Depicting EHR’s Immunization capability

HL7 WGM - May 8, 2006

PeDS SIG Immunization Storyboard projectStoryboard Subgroup

Milestones May 2005 WGM

Storyboard project scope June 2005

Topic selection Definition of Storyboard vs.

Use case July 2005

Storyboard/Activity diagram Webinar (Dan Russler)

CHCA Sharepoint August 2005

IZ topic selection Storyboard iterations Activity Diagram building

September 2005 WGM Presented IZ storyboard and

activity diagram at WGM

October 2005 Glossary Webinar (Dan

Russler) November 2005

Glossary iterations Scoping for future directions HL7 v3 IZ project (Pharmacy

SIG) December 2005

Storyboarding strategy January 2006 WGM

Official engagement with HL7 v3 IZ project

Submitted project to Patient Care TC

Storyboard Activity diagram Glossary

Immunization Storyboard topic

Domain experts within PeDS SIG Public Health

Public Health Data Standards Consortium – presence of existing standards

American Immunization Registry Assn (AIRA) CDC

Primary Care CCHIT PeDS SIG

High Impact factor EHR-S DSTU (context)

EHR-S DSTU

ID Functionality

DC.2.2.1.2 Support for context-sensitive care plans, guidelines, protocols

DC.2.3 Medication and immunization management

DC.2.3.1 Support for medication and immunization ordering

DC.2.3.2 Support for medication and immunization administration or supply

DC.2.5 Support for Health Maintenance: Preventive Care and Wellness

DC.2.5.2 Notifications and reminders for preventive services and wellness

DC.3.2.5 Communication with medical devices

S.1.1 Registry Notification

S.2.2 Report generation

S.3.1.2 Encounter specific functionality

S.3.3.2 Eligibility verification and determination of coverage

S.3.3.6 Health service reports at the conclusion of an episode of care.

Depicting EHR’s Immunization capability

Focus on function than patient scenario immunization registry connectivity of EHR

Four basic functions from EHR-S DSTU Storage of IZ data Retrieval of IZ data Connection to the state/local registry Decision support capability (EHR or registry)

High level representation Consensus building Room for expansion Allow broad-based input

PeDS SIG Immunization Registry Storyboard iteration #4

Precondition: Billy Newpatient is 4 years old. He has been seen at other clinics in the state.However, he is a new patient at Dr. Shotz’s clinic. He is there for a pre-school physical. Dr. Shotz's clinic EMR is able to interface with state/local immunization registry.The state/local immunization registry conforms to CDC Minimal Functional Standards for Immunization Registries.The clinic EMR conforms to HL-7 EHR-S Functional Model.The state/local registry is able to locate the patient’s immunization record.

Storyboard: Billy has previously been seen at other clinics in the same state. The caretaker does not have his immunization record. In preparing his new patient record for Dr. Shotz to review, the nurse initiates the clinic EMR to query the state immunization registry. The immunization registry finds and sends data to clinic EMR. The clinic EMR populates Billy’s patient record with that data. The clinic EMR generates immunization recommendations using a decision support engine.

Alternate Flow #1: The state registry uses a decision support engine and sends recommendations along with Billy’s immunization data. Dr. Shotz reviews the record and notes (amongst other data) Billy’s immunization record (or its absence thereof) and recommendations. After taking history from the caretaker and performing physical exam, she orders immunizations. The nurse administers the shots and documents them in the clinic’s EMR. The clinic EMR sends the message about the new immunizations to the state registry which updates its record. The nurse also prints an updated paper record of Billy’s immunizations.

Alternate Flow #2: Dr. Shots determines that Billy does not require or decides to withhold immunizations at this stage. No updates are made to the immunization history in the patient record. No data is sent to the registry.

Post-condition: The state registry has successfully sent Billy’s immunization history.The state registry has successfully recorded Billy’s new immunizations.The clinic EMR has an updated immunization record.The patient has an updated immunization record.

Patient State/Local RegistryClinic EMRPhysicianRN

Prepares pt record for review

Initiates immunizationrecord retrieval

No immunization record

Generatesrecommendations

using decision support

Sends immunizationhistory to Clinic EMR

Populates immunizationdata in patient record

Searches forImmunization history

Requests immunizationrecord from registry

Populates newImmunization data

Administers shots

Orders immunization

Hx and PE; reviewsPx record and

recommendations

Unique patient identifier: Query

Unique patient identifier, Immunization record: Send

Accepts/Updates new Immunization information

to patient record

Prints updatedImmunization record

for patient

Updates immunizationInformation in EMR

Unique patient identifier, Update immunization record: Send

The state registry has successfully sent Billy’s immunization history.The state registry has successfully recorded Billy’s new immunizations.The clinic EMR has an updated immunization record.The patient has an updated immunization record.

Billy Newpatient is 4 years old. He has been seen at other clinics in the state.However, he is a new patient at Dr. Shotz's clinic. He is there for a pre-school physical.Dr. Shotz's clinic EMR is able to interface with state/local immunization registry.The state/local immunization registry conforms to CDC Minimal Functional Standards for Immunization Registries.The clinic EMR conforms to HL-7 EHR-S Functional Model.

Patient State/Local RegistryClinic EMRPhysicianRN

Billy Newpatient is 4 years old. He has been seen at other clinics in the state.However, he is a new patient at Dr. Shotz's clinic. He is there for a pre-school physical.Dr. Shotz's clinic EMR is able to interface with state/local immunization registry.The state/local immunization registry conforms to CDC Minimal Functional Standards for Immunization Registries.The clinic EMR conforms to HL-7 EHR-S Functional Model.

Prepares pt record for review

Initiates immunizationrecord retrieval

No immunization record

Populates immunizationdata in patient record;

displays recommendation

Sends immunization history and

Recommendations (using decision

support engine) to Clinic EMR

Searches forImmunization history

Requests immunizationrecord from registry

Populates newImmunization data

Administers shots

Orders immunization

Hx and PE; reviewsPx record and

recommendations

Unique patient identifier: Query

Unique patient identifier, Immunization record, Recommendations: Send

Accepts/Updates new Immunization information

to patient recordPrints updated

Immunization record for patient

Updates immunizationInformation in EMR

Unique patient identifier, Update immunization record: Send

The state registry has successfully sent Billy’s immunization history.The state registry has successfully recorded Billy’s new immunizations.The clinic EMR has an updated immunization record.The patient has an updated immunization record.

Alternate Flow 1

Patient State/Local RegistryClinic EMRPhysicianRN

Billy Newpatient is 4 years old. He has been seen at other clinics in the state.However, he is a new patient at Dr. Shotz's clinic. He is there for a pre-school physical.Dr. Shotz's clinic EMR is able to interface with state/local immunization registry.The state/local immunization registry conforms to CDC Minimal Functional Standards for Immunization Registries.The clinic EMR conforms to HL-7 EHR-S Functional Model.

Prepares pt record for review

Initiates immunizationrecord retrieval

No immunization record

Generatesrecommendations

using decision support

Sends immunizationhistory to Clinic EMR

Populates immunizationdata in patient record

Searches forImmunization history

Requests immunizationrecord from registry

Withholds immunization

Hx and PE; reviewsPx record and

recommendations

Unique patient identifier: Query

Unique patient identifier, Immunization record: Send

Patient waits for next shot schedule

Prints updatedImmunization record

for patient

The state registry has successfully sent Billy’s immunization history.The state registry has successfully recorded Billy’s new immunizations.The clinic EMR has an updated immunization record.The patient has an updated immunization record.

Alternate Flow 2

Lessons learned

Significant domain expert involvement Considerable iterations Constant communication during the build Balance between level of detail and

granularity vs. degree of consensus vs. work effort

Requires a standardized building approach

Updates

1st Immunization Storyboard deliverable HL7 Immunization project – Scott Robertson

Part of submitted IZ projects HL7 Version 3 Standard

Previously included in the Care Provision domain for May ballot; for “information only”

Now formally part of the Care Provision DSTU - see the Care Provision Domain-Storyboard Section.

Not attached to specific immunization messages http://www.hl7.org/v3ballot/html/welcome/environment/index.htm

Pediatric Immunization (DOPC ST000030)

Pediatric Immunization (DOPC ST000030)

Road to HL7 Standard Dev’t Process

Storyboard Text UML Storyboard Activity Diagram Domain Glossary

UML Domain Analysis Model Static Model Cross-Reference (to HL7 RIM)

SIG

HL7 Engineers

Domain Experts

TC

PeDS SIG Immunization Storyboard

Next Steps

Scope of future project (focus on Immunization) Breadth – requires more domain expertise Depth – requires more technical expertise (i.e., informatics,

engineers, developers, etc.) Pediatric focus?

PeDS SIG resources Clinicians Registry experts Public health Informaticians Vendors? International?

Examples of Breadth

Information System and Registry communication Hospital Military Health systems (i.e., Indian Health Service) School health systems RHIO Surveillance system

Registry to Registry communication (high level) HL7 Continuity of Care Document

Harmonization of CCR and CDA Immunization section

Others?

Examples of Depth EMR process

EMR queries registry EMR receives info from registry EMR updates registry EMR updated by registry EMR IZ decision support processes

EMR and Registry Process map for indications to withhold IZ (contraindications, previous

disease, etc) Inventory information exchange between registry and EMR Reporting of adverse reactions Sending batched requests from registry

Registry processes Registry receives query for a client from a registry or other IS Registry receives answer to query for client info Registry receives unsolicited update of a client record Registry receiving batched request for a number of patients

Next Steps

Divide and conquer Breadth? Depth?

Engage with HL7 IZ project Follow-up Patient Care TC

Follow-up leading to message definitions Pursue evidence of tangible impact/contribution within

HL7 development process Begin project documentation (storyboarding

process) Publish Guidebook

Process documentation for the storyboarding activities

Storyboarding How to choose topic

Priorities How to choose domain experts How to update versions (group editing

process/procedure) How to add granularity

Activity Diagram Glossary build