ServiceOriented Architecture and Immunizations

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Service-Oriented Architecture and Immunizations
American Immunization Registry Association
(AIRA) Ina Kichen, AIRA Alean Kirnak, Software
Partners LLC Sue Salkowitz, Salkowitz and
Associates Cindy Sutliff, AIRA
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AIRAs 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

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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

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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
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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

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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• The CDC has provided yet unpublished information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.

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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

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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 NCIRDs HL7
  implementation guide?
• YES 54
• NO 41
• No IIS 5

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IIS Supporting Reminder/Recall

• Can your IIS electronically generate reminder
• notifications?
• IIS reporting capable 82
• IIS not yet capable 13
• Can your IIS electronically generate recall
• notifications?
• IIS reporting capable 84
• IIS not yet capable 11

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HL7 V2 Communication is Point-to-Point
Point to point Hub Bus
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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 thats just for immunization data

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And thats just for immunization data

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

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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

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Example Canada Health Infoway
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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

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Computing in the Cloud (Service-Oriented
Architecture)
Services
Security
Data Transform
Other Service
HL7 V2
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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

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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,
  Childrens 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?

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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

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Documents and Repositories

• Human-readable part
• .xslt
• Structured data part
• Clinical authentication
• Wholeness
• Persistence

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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/lan
  g,english

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Identification Service

• Commonly referred to as eMPI
• Cross-references identifiers for the same person,
  enabling complete medical record to be retrieved

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Identification Service
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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

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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

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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

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Discussion of ARRA Opportunities