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

The Immunization Provider’s Toolbox:  Immunization Interfaces with State IIS

Cecile Town, MPH IHS Immunization Program

Division of Epidemiology & Disease Prevention

July 24, 2012

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.

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.

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.

The IHS Data Exchange InitiativeA 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

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

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.

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

CA

CO

SD

AK

WA

OR

MT

ID

NV

AZNM

UT

WY

ND

NE

KS

TX

OK

LA

AR

MO

IA

MN

WIMI

ILIN

KY

OH

MS

PA

NY

ALGA

FL

SC

VA

TN

ME

NH

MD

WV

Pending (13)

MA

RI

CT

DC

DE

VT

One Way(2)

Current IHS Immunization Data Exchange Operations

States w/non-Federally

Recognized Tribes or No Tribes (16)

Two Way (12)

NC

NJ

San Diego County IIS

Onboarding(8)

IHS Data Exchange 2012

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

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

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

ENHANCED IMPLEMENTATION PROCESS

Planning for Increased Uptake

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.

HL7 2.3.1 Process

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.

HL7 2.3.1 Process - Site

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.

Local Engagement

Pre-Deployment Testing

Verify with IHS Standard

Verify withNIST Certification

Verify withIIS Directly

Profile IIS InterfaceTest

Interfaces with IIS(Real-time or Batch)

RPMS 2.5.1 Development

Engage IISto connect local

IHS site

in progress...

in progress...

Engage local IHS site

Install Software

Create DQA Report

CDC Specification

IIS Specifications

HL7 2.5.1 Process

CA

Envision

SD

STC

STC

WIR HP

STC

WIR HP

Envision

STCWIR

UT

STC

ND

WIR HP

Envision

TX

OK

STC

AR

MO

WIR HP

MN

WIRMI

ILIN

KY

OH

STC

PA

NY

ALGA

FL

SC

VA

TN

STC

NH

MD

WV

ITU State, No Exchange

(13)

MA

RI

CT

DC

DE

VT

One Way Exchange

(2)

Current IHS Immunization Data Exchange Operations

States w/non-Federally

Recognized Tribes or No Tribes (16)

Two Way Exchange

(12)

NC

NJ

EDS

Onboarding(8)

IHS Data Exchange 2012

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.

Local Engagement

Pre-Deployment Testing

Software Development

Verify with IHS Standard Verify with

NIST Certification Verify withIIS Directly

Profile IIS InterfaceEstablish Test

Interface(Real-time or Batch)

RPMS v2.5.1 Development

Engage IISto connect local

IHS site

SSM Development

Engage local IHS site

Install Software

Create DQA Report

CDC Specification

Feedback

IIS Specifications

IIS

IIS

IIS

IIS

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.

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

Meaningful Use and Data Exchange

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

Meaningful Use ImplicationsStage 2 Proposed

For Providers IHS Comments & BYIM Process Enhancements:

Core All 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

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

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

Questions?

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

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

Local Engagement

Pre-Deployment Testing

Software Development

Verify with IHS Standard Verify with

NIST Certification Verify withIIS Directly

Profile IIS InterfaceEstablish Test

Interface(Real-time or Batch)

RPMS v2.5.1 Development

Engage IISto connect local

IHS site

SSM Development

Engage local IHS site

Install Software

Create DQA Report

CDC Specification

Feedback

IIS Specifications

Open Source Partnering

IIS Profiling Project

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/

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.