discussing• IIS community should discuss and harmonize the format and contents of

Acknowledgement (ACK) messages – Completed, included in release 1.5 guide

• IIS should continue adopting the national transport standard recommended by the Transport Layer Expert Panel – In Process, IIS are increasing adoption of this standard

Recommendations

• Long Term for 2013-2020• IIS Interoperability Status Check or equivalent process should be conducted

on a regular basis – In Process, at least a few major vendors and other IIS have implemented a version of the Status Check process in their software quality assurance process

• The process of identifying local requirements and aligning them to national standards should continue, either by encouraging the adoption of national standards at the local level or by defining and creating a national standard to support the common local usage – In Process, issues are being identified and discussed by SISC.

• Certification standard or conformance process for IIS HL7 interfaces should be developed

Get Involved and Next Steps

• The IIS Interoperability Status Check project has completed• A continuation project is now in beta stage of testing

• Open Immunization Software project• IIS HL7 Tester application• Testing application can be used to automatically test a real-time HL7 interface• Self-directed

• Next steps for community• Exploring creation of an HL7 user group• Expansion of input of testing process to entire community

For more information please visit:http://openimmunizationsoftware.net/interfacing/IIS%20HL7%20Tester.html

Organization UpdatesRob Savage

Public Health and Emergency Response (PHER)• Covers the following topics:

• Immunization• Electronic Lab Reporting• Case Reporting• Vital Records• Public Health-related CMETs

• Meets every Thursday at 4:00 pm Eastern• HL7 wiki: http://wiki.hl7.org/index.php?

title=Public_Health_and_Emergency_Response_work_group_%28PHER%29

Standards and Interoperability Steering Committee (SISC)• Provides technical support and guidance to interoperability efforts of

AIRA members and the IIS community• Changes to the CDC HL7 Immunization guide are discussed and

planned in this committee• Activities in March:

• Reviewed improvements for CDC HL7 Immunization Guide release 1.5. • Reviewed proposed changes to CDC WSDL• Dissolved Web Services Workgroup• Began discussions on Office of National Coordinator (ONC) Notice of Proposed

Rulemaking (NPRM) relating to an update to EHR certification

CDC Implementation Guide release 1.5• March 11, 2015 latest version published here: http://

www.cdc.gov/vaccines/programs/iis/technical-guidance/hl7.html• Some of the areas that were updated:

• Processing of errors• Acknowledgement and error handling• Query/response

• Corrected error and no match acknowledgement• Query for requesting evaluated history and forecast

Future Work Group TopicsNathan Bunker

Proposed Future Topics

• Identify gaps or areas of confusion in current standards• Demonstrations or updates on test systems

• Updates from NIST on EHR and IIS testing systems• Review of the Open Immunization Software (OIS) test process• Updates from HL7 on conformance testing software• Others?

• Review of systems that support automated onboarding processes• Discussion on recruiting additional user group members• Other topics?

Examples of Identifying Gaps

• Use of PID-3 for transmitting the Medical Record Number• Use of RXA-11.4

• Defined for transmitting location of administration• Used by many IIS for inventory tracking purposes

• Old administered vaccinations• An administered vaccination from 10 years ago with no lot number

• What standard should be used for two factor authentication on web service messages?

Homework Assignment

• Identify Gaps• What gaps have you seen in the standards?• What areas do you have questions on?• Are there items that have been problematic that you think need to be

clarified?

• Other Topics• Review list of topics proposed• Propose any other topics that need to be discussed

Open DiscussionKim Salisbury-Keith

Open Discussion

• Questions• Issues• Suggestions

Next Meeting

• May 8, 2014 – 2:00 pm EDT / 11:00 am PDT• Assignments before next meeting:

• Complete survey that will appear after the meeting• Forward list of gap, questions, and problem areas in the current standards to

[email protected] so they can be collected and discussed in the next meeting

• Think of other topics that could be discussed by the group

More Information

• Web Links• Subscribe to immunization group

http://www.hl7.org/participate/UserGroups.cfm?UserGroup=Immunization

• Public User Group Wiki http://www.hl7.org/special/committees/iug/index.cfm

• Private User Group Wiki http://iugwiki.hl7.org/

• HL7 Press Releasehttp://www.hl7.org/documentcenter/public_temp_F760602A-1C23-BA17-0C0D326E635471F9/pressreleases/HL7_PRESS_20140402.pdf

• AIRA Press Releasehttp://www.immregistries.org/events/2014/04/10/hl7-immunization-user-group

Contact Information

If you have any questions or comments:

Kim Salisbury-Keith [email protected]

Nathan Bunker [email protected]

Thank you!