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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