Service-Oriented Architecture and Immunizations

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American Immunization Registry Association (AIRA)Ina Kichen, AIRAAlean Kirnak, Software Partners LLCSue Salkowitz, Salkowitz and AssociatesCindy Sutliff, AIRA

AIRA’s Standards and Interoperability Initiatives Early promoters of HL7, even prior to provider system

readiness Members of HL7 and sponsors of immunization

messages; work with pediatric EHR HL7 endorsed by NVAC as an IIS functional standard Work with CDC on HL7 v2.3 guide; now working on v2.5 Members of Public Health Data Standards Consortium

(HITSB, HISPC) Participation in Integrated Health Enterprise (IHE) Developer of IOA for interstate exchange of IIS data

with HISPC and PHDSC endorsement

Child Health Record and Public Health

Just as a complete health record exists for each child, an integrated view exists on a population basis

Immunizations have one place in that continuum How to achieve an integrated view of child health Service-Oriented Architecture (SOA) – provides a

direction for an integrated view

Source: Public Health Data Standards Consortium (PHDSC). Pediatric Electronic Health Record Public Health Perspectives. Report to Health Resources and Services Administration (HRSA), 2004, Baltimore, MD

Traditional Immunization Information System Approach

Point-to-point communication between providers and Immunization Information Systems (IIS)

Immunization Implementation Guides Existing HL7 V2.3.1 Implementation Guide New HL7 V2.5 Implementation Guide

IIS HL7 V2-capable sites

The CDC collects information annually from IIS grantees with regard to their HL7 capability and the extent of their deployment – IISAR (IIS Annual Report)

The CDC has provided yet unpublished information from the 2008 IISAR which shows a growing number of IIS have some level of HL7 uni- or bi-directional interface implemented including with many EHR vendors such as EPIC, GE, Next Gen, Allscripts and other smaller and more ambulatory products.

IIS HL7 V2-capable sites

If we were to send your IIS a query today for a specific immunization record via an HL7 message, could your IIS process that message and return either an HL7 message showing multiple matches to the query or return the immunization record in an HL7 VXR message?

IIS reporting capable: 45%

IIS not yet capable: 50%

States without an IIS 5%

IIS HL7 V2-capable sites

If we were to send your IIS a new immunization today via an HL7 VXU message, could your IIS process that message and upload the record into your database consistent with the specifications in the current version of NCIRD’s HL7 implementation guide?

YES: 54%

NO: 41%

No IIS: 5%

IIS Supporting Reminder/Recall

Can your IIS electronically generate remindernotifications? IIS reporting capable: 82% IIS not yet capable: 13%

Can your IIS electronically generate recallnotifications? IIS reporting capable: 84% IIS not yet capable: 11%

HL7 V2 Communication is Point-to-Point

Point to point:

Hub:

Bus:

HL7 V2 Economics

Approximately 75 U.S. IIS Completely connected point-to-point IIS network:

74 * 75 / 2 = 2775 connections Assume 200 regional provider EHRs per IIS:

200 * 75 = 15,000 connections Each connection costs $10K-$30K per side Approx $40K each * $711,000,000 total

And that’s just for immunization data

And that’s just for immunization data

Labs Meds Problem Lists …etc. Intra-enterprise communication Provider-to-Provider communication Provider-HIE communication ...

HL7 V2 Depends Upon Common Codesets

Canada Health Infoway Panorama project found they needed to address: 60 reference codesets (i.e. LOINC, SNOMED) 461 Panorama codesets 1,000 vocabulary domains 1,600 drop-down lists 495,763 drop-down options

Example: Canada Health Infoway

What Can Be Done?

HL7 V2.5 Implementation Guide aims at reducing customization by more accurate specification of codesets

Service-Oriented Architecture and Structured Document Approaches may offer a better direction

Computing in the Cloud (Service-Oriented Architecture)

Service Interfaces

Identity Resolution

Decision Support

Retrieve and Update

Hospital #2

Clinic #2

Hospital #1 EMR

Clinic #1 EMR

Internet

Browser interface

Existing IIS

Master Person Index

Document Repository

Data Stores

Document Registry

Services

Other Service

Security

Data Transform

Clinical Decision Support Service

Immunization Decision Support Service Takes immunization history and other medical conditions as input Returns evaluated immunization history and recommendations Includes contraindications and precautions Can support reminder and recall functions

Demo

Advantages

Accessible from anywhere Massachusetts example: immunization forecast accessed from

Personally Controlled Health Record (PCHR) Described in AMIA article by Kenneth Mandl MD, James Daniel

MPH and others at Harvard, Children’s Hospital and State Dept of Public Health

http://www.matchmerge.com/images/stories/amia-0439-s2007.pdf

Rules directly loadable into web service Offers possibility of AAP-CDC direct update

De-identified Accepts more medical history

Where to get that history?

Immunization Web Service IIS Sites

Massachusetts, San Diego County Software Partners Immunization Decision Support Service

Rhode Island KIDSNET service-enabled immunization algorithm service-enabled

by HLN Consulting. Could be expanded for EHR systems to access as well

New York City CIR immunization query/response and update for EHR systems

to send/receive histories and recommendations - service-enabled by HLN Consulting

Texas, Utah Web service version of IZ forecast used by Scientific

Technologies (STC) system

Documents and Repositories

Human-readable part .xslt

Structured data part Clinical authentication Wholeness Persistence

Document Examples

Continuity of Care Document (CCD) Particular type of medical summary doc CDA and Continuity of Care Record Based upon V3 Care Provision standard Increasing adoption of CCD and other Care Record

variants

IHE Cross-Enterprise Document Sharing (XDS) IHE Immunization Content (IC)

Based upon V3 Care Provision standard

http://www.matchmerge.com/content/view/146/283/lang,english

Identification Service

Commonly referred to as eMPI Cross-references identifiers for the same person,

enabling complete medical record to be retrieved

Identification Service

Benefits of SOA and Documents

Handles complete medical record, not just immunizations

Direct AAP access to decision support rules Economies of bus architecture (one hop to bus) User can glean value from human-readable

documents even if codesets not 100% compatible

Works with existing HL7 V2 infrastructure Workflow optimization (“agility”) Ability to create security layers Compatible with HITSP standards and direction

SOA implemented or planned in other IIS San Diego County – most IIS functions

Decision support, HL7 V2, patient identification and official immunization card

Massachusetts – statewide SOA initiative 10 states with STC implementations

HL7 V2 and WIC web service interfaces Contra-Costa County, CA – prototyping MI- WIC IZ status and planned expansion MN- using in DOH, planned expansion KS- WIC IZ status NYS- HIE grant, Electronic death registry AZ- looking at for HITECH

Putting it all together

“The Internet disrupted the music business; Google disrupted the media; cloud-based companies could become

disrupters in other inefficient industries. Buzzwords such as “Health Care 2.0”, … could soon acquire real meaning.”

- The Economist, Oct 25, 2008

Discussion of ARRA Opportunities