Meaningful Use and Bi-directional
Exchange of Immunization Data in
New York City
Kristen Forney, MPH
Citywide Immunization Registry
New York City Department of Health and
Mental Hygiene
Public Health Informatics
Conference 2014
OVERVIEW
 Citywide Immunization Registry (CIR)
Background: HL7 Data Exchange
 Definitions
 Interoperability Standards
 Interoperability Demo
 Benefits for Providers
 Benefits for IIS
 Supporting Data
 Future Directions
 Conclusion
CIR HISTORY
 Started in 1997
 Contains 70 million immunizations for 5.2
million patients
 Approximately 1800 active provider sites
 Reporting is mandated for patients 0-18,
consent is required for reporting immunizations
given to adults
 Paper reporting  Online registry  Flat file
 real-time HL7
CIR’S HL7 DATA EXCHANGE
 Real-time, bi-directional exchange through a
SOAP web service
 No batch file option for providers
 First facility began submitting data through the
web service in February 2011
 Currently 465 provider sites + 400 pharmacies
sending HL7 data through the web service; (189
provider sites are bi-directional)
DEFINITIONS
 Real-time
 Synchronous Transport- User submits an HL7 message,
and as part of that transaction/connection to the IIS, the
application waits for an acknowledgment response
 Synchronous Processing- Upon receipt of an HL7
message, IIS processes the message and
acknowledges the results of processing. Data is
immediately accessible to users of the IIS.
 Bi-directional
 EHR sends an HL7 query message (VXQ or QBP) and
receives a response containing patient’s immunization
history, evaluation and decision support
 EHR imports IIS data and stores it as structured data
INTEROPERABILITY STANDARDS
 HL7 2.5.1
 Supported by 44 immunization registries as of Sep
2013
 Well-defined standard for immunization reporting
(VXU) and query/response (QBP/RSP)
 SOAP Web Services
 National standard recommended by CDC’s
Transport Layer Expert Panel
 Supported by 30 immunization registries as of Sep
2013
[ B I - DIREC T IONA L D EM O ]
BENEFITS OF REAL-TIME
BI-DIRECTIONAL EXCHANGE
For Providers:
 Avoid double data entry (89 CIR facilities have moved
from online registry to HL7 web service)
 Accessibility of information (both immunization history
and clinical decision support) within provider workflow
 Accuracy of data within provider EHR
 Data immediately available in IIS for use with school
forms, other pre-completed forms
 Particularly beneficial for first-time EHR implementers
COLUMBIA PRESBYTERIAN HOSPITAL
* P < 0.05; ** P <0.01; *** P < .001; **** P < .0001
Stockwell, et al, 2010.
http://cdc.confex.com/cdc/nic2010/recordingredirect.cgi/id/6746
BENEFITS OF REAL-TIME
BI-DIRECTIONAL EXCHANGE
For an IIS:
 Timeliness
 Completeness of immunization information (lot number,
manufacturer, expiration date, etc)
 Providers have continuous interaction with the IIS
IMPROVED
AND
IMPROVEDVFC
VFCELIGIBILITY
AND LOT NUMBER
LOT NUMBER CAPTURE
CAPTURE
Data source
Percent of
Percent of
immunizations
immunizations
with VFC status* with lot number**
Flat File
88.1
59.0
Online Registry
93.6
45.3
HL7 Web Service
94.1
97.4
Total
90.5
68.4
*Data from all newly administered immunizations reported to the
CIR during calendar year 2013 for patients < 19 years
**Data from all newly administered immunizations reported to the
CIR during calendar year 2013
INCREASE IN ADULT DATA CAPTURE
Number of new immunizations reported for
adult patients
300000
250000
200000
HL7 WS
Flat file
150000
Online
DOH clinics
100000
50000
0
2011
2012
Year
2013
MEANINGFUL USE AND IIS
CIR built HL7 web service in 2009
Stage 1:
Began January 2011; Eligible providers and
hospitals must perform a test of EHRs
capability to send data to an IIS in HL7 format
Stage 2:
Began January 2014; Eligible providers and
hospitals must institute ongoing reporting to
an IIS in HL7 2.5.1 format
Number of provider sites using the HL7 web
service
INCREASE IN HL7 SITES
500
Uni-directional (report immunizations to the CIR)
450
400
Bi-directional (report to and receive immunizations from
the CIR)
350
300
250
200
150
Start of MU (Jan)
100
50
0
Feb-14
Dec-13
Oct-13
Aug-13
Jun-13
Apr-13
Feb-13
Dec-12
Oct-12
Aug-12
Jun-12
Apr-12
Feb-12
Dec-11
Oct-11
Aug-11
Jun-11
Apr-11
Feb-11
SHIFT IN REPORTING METHOD
100%
90%
80%
70%
57.2%
51.6%
46.9%
42.1%
39.8%
37.6%
37.4%
36.5%
35.4%
37.2%
35.4%
35.8%
32.9%
60%
25.5%
50%
35.1%
40%
38.5%
37.3%
34.5%
32.9%
34.4%
34.3%
28.3%
Online Registry
HL7 Web Service
40.9%
44.1%
30%
43.3%
20%
39.1%
25.1%
10%
0%
23.9%
25.3%
28.9%
31.7%
28.4%
30.3%
35.9%
41.7%
17.0%
3.7%
5.2%
Flat File
9.1%
Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013 Q4 2013 Q1 2014
CHALLENGES OF BI-DIRECTIONAL
HL7 EXCHANGE
 How can we ensure that the IIS finds and
returns the correct patient?
 EHR should send all possible demographic information
 Exchange unique IDs (Medical record number, IIS ID)
 Will the EHR display IIS data correctly?
 Thorough testing with the EHR vendor
 Involve providers in testing
 How will the EHR de-duplicate immunizations?
 EHR record and IIS record must be fully synced
to ensure accurate clinical decision support
BEST PRACTICES FOR REAL-TIME
BI-DIRECTIONAL EXCHANGE
For IIS:
 Webinars (or site visits) with providers to understand
how their EHR works
 Set up the ability to restrict queries from specific
accounts
 Store unique IDs sent by the EHR
 Data quality monitoring; daily e-mails
For EHRs:
 Store patient’s registry ID and send in all transactions
 Automatic re-query to get decision support updated
 Full sync of registry record with EHR record —critical
for accurate decision support
FUTURE DIRECTIONSIIS COMMUNITY
 Advocate for MU Stage 3 to include bidirectional exchange
 Reduce Variability in HL7 implementations
between IIS
 Find ways to partner with EHR vendors that will
be mutually beneficial
 Create a set of recommendations to EHR
vendors for best practices
CONCLUSIONS
 Meaningful Use has facilitated increased adoption
of HL7 standards among practices reporting to CIR
 Real-time, bi-directional exchange is feasible and
scalable to a large number of facilities
 Presents a number of benefits to both providers
and IIS
 IIS nationally have well-defined standards for
message content and transport
 Preference of EHR vendors in MU stages 1 and 2
has been for a unidirectional HL7 interface;
inclusion of a bi-directional requirement in stage 3
would accelerate implementation of bi-directional
interfaces
THANK YOU!
Amy Metroka
Vikki Papadouka
Angel Aponte
Paul Schaeffer
Contact Information
Kristen Forney
Director, EHR-IIS Interoperability Project
kforney@health.nyc.gov
347-396-2578