HIE-IIS Integration at the Sedgwick County Level
This report, initially submitted on February 13, 2011, is updated with information collected from
interviews and vendor-provided information at HIMSS11 in Orlando, FL, 2/20-2/22/11.
HIEs are emerging around the country, spurred by ARRA HITECH funding and provisions of the
Accountable Care Act. Public health departments at the state and local levels have varying
degrees of participation and influence on policy and operations. The Meaningful Use incentives
for testing the capability of reporting certain public health quality measures and in later stages,
the reporting itself from “certified” EMRs or HIEs give public health the hope that this required
reporting will be both less burdensome and more in real time, and therefore more complete and
useful than in the past, and support more effective tools for public health monitoring and
intervention.
Role of Public Health in HIEs
At the same time, many health departments, and specifically programs within them, have been
marginalized in the HIE process, at both state and local levels, despite their role and interaction
with community stakeholders as shown in the NACCHO diagram below: Many of the HIE
integrators have vastly superior technical capability and better funding, and the fear is that they
will have the ability to collect, manage analyze and report on a population health basis, and that
this data will be a salable commodity that will crowd out public health considerations as well as
public health institutionally.
Local public health agencies are more in danger of this outcome than the state health department
which has more statutory authority and funding than the local level. However, many local health
departments, in addition to their public health role, provide more direct health services to
individuals and therefore have personal health data of interest and importance to providers in the
exchange. How to capture individual personal health data from public health to exchange and at
the same time to supplement population health and public health program data via the HIE for
use by the health department is the important policy question that is the background for this
study.
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Sedgwick County Public Health Department Issues
Sedgwick County Health Department and its potential role in the HIE exemplifies these tensions.
They provide a number of clinical health services to individuals who may be considered clients
or patients. These are recorded as clinical encounters and billed to the patient or third parties as if
they were conducted in a private provider setting. Unlike some local health departments that
operate a complete set of primary care services in a FQHC or look-alike, these clinical services
are imbedded in programs which are categorically funded through Federal, state and local dollars
and are supported by a public health IT application specific to these requirements. The Sedgwick
County Health Department is not an eligible provider for meaningful use EHR adoption or
incentive payments.
Clinical Services
The clinical services which include immunizations, maternal and child health, TB, STD and HIV,
include preventive and therapeutic data which would be considered essential additions to the
person’s total health records that is the focus of the HIE. Moreover, the health department often
has to refer these patients to specialty services, and the private providers often need to access
community-based services or health information which the health department can provide. This
mutuality is especially present in the Patient Centered Medical Home primary care model and the
NCQA standards for PCMH recognition. The presence of a large number of both Medicaid and
Blue Cross sponsored PCMH practices should be a major driver for Sedgwick County Public
Health participation in the data exchange functions of the HIE.
Programmatic Services
The programmatic services, which are the population health and primary role of a public health
department are less understood by the public and are the most contentious with regard to the role
of the HIE. Immunizations are more widely considered a public health function because when an
outbreak of vaccine preventable disease is forecast or occurs, the public expects the health
department to respond and intervene, even though most of the immunizations are administered in
the private provider setting. The health department, is at its public best when it is mobilized and
visibly performing it functions.
Essential Public Health Community-based services
What is less understood are the Ten Essential Public Health Functions:
1. Monitor health status to identify community health problems.
2. Diagnose and investigate health problems and health hazards in the community.
3. Inform, educate, and empower people about health issues.
4. Mobilize community partnerships to identify and solve health problems.
5. Develop policies and plans that support individual and community health efforts.
6. Enforce laws and regulations that protect health and ensure safety.
7. Link people to needed personal health services and assure the provision of health care
when otherwise unavailable.
8. Assure a competent public health and personal healthcare workforce.
9. Evaluate effectiveness, accessibility, and quality of personal and population-based health
services.
10. Research for new insights and innovative solutions to health problems.
In the diagram below, which I developed for a workshop in Public Health Informatics, I superimpose some
of the informatics support on the Core Public Health functions “wheel”.
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These functions are sometimes invisible to the public even though they greatly affect the quality
of life of the community. With the aging of the population and the rise of chronic disease, public
health is a critical partner of the healthcare delivery system to promote wellness, reduce cost,
ensure safety and improve health outcomes. Public health functions are heavily data driven, and
the ability to collect, aggregate and analyze the data are core public health activities.
Public Health Data and Information
The vendor overview of the KHIN HIE solution addresses public health in both its provider and
population health roles, at least from an IT standpoint, and proposes a technical architecture with
an array of alternatives for extracting, exchanging and storing clinical data in almost any format
for both individual and population health purposes. Even more impressive are its range of
analytical and reporting tools available also at the individual, practice, community and population
health level.
What is not yet apparent is the governance, business and financial model of KHIN. The analytics
and the reporting have real monetary value. Is the HIE going to provide all of these services for a
fee? Are they going to be able to sell some of the data to other parties, or to charge a fee to users
for reporting their quality measures to CMS, NCQA, AHRQ, health plans and others from whom
providers obtain incentives? Will the health department have to pay to play, or do providers
choose whether to access state public health sites individually to avoid HIE fees, which are a
problem in some other states. How are population health and the public health functions going to
fare in the KHIN both at the local and state level?
Immunizations as a Public Health Case Example
Immunizations provide a good case study to examine these issues. They are a clinical preventive
health procedure and record. Proof of immunization is needed for day care, school entrance,
college, employment, and to be documented as a standard of care for chronic diseases and general
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health. Schedules of required vaccines are complex and cover ages birth to death. Therefore many
individuals do not keep their records over time and place, and are happy with a resource that
keeps them for presentation at the point of care or use. Immunization history is an essential
component of proposed personal health record (PHR) designs.
The states maintain Immunization Information Systems ( IIS), formerly called Immunization
Registries, and KS WebIZ is such a resource. IIS accept immunization data in a number of
formats to make it easier for providers to report, and these include direct data entry into the IIS
via a web interface, batch ascii formats, XML, and HL7, batch, bi-directional and unsolicited
query. These standards are converging on HL7 2.5 and have an Integrated Health Enterprise
(IHE) use case which has been tested and adopted.
Immunizations are represented as procedures (CPT codes) in administrative /billing systems and
as clinical health data, with HL7(CVX codes), content and interoperability standards developed
and managed by the CDC, the American Immunization Registry Association and the Public
Health Data Standards Consortium who are all members of HL7, among many. CDC Title 317
funding for both vaccines and operations, and under the latter, funds state Immunization
Information Systems (IIS), of which KS WebIZ is one, supports both the HL7 implementations
and the technical and operational infrastructure of the IIS according to a set of published
functional standards which are now undergoing review and revision. It is presumed that IIS will
have some certification standards and process in the future to be consistent with HIT and EHR
certification.
IIS Focus on Private Providers
CDC’s support of interoperability of the IIS with provider electronic health record systems
evolved from the initiation of the VFC program, which moved the administration of
immunizations from the public health department to the medical home, specifically a private
provider.
Many of the states where either independent or state-run local public health departments had been
the major source of immunizations, began to see higher percentages of those vaccinations move
to private providers, and many local health departments don’t provide them routinely, except for
flu campaigns or in the event of outbreaks where mass clinics are conducted, often under standing
orders of the health department if not done directly by health department staff.
Public and Private provider participation in KS WebIZ
As vaccines have become more expensive and reimbursement for providers does not cover the
cost, or because of the convenience of walk-in clinics, there has been a shift in some jurisdictions
of some providers advising their patients to get their vaccinations in a public health department,
or for adults particularly, at a pharmacy or related retail outlet. In addition, providers did not want
the burden of reporting immunizations to a state IIS, especially if it involves double data entry for
their staff.
For whatever reason, in Sedgwick County, a relatively high number of immunizations are
administered by the health department, and a recent study indicates that there is a shortage in the
number of private providers who administer vaccinations in their practice at all. This, along with
possible other factors, is reflected in a very low percentage of private providers, at least across the
state, if not in the county itself, participating in WebIZ at all.
Role of CDC IIS funding on IIS HIE integration
Most immunization program funding comes from the CDC to the states and includes the VFC
vaccine program as its most important funding component. Only a few non-state jurisdictions are
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funded for an IIS directly with Federal funds, such as Philadelphia, Chicago and New York City,
which have operated independently, until recently, when funding was available to link them to
their state IIS. A few states support regional IIS efforts by allocating the state funding, such as
CA, but even in the face of the growth of regional HIEs, the CDC is strongly encouraging a
centralized structure. Therefore, the Sedgwick County Health Department has no funding or role
to establish an independent local IIS, but will participate in the KS IIS as a provider, even if the
HIE later replaces their direct bi-directional HL7 interface with a local portal.
The CDC funding is categorical (siloed), even within the CDC, and only loosely coupled with
the CDC Public Health IT Program Office (PHITPO). Because public funding of vaccines is
politically controversial, and the 317 funding is discretionary and subject to annual
appropriations, the CDC IIS Support Branch, while promoting interoperability with EHRs, have
not specifically addressed the HIE role. CDC has very strong guidelines for the use of IIS
funding, and monitors performance closely with a required annual report known as the IISAR.
The IIS is closely linked to Immunization Program performance, so its main functions are to
support timely and complete vaccination according to published ACIP schedules of target groups
of babies, children, adolescent and adults, to promote the uptake of new vaccines, and to manage
the VFC program of distribution, administration, accountability and proper storage and handling
of VFC-funded vaccines. In the last month (February 2011) the CDC announced funding to link
the vaccine ordering system, VTrckS to state IIS. IIS are also used to conduct surveillance,
emergency and outbreak response, perform population-based coverage assessments and pinpoint
pockets of need for state and local public health intervention.
How this functionality is currently distributed to providers and other stakeholders such as local
public health departments, schools, WIC, foster care, correctional facilities, etc., and how the
HIE will facilitate and/or change these relationships has not been determined.
Population based
The CDC funded IIS are population-based and require the timely inclusion of birth records, along
with the hospital administered HepB vaccine at birth (where required) as the initiation of a record
in the IIS. One measurement of participation saturation is the number of birth records with the
hospital-administered Hep B recorded, which have two additional immunizations for that child.
In many states, the lack of additional immunizations following a birth record triggers an outreach
by the local health jurisdiction of the child residence to determine whether the child still lives in
the jurisdiction, or moved after the birth and needs to be removed from the denominator of active
persons.
This population health denominator can be generated only by the state, which executes privacy
and use agreements between the IIS and the state vital records function. The differences among
states with regard to these agreements, in some instances, create barriers to interstate record
sharing. This issue will have to be explored with the KS border states with which the HIE will
facilitate record-sharing.
State and Local Funding of IIS
Very few jurisdictions provide additional local revenue to fund the state IIS. Those that do often
have legislation authorizing the IIS and requiring reporting to it, and some even have a dedicated
funding source, such as the proceeds from tobacco settlements or taxes. KS has none of these
conditions. Therefore, the requirements and recommendations for integrating the IIS into the HIE
have to be financially sensitive to the burden of development and technical support, while
preserving the essential public health role of protecting the health of the population.
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The balance between the public health and immunization program roles and the role of the IIS in
HIT generally has just been affected by two recent announcements: One by the National Vaccine
Program Office and the National Vaccine Advisory Committee (NVAC) on February 24, 2011,
Electronic health records and other health information technology will play a growing and
significant role in vaccine safety surveillance and reporting to registries as part of the recently
released National Vaccine Plan, according to senior Health and Human Services Department
officials.
One of the top priorities of the vaccine plan is to expand and improve the use of health IT and
electronic health records that can exchange health information……In terms of better use of
vaccines, the report said that “immunization information systems and electronic health records
may become increasingly important components of immunization programs,” reducing the
problems created by people having unknown immunization status and receiving unneeded
vaccine doses. (Government IT News, Kathryn Foxhall)
The other by a CDC announcement on February 24, 2011 The Centers for Disease Control and
Prevention plans to enable the electronic health records (EHRs) of state and local health
departments to share data with immunization information systems, and to integrate the
immunization systems with CDC’s vaccine tracking system. All state health departments have
some type of immunization information system, but they have a variety of functionality. CDC
wants to assure interoperability between these systems and EHRs.
CDC plans to award a contract to provide technical assistance to enable this functionality,
including project management, operations and assessment to support CDC grantees’
immunization information systems and to interface with CDC tools, including its vaccine tracking
systems, according to a Feb. 24 announcement in Federal Business Opportunities
The Vaccine Tracking System (VTrckS) integrates the publicly-funded vaccine supply chain
from purchasing and ordering to distribution of the vaccine. It allows healthcare providers to
order vaccines directly. The system evaluates vaccine orders against specific guidelines set
by state, local and territorial health department grantees and CDC. VTrckS went operational
in December 2010 with four public health pilots in Michigan, Colorado, Washington State, and
Chicago, CDC said. ( Government Health IT, News, Mary Mosquera)
The more the CDC funding is tied to functional requirements and technical architectures that
favor point to point bi-directional exchanges between the IIS , the more difficult it might be for
regional HIE efforts to distribute the functions and the data locally. Some of this funding is newly
announced and program guidance has not been issued to grantees. The National Immunization
Conference at the end of March might provide some global discussion of these topics,
Record Matching and Record Locator
Probably the most significant support of public and population health that the HIE will support is
the creation and operation of an Enterprise Master Person Index and a Record Locator Service.
This will be essential to support efficient and effective record searches and provide criteria to
establish matches without returning a large number of “probable’ matches.
Two conditions are barriers to participation and use of an IIS:
 Search criteria for queries that do not identify matches so that the process is either too
time consuming or not selective enough to prevent new records established when a record
exists.
Record matching facilitates deduplication of duplicate records already in the system.
 Not a large enough critical mass of records to make the search worthwhile even if the
search arguments are effective.
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Since KHIN will be searching for the record for wherever information on the person exists, the
record locator service is essential to decreasing search time and finding the records.
However, the increased provider participation which the HIE might promote is essential to
improve the second barrier which now exists.
Policy and Technical Considerations
A recent, very extensive study conducted by the Public Health Informatics Institute examines the
policy and technical considerations of HIEs and IIS. It was mainly written by Shaun Grannis and
Brian Dixon of the Regenstrief in Indiana, which uses a technical architecture similar to that
which the ICA will deploy in KS.
Business Process Analysis
Because the study has already described the business processes that mirror the ones in KS which
were documented in the report by Alastair Matheson, and the policy issues are the same, I have
received permission from Bill Brand to use this report extensively with the following attribution:
“From Leveraging Immunization Data in the e-Health Era: Exploring the Value, Tradeoffs, and Future Directions of
Immunization Data Exchange, Copyright 2010 by Public Health Informatics Institute. All rights reserved.” Quoted
sections will appear in italics.
Sedgwick County has this report, so that rather than replicate all of the diagrams, I am going to
cite passages in the report and their relevance to possible Sedgwick County directions.
In the section above, I have already described some of the tensions between the patient
centric care approach of KHIN and the population and public health requirements of
KDHE and also Sedgwick County and other local health departments.
Technical Architecture
The PHII report outlines 3 architectural approaches to exchanging immunization data
between source systems, the HIE and the IIS. The model that best suits the present state
in KS, takes the best advantage of the IIS existing infrastructure and promotes provider
participation by better managing the interfaces is what the report calls the Synchronize
all sources p 19 and which I will call the Hybrid Model:—The third model aims to
synchronize immunization data between the HIE, IIS, and EHRs. This approach
recognizes the current status quo: immunization data are distributed among separate
systems and no single source may be authoritative for any given patient. It is important
to note that the data synchronization/update process as discussed in this document only
occurs for a specific EHR system when triggered by that EHR’s query to the HIE on a
specific patient; immunization information is not “pushed” to multiple EHR systems
every time a new immunization is given to that patient by another clinic.
Recommendation: Initially adopt this Hybrid model. In it, the Sedgwick County Health
department would be treated as a provider. It will continue to access and report to WebIZ via the
KIPHS interface, since it is not an eligible provider for Meaningful Use incentives and does not
need to participate via a “certified” agent.
Other providers could continue to report through their EHRs or via the HIE, even using DIRECT
via the HIE. As the HIE developed its protocols and became a “certified” source, providers could
meet their meaningful use requirements by reporting via the HIE.
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This approach would have the effect of promoting reporting to WebIZ and improving the
completeness and accuracy of its records. IIS participation improves dramatically when there is a
critical mass of records in a community and providers can see the immunizations its patients have
had outside of their offices, and particularly by the health department.
Community- Based Reports:
Recommendation:
When WebIZ is able to produce community-based reports for local health jurisdictions, they will
have more value to Sedgwick County in assessing coverage and determining pockets of need.
Alternatively, perhaps the extraction, reporting and analysis functions described in the ICA
overview could be directed to Sedgwick County Health Department to produce the reports for the
county.
Query and Response
WebIZ does not yet support the unsolicited HL7 query which would push the information to
multiple systems, so the hybrid approach, which also does not support this, does not deliver less
functionality than is already available.
Recommendation:
The workflow should begin with a query to WebIZ which would return a record with all of the
immunization history in the record as of that date. Because the records are updated at the point of
care, even if different from the one where the last immunization was administered, it would have
the information at the time it was needed.
If the provider organization wanted to run quality reports or reminder recall, the process should
be conducted using the WebIZ records, not the local ones unless the provider EHR incorporated
the WebIZ immunization history that it did not have into its own EHR.
Role of IIS
As the PHII report suggests, the Hybrid Model might be the most practical and incremental step
until either or both the HIE and the IIS mature and penetration of the HIE is fully expanded. At
that time the role of the IIS itself should be re-examined. Perhaps it becomes only a data
repository for reporting and assessment and is used by KDHE for immunization program support.
Immunization Forecasting Algorithm
A key element of immunization data exchange and use in the clinical setting is immunization
forecasting which is a clinical decision support component which assesses the immunization
history compared to the official ACIP Recommended Schedule of Immunizations for the
appropriate age group of the patient. It is clear that the NVPO and NVAC view this assessment
and recommendation feature of the IIS to be critical in reducing the over immunization which is a
cost and safety issue affecting vaccine uptake and coverage.
All IIS are required to have a recommendations algorithm, and these are managed and deployed
differently. All are table driven and updated and maintained, either by IT support or program
staff, upon directions from the state health department based on the CDC schedules. However,
some are within the IIS application and some are delivered via Service Oriented Architecture.
State immunization program maintenance of the algorithm is preferred to insure consistency of
the measurement for accurate coverage assessment and for the generation of reminders and
recalls. Often these have to be adjusted during shortages of specific vaccines or introduction of
new vaccine combinations.
Some jurisdictions allow certain areas of flexibility to conform with local practices or
recommendations of different medical organizations such as the AAP. There are also accelerated
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schedules for persons getting a late start in beginning a series or to meet school entrance
requirements.
EHR certification requires various clinical decision support tools and many EHRs have local
immunization forecasting algorithms. Particularly in patient centered medical homes, where
patient reminders for preventive services are part of the standards, this functionality is included.
However, unless the algorithm is operating against a complete up to date immunization history,
its recommendations will be flawed, reducing provider confidence in its use. This results in
several negative consequences: over immunization of patients who cannot document more
immunizations than are in the record; provider “eyeballing” the immunization history and
recommended based on “experience”; and use of local algorithms that have not been tested
against the most current ACIP schedules.
Recommendation:
The state will need to continue to support the algorithm in WebIZ to perform statewide coverage
assessments. While it will not be likely to have only this instance of the algorithm, it will be
practical to have a source of algorithm specifications and an approved testing procedure by NIST
for this and other iterations. This is a work in progress, and once it is in place, it will be used for
EHR and HIE certification.
In the interim, since we are recommending a hybrid approach, the WebIZ algorithm will improve
both by application changes and by a larger body of immunization records in the system and local
algorithms will be standardized via the certification procedure.
As the KHIN rolls out and some of the complexity is reduced, a policy decision can be made
regarding how many iterations of the immunization algorithm and other clinical decision support
elements will be needed and which of these will reside in the HIE. For example, ICA could
provide a recommendation algorithm via web services as an adjunct to CareAlign lite. Approved
algorithms are available for Microsoft Health Vault architecture which may be used by ICA.
Linkage and Synchronization:p.21-22
There are two categories of linkage challenges that immunization data management
systems face; data must accurately link at the person level (identify duplicate patients),
as well as at the immunization level (identify duplicate vaccines). While the EHR and
HIE systems ideally deliver de-duplicated patient-level immunization data to the IIS,
systems that exchange “round-robin” transactions in an effort to synchronize records
will invariably transmit duplicate transactions. Robust matching methods and tailored
business rules are needed to accommodate the vagaries of the data. In addition to robust
matching algorithms and business rules, the INPC uses “data source” to aid in detecting
duplicates. The INPC requires that each transaction clearly and consistently identify the
sending organization. This is true for all transactions received by the INPC, without
exception, and is also true for almost all IISs nationally. This requirement can help track
duplicate immunization information across multiple data sources by tagging each
immunization transaction with the identity of the sending organization.
Recommendation:
Adopt the recommendation to tag the data source and apply the best practice guidelines
Vaccination Level Deduplication in Immunization Information Systems
Recommendations of the American Immunization Registry Association (AIRA)
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Modeling of Immunization Registry Operations Workgroup (MIROW)
December 7, 2006
The report section Existing and Emerging Technical Guidance, beginning on p. 21 – 26
contains all of the relevant standards, vocabulary and testing criteria necessary for implementing
the recommendations.
The report documents the workflow and the technical standards that obtain. The report also refers
to system barriers to integration. Here are some of these in detail:
Privacy policies: p.27
A fundamental issue related to the exchange and synchronization of immunization data is
whether the state’s immunization laws allow the HIE to function as an intermediary for
information exchange.
Two types of laws may pertain: (1) an immunization data sharing law; and (2) enabling
legislation for the IIS
KS does not have legislation or regulations enabling the IIS, or requiring provider reporting to it.
A state’s immunization data sharing law likely specifies whether consent is required, who can
disclose the immunization information (especially without consent), and perhaps for what
purposes.
KS does have a law requiring written consent for sharing immunization data to the IIS.
At this time, consent is managed at the provider level and records where consent has not been
recorded are not reported to WebIZ. These provisions are covered in the Provider Agreement with
WebIz which governs provider reporting and access. It is not known how this will affect provider
reporting to WebIZ to comply with Meaningful Use.
KS is proposing privacy legislation governing the exchange of records and the consents required.
ICA has the option for opting out at any level, patient, provider or procedure, and providers may
determine not to enter certain procedures and has the capability of managing consents and
privacy.
Recommendation:
Proposed legislation might consider specifically addressing public health information, following
the HISPC Collaborative recommendations and permit the HIE to manage the consents for these.
These policies should be harmonized at the outset and incorporated into the technical design.
Workflow and Data Characteristics p.27
Not only do HIEs/IISs face differences in privacy policy requirements, but there can be
differences related to data characteristics, quality, and workflow. Clinicians rarely
capture inventory data, whether for vaccines or supplies, as part of routine care
processes; if necessary, inventory data must be captured through other means.
Inventory tracking methods vary from fully electronic in larger systems to paper-based in
smaller settings. Few EHRs incorporate inventory tracking as a core, standardized
component. Also, the field level data elements routinely captured may vary across care
settings, and while successfully capturing new data elements in local clinical applications
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is ideal, gathering new data in deployed local systems is challenging, because it requires
changes to either software or workflow, or both.
Many IISs provide vaccine inventory functionality but it is typically dependent upon the
provider manually entering data on vaccine(s) administered. Use of a standalone
application outside of a clinic’s EHR or other system does not readily fit into a clinic’s
workflow.
New national EHR certification requirements, as well as the natural maturing of the EHR
marketplace over time, may improve inventory functionality but this is not likely to occur
very rapidly given much larger emphasis nationally on care improvement functionalities.
WebIZ has a decrementing inventory function, and this is optimized for VFC vaccines.
Sedgwick County maintains inventory functions in KIPHS and therefore does not use the
function in WebIZ. CDC has been developing a coordinated inventory and vaccine ordering
system, VTrckS, over the last decade has piloted in four IIS, one, Chicago, at the local level, and
one, Washington, a universal vaccine state. Another, Colorado, has the same IIS vendor as KS. .
CDC describes VTrckS as follows: The Vaccine Tracking System (VTrckS) integrates the
publicly-funded vaccine supply chain from purchasing and ordering to distribution of the
vaccine. It allows healthcare providers to order vaccines directly. The system evaluates vaccine
orders against specific guidelines set by state, local and territorial health department grantees
and CDC.
CDC’ announcement may eventually lead to a mandate for providers to use this functionality in
the IIS to order and account for VFC vaccines, but this does not seem to be an essential
requirement for either EHRs or the HIE to prioritize, especially because KS is not a universal
vaccine state, and providers maintain inventories for both VFC and privately purchased vaccines.
Because the KS IIS vendor will be developing this capability for its client CO, it may only require
adaptation in KS to support this function for the KIPHS interface.
Recommendation:
HIE: The reporting of a vaccine directly administered (as compared to a recorded vaccine history)
requires the lot number and manufacturer as documentation whether or not the information is
automatically provided by a vaccine inventory function, scanned from the vaccine vial or entered
on the clinical immunization record.
Since the decrementing inventory is a feature of WebIZ, those providers who wish to access and
use it would not be precluded, if it is useful to their operation.
The issue will need to be re-examined if use of the inventory is essential for VFC accountability
or ordering for those providers that participate in the VFC program, or if the state were to move
to universal vaccine status (unlikely.)
Improving Integration by Extending IIS Functionality to Meet Stakeholder Needs
Most IIS have generated provider participation by accepting incoming records via direct data
entry into the application and by a variety of electronic formats in a batch mode with varying
periodicity based on the provider’s ability to generate them and the volume. With the growing use
of EHRs by providers, IIS are increasing supporting HL7 interfaces to provider systems in a oneoff manner, which is both costly and time consuming. Using the HIE to mitigate the need for
maintaining all of these interfaces is one solution. Using DIRECT from the EHR or via the HIE is
another strategy for sending records to the IIS as updates.
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Query Capability
With regard to the query, the best of these interfaces bring the provider to the IIS application
through a query to the EHR itself as a pass through to the IIS and respond to a query on a single
records with a record match or group of possible matched records.
Extending performance and functionality
In order to interoperate with HIEs, IISs must either rely on HIEs to respond to such data
requests, or implement architectures that accommodate a broader range of data exchange
methods and system response requirements; in fact, an increasing number of IISs can do so.
For example, IIS implementers may consider ensuring the system’s ability to efficiently receive
and respond to high-volume, real-time immunization transactions on a patient-by-patient basis,
rather than solely in batch mode.
Further, IISs may extend beyond single-patient queries by implementing the ability to promptly
accommodate multi-patient (cohort) queries (beyond requesting a summary or line-listing report
If these conversations have already begun with WebIZ, the results have not been conveyed for use
in this report. A recent e –mail, March 7, 2011 from the Ray Seggelike, Envision Technology,
the KS IZ vendor, says:
We can't really speak to the plans or progress of an HIE within the state of Kansas as we are not
currently involved in any direct conversations with this initiative. The last I heard, the KDHE
Immunization Program was participating in the HIE discussions. I would assume that Deb
Warren would be the best source of additional information. The only thing I can assure everyone
is that Envision will only become involved in integrating KSWebIZ with KHIN if/when the KDHE
Immunization Program approves any related tasks.
From a more general Envision/WebIZ product perspective, all discussions we've had with our
clients regarding integration with an HIE have been centered around how we can capitalize on
our HL7 interface. It only seems logical to approach this type of information exchange by using a
proven interface standard. Some of our clients are starting to explore the idea of integration with
VTrckS, but we haven't gotten into detailed design discussions with them yet. I would anticipate
this interface to be based on the existing data exchange mechanisms that VTrckS has defined.
KHIN Goals and Objectives include the following related to immunizations:
In 2012 KHIN will provide community level monitoring of immunizations .
In 2012 provide community health information exchange organizations, KDHE and other health interested
organizations with the state immunization information system, WebIZ
Outcome: Provide aggregated de-identified community level reports to public health and other health
interested organizations
Meaningful use: Improves targeted delivery of care and more efficient use of county resources.
Recommendation:
Adopt the Hybrid architecture approach, described above, which expands the current state with
services offered by and complementing the current state with KHIN capability.
Web-IZ is designated as the data store for all immunization histories in KS and must be linked to
KHIN.
All public and private providers query, add or update records in Web-IZ via one of these
methods
 Direct data entry into WebIZ
 EHR interface
 DIRECT
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

KHIN
Sedgwick county continues to administer and record immunization histories into Web IZ
using the KIPHS interface
Complete accurate record of immunizations is accessible to authorized providers, either as view
only or as importable record depending on permissions and use and need.
Standards
HL7 v2.5 or IHE are the defined standards for immunization records, and there is a CDC
endorsed HL7 balloted HL7 implementation guides which is observed by WebIZ and other state
IIS and defined in Meaningful Use Stage 1 for reporting immunization messages to the IIS.
An HL7 message can be either the response to a query. An unsolicited update may be supported
when implemented by Web IZ for EHRs with this competence .
A query may be a simple as one system requesting WebIZ to send all of the immunization history
for a patient with the complete name and date of birth (or record number is that is used) .
Unsolicited updates, when available, typically contain data about the completion of an action
concerning a given patient and are sent without one system querying the other.
You can query or re-query for anything that has been sent. Both queries and unsolicited updates,
when enabled, messages may be either display or record-oriented.
Only Provider who administered immunization has permissions to change or correct record in
WebIZ
The following are services and options which are available in multiple systems. It is likely that
those services offered by ICA will be the most robust and efficient to administer. However, it will
have to be determined how instances of these functions in other enterprise systems participating
in the HIE will be prioritized and harmonized:

Master Person Index

Record locator service

Deduplication algorithms

Decision support –recommendation algorithm

Maintenance of CDC childhood, adolescent and adult schedules
Master Person
Index
Record Locator
Service
Record matching
and deduplication
Decision Supportrecommendation
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HIE
X
Provider EMR
X
Web IZ
KIPHS
X
X
X
X
X
?
Page 13 of 21
algorithms
Management of
patient consent
Management of
exemptions/refusals
Authorizations
Auditing & alert
Privacy & Security
*Patient/Parent
access to record
Quality measures
HEDIS, MU
Dashboard metrics
Reporting and
analysis
X
May or may not
X-up to a point
X
?
May or may not
X
?
X
X
May or may not
May or may not
X
Limited
X
?
X
May or may not
X
Does not offer
electronic access
X
May or may not
X
X
May or may not
May or may not
X
Does not offer
Electronic
access
Working on
HEDIS
Do not have
Limited but
being expanded
X
* Parents are provided with printed immunization history in state approved format from provider
or local health department but cannot log into the IIS and obtain a record electronically.
IIS Functions:
Administrative
 Enrolling IIS Users
 Provider agreements
 Sign on and authentication
 Training and help functions
 Managing consent
 Documenting exemptions/refusals
Record Search
 Query- looking up the patient record in the IIS
Best practice: single data entry: one query into a local system or EHR via a window to the IIS
Query into the IIS application- possible double data entry to a local system as well
 Locating and matching the query to a record in the IIS
Exact match issues
Record Locator Service
 Retrieving immunization history
 Adding history provided by patient if not in presented record
 Adding history of disease, if applicable
Assessing immunization recommendations
Administering vaccine
Documenting vaccine administration, vaccine, lot number, manufacturer, date of administration,
site of administration
*Adverse events
* Contraindications
VFC functions
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 Identifying eligibles
 Vaccine ordering
 Vaccine inventory
Reporting to IIS
 Upon administration
Update IIS via data entry into application
Update EHR or local system which also updates IIS
 Batch
HL7
Formatted file as defined by IIS
Population coverage assessment
IIS-enabled patient panel and canned reports
Available to Sedgwick County only for those whom they vaccinated, not all in county
New access possibilities
New algorithm possibilities
New reporting alternatives
Detailed Technology Discussion added from HIMSS
PROPOSED APPROACHES
Continued Use of KIPHS by Sedgwick County Department of Health
PROS:
The KIPHS system is an old, but serviceable public health system which supports both the
clinical and program activities of the health department.
The bi-directional HL7 interface between KIPHS and KSWebIZ is standards-based, functional,
appropriately scaled and technically supported.
This is an appropriate starting point for the Sedgwick County Health Department while IIS
participation is increased, and while other clinical functions supported by KIPHS are examined
for exchange within the HIE.
Proposed work between NACCHO and Public Health Data Standards Consortium of business
process and requirements for a local Public Health EHR IHE profile will inform Sedgwick
County Health Department on future direction.
CONS:
Weak points, which include patient search algorithm, recommendation algorithm and vaccine
inventory, which are used via local system instead of through WebIZ . However, some of these
are a function more of the data insufficiency and usage rules than in functionality of the system
itself.
Sedgwick County might miss an opportunity to replace an aging system if such change would be
funded now by HIE implementation.
Selective Use of DIRECT
The Direct Project establishes secure, scalable and standards-based specs to transfer medical data
to trusted recipients over the Web.
Envisioned as an easy-to-use, Internet-based complement to the Nationwide Health Information
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Network ( NHIN), the Direct Project enables the encrypted "push" of health information from a
sender to a known receiver – replacing paper-based mail and fax transmissions.
PROS:
High Level Endorsement
Speaking on a conference call Wednesday afternoon, IT chief David Blumenthal, MD, said that
the "NHIN Direct Project is an essential element" in making the regular electronic exchange of
patient data a reality nationwide.
Importantly, he said, it does so "not just for big sophisticated healthcare systems that have hot and
cold running health information technology support, but for 'the little guy' – the solo practitioner,
the storefront, the critical access hospital. Basically anyone in the world who can use the
Internet."
The system, he said, is "simple and elegant and very meaningful for patients and their caretakers."
Published on Healthcare IT News (http://www.healthcareitnews.com) mmiliard, 2-2-11
Relevant pilots
Since mid-January, HCMC, Minnesota’s premier Level 1 Adult and Pediatric Trauma Center, has
been successfully sending immunization records to the Minnesota Department of Health.
"This demonstrates the success that is possible through public-private collaborations,” said James
Golden, PhD, Minnesota’s state HIT coordinator. “This is an important milestone for Minnesota
and a key step toward the seamless electronic movement of information to improve care and
public health."
Vendor participation
The Direct Project was launched in March 2010 as a part of the Nationwide Health Information
Network.
Participants include EHR and PHR vendors, medical organizations, systems integrators,
integrated delivery networks, federal organizations, state and regional health information
organizations, organizations that provide health information exchange capabilities and health IT
consultants. Participating vendors included Allscripts, Cerner, Epic, GE, Google, IBM, Intel,
Microsoft, NextGen, Siemens and SureScripts.
KS Vendor ICA will be supporting DIRECT as part of its KHIN deployment
Support for Providers
In addition to ICA support, the Academy of Family Physicians, sponsor of TransforMED, the tool
for transformation of practices into Patient Centered Medical Home, has announced on Feb 15,
the AAFP Direct Portal. AAFP Physicians Direct is a secure electronic messaging service for
family physicians and other health care professionals, which has been developed in conjunction
with SureScripts, a large electronic prescription network.
At HIMSS, I had an opportunity to interview Shaun Grannis, the lead author of the IIS –HIE
integration document. I talked to him about the DIRECT portal that the American Academy of
Family Physicians specifically to meet MU reporting. Dr. Grannis, a practicing Family Physician
himself, said that having an organization to manage the portal and its privacy and security
requirements will help small providers to meet meaningful use before they may have fully
implemented an EHR or participate in an HIE.
CONS:
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This is PUSH technology and supports only the simple exchange of records between parties, It
would not, in itself support the kind of robust query and response of a fully-bidirectional HL7
interface or access to the decision support and other features if an IIS.
Although the ONC is supporting DIRECT projects, there are some questions of how or whether
DIRECT will compete with other EHR interface or HIE architecture and/or how will it fit within
the financial sustainability model for the HIE.
Will providers be content with the minimum necessary to report public health and not develop
more feature rich interaction with the IIS.
Recommendation:
ICA will be supporting DIRECT and so will AAFP along with other vendor systems that
providers may already be using. If one of the goals is to populate KS WebIZ to increase the
number of complete immunization histories, including those from providers now not
participating, the encouragement of using DIRECT for this purpose, while also allowing
providers to report immunizations for MU incentives is a good strategy. It would also promote
reporting from pharmacy and retail clinics who administer immunizations to increase the number
of adult records in the IIS.
It could also be used by Sedgwick Department of Health to send referrals for specialty services
and other clinical data than immunizations which is not in standard HL7 format but could be
pushed to providers who need it as a first step in an interoperable solution.
As a long term strategy, it will need to be examined with regard to the CDC's initiative to link
providers to the vaccine ordering, and possibly at some later time to require such linkage to
manage VFC vaccine accountability if that evolves.
Selective Deployment of ICA EHR Lite
ICA representative, John Ingram, with whom I met at HIMSS described their proposed EHR-lite
offering, Care-Align lite, a stripped down version of their CareAlign EHR. It has a set of limited
EHR functions that a provider might deploy as a “starter” product on the way to implementing an
EHR, or a product to supplement a practice management or disease registry software that would
allow the provider to exchange records and also report quality measures for MU including the
public health menu options.
Unlike DIRECT, the EHR lite provides bi-directional exchange
PROS
This would resource providers with an entry level product in a hosted environment and would
probably be certified as a “module” to be applicable for MU for defined functions. Deployed via
the HIE, in the cloud, it will obviate the need for local servers and technical support. It could be
used by providers with limited services, such as a retail clinic, and possibly a local health
department .
CONS:
EHR-lite is not in full production and may lack functionality it might deliver at a later time as
web services.
Recommendation:
Likely, the Regional Extension Center will need to work with providers to help them determine
the applicability of the Lite version to their needs This proviso might also apply to the Sedgwick
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County Health Department.
Longer Term Strategic Issues:
As HIT and HIE’s mature, many of these alternate paths will have to converge, as maintaining
and managing all of these point to point interfaces will become too complex and expensive.
The Integrated Health Enterprise (IHE) (http://www.ihe.net/) is an international standards effort
which promotes the coordinated use of established standards such as DICOM and HL7 to
address specific clinical needs in support of optimal patient care. Systems developed in
accordance with IHE communicate with one another better, are easier to implement, and enable
care providers to use information more effectively.
The KS vendor, ICA, is a participant in IHE, along with the Public Health Data Standards
Consortium (PHDSC) which has developed IHE profiles in HL7 for immunizations, early hearing
screening, newborn screening, Syndromic surveillance, Electronic Laboratory reporting, cancer
registry, vital records and is working to provide use cases for other public health domains.
Some states are looking strategically at IHE as the technical approach to more seamlessly connect
public health and healthcare, but much of the software in use now, even if from vendors
participating in IHE, is at much lower version levels of HL7, but it is still important that ICA is
an IHE participant and support this growth direction.
Consumer Access:
Consumers are being given access to their own records as well as seeking other health
information, and public health information and community health resources will move from
medical home to medical neighborhood to medical community. Indeed, access to the patient
record electronically is a later stage Meaningful Use Requirement.
All IIS provide for the printing of a state-certified immunization history for school entry and
other purposes, usually at the conclusion of a visit, or by request. Some states, like Florida,
provide electronic access via kiosk or over the Internet on home or other computers, all with
appropriate access security. This functionality needs to be supported and managed by the IIS, the
HIE and the provider.
Development of a Public Health EHR Record
The Public Health Data Standards Consortium and NACCHO have begun discussions on the
development of a Public Health EHR Use case as part of the Business Case for public health IHE
profiles.
Sedgwick County should be an active participant in this development as a follow up to this
project.
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List of Resources:
(documents will be sent on CD)
PHII: EHR-HIE-IIS Report - Oct 2010.pdf
CDC & KS WebIZ
EHRs and National Vaccine Plan.docx
CDC will link PH EHRs IIS.docx
KS Provider participation in IIS.pptx
IISAR_DATA_2009.xls
CY2009 Final IISAR.pdf
IISAR_Questions_2008.doc
IISAR08KS.xls
Implementation Guide for Transmitting Immunization Records%0911 17 09.doc
Registry ProfilesKS2007.pdf
KsWebIZ_Marketing_Plan_Presentation.ppt
KSIIS laws.docx
Sedgwick County Health Departmentiz.pdf
KSWebIZ Business Plan Updated for 2010 grant app 8-7-09 wo budget.pdf
CS_Johnson_County_7_09_FINAL.pdf
brochure_for_users.pdf
AIRA_dedup6.pdf
AIRA_BP_guide_Vaccine_DeDup_120706.pdf
DIRECT
Exchange Versus Direct.docx
Direct Project - HIT Vendor.pdf
Direct Project - Primary care provider sends patient immunization data to public health.pdf
145.pdf- Update on Direct project-HIMSS
HIE
State_eHealthPlansRFPs-Sept09.XLS
2010-0510%20Building%20and%20Maintaining%20a%20Sustainable%20Health%20Information%20Ex
change.pdf
3.1.2HIE_Goals_and_Governance_Models.doc
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https___www.khi.org_resources_Other_1046-1-22-08AgendaFinal%5B1%5D.pdf
Summary_Proposed_ IKK_Strategies_by_Agency_2007.xlsx
9-15-09 KHPA Board meeting Agenda Final mks 9-11-09.pdf
CoreKFMCBusiness2009.pdf
ProfileofSLHIEInitiatives.doc
ICA
CareAlign Suite Overview with Detailed Clinicial Portal oct 2010.pdf
Governments | ICA.pdf
2010-0510%20Building%20and%20Maintaining%20a%20Sustainable%20Health%20Information%20Ex
change.pdf
eHealthAlign Health Information Exchange Names ICA as Health Information Exchange (HIE)
Solution Provider for Multi-State HIE | Business Wire.pdf
Kansas Stats:
KS.pdf
State RankingKS.pdf
KSHIT.pdf
Kansas HIT State Profile.pdf
KHIN
KHIN Goals and Objectives.docx
strategic-and-operational-plan-full-document.pdf
Operational-Plan-Core.pdf
Services_updated 2010_08_24.pdf
State health exchange in the works | Health Care | Wichita Eagle.pdf
11-10-2009-Presentation.ppt
11-10-2009_Notes.pdf
Participating_Stakeholders.pdf
Historical_Overview_Kansas_Health_Information_Exchange.pdf
KSHITECHMeeting.pdf
12-7-06PrPointHIE updateMN FINAL(KB).ppt
KIPHS
KIPHS Overview.doc
The database that runs the PHClinic Engine.doc
KALHD HL7 Webinar Instructions.doc
Meaningful Use
Meaningful Use Objectives & Measures Matrix - Requirements & Business Processes - 3-810.xls
Immunization HL7
PHER POIZ Domain Analysis Model 20071026.ppt
CDC Interop Preso_Lori F_Jan 09.ppt
Medicaid
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SMHP-Timeline-and-Provider-Incentive-Payment-Info.pdf
KS Menu setMKD changes.docx
Kansas extends HP’s Medicaid tech services contract | Healthcare IT News.pdf
Other states/LHDs
2009 Annual Meeting - Local Health Department Perspective - Kathleen Cook.ppt
Privacy
KS privacy.pdf
Private Provider- PCMH
Private_Immunization_Delivery_System.pdf
The Business Case for Pricing Vaccines copy.pdf
nr_pcmhsurvey.pdf
Broader_KS_PCMH_Initiative.ppt
Insurer provides docs with IT for medical home pilot | Healthcare IT News.pdf
030209SN_PHW_HIT_HIE_Barnett_Committee.pdf
Development of the Kansas Medical Home Model.pdf
PatientCenteredMedicalHome.pdf
Sedgwick County
NMW_WichitaClinic_CS_June2010.pdf
The Status of Local Health Department Information Systems_1 PDF.pdf
WebIZ HIE grant-NACCHO.doc
CoreMeasuresMar09.pdf
Wichita officials concede push for health exchange to state - Wichita Business Journal.pdf
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