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  • This one is really relevant. Do you have a slide or can you add some talking points by imbedding this as a picture in a larger slide?
  • Need a more legible version of this if we are going to use (ak) Can remove?
  • This is not really legible, ditto the Swedish. We might want to drop those slides and you can just mention the international aspect in your presentation
  • Here, we can run the vaccine forecast demo from our web site found at,com_wrapper/Itemid,274/lang,english/
  • Need reference to Mandl article
  • Do need a slide with a legible example
  • Walk through,english/ ?
  • AIRA_SOA_presentation_062909.ppt

    1. 1. 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
    2. 2. AIRA’s Standards and Interoperability Initiatives <ul><li>Early promoters of HL7, even prior to provider system readiness </li></ul><ul><li>Members of HL7 and sponsors of immunization messages; work with pediatric EHR </li></ul><ul><li>HL7 endorsed by NVAC as an IIS functional standard </li></ul><ul><li>Work with CDC on HL7 v2.3 guide; now working on v2.5 </li></ul><ul><li>Members of Public Health Data Standards Consortium (HITSB, HISPC) </li></ul><ul><li>Participation in Integrated Health Enterprise (IHE) </li></ul><ul><li>Developer of IOA for interstate exchange of IIS data with HISPC and PHDSC endorsement </li></ul>
    3. 3. Child Health Record and Public Health <ul><li>Just as a complete health record exists for each child, an integrated view exists on a population basis </li></ul><ul><li>Immunizations have one place in that continuum </li></ul><ul><li>How to achieve an integrated view of child health </li></ul><ul><li>Service-Oriented Architecture (SOA) – provides a direction for an integrated view </li></ul>
    4. 4. 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
    5. 5. Traditional Immunization Information System Approach <ul><li>Point-to-point communication between providers and Immunization Information Systems (IIS) </li></ul><ul><li>Immunization Implementation Guides </li></ul><ul><ul><li>Existing HL7 V2.3.1 Implementation Guide </li></ul></ul><ul><ul><li>New HL7 V2.5 Implementation Guide </li></ul></ul>
    6. 6. IIS HL7 V2-capable sites <ul><li>The CDC collects information annually from IIS grantees with regard to their HL7 capability and the extent of their deployment – IISAR (IIS Annual Report) </li></ul><ul><li>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. </li></ul>
    7. 7. IIS HL7 V2-capable sites <ul><li>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? </li></ul><ul><li>IIS reporting capable: 45% </li></ul><ul><li>IIS not yet capable: 50% </li></ul><ul><li>States without an IIS 5% </li></ul>
    8. 8. IIS HL7 V2-capable sites <ul><li>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? </li></ul><ul><li>YES: 54% </li></ul><ul><li>NO: 41% </li></ul><ul><li>No IIS: 5% </li></ul>
    9. 9. IIS Supporting Reminder/Recall <ul><li>Can your IIS electronically generate reminder </li></ul><ul><li>notifications? </li></ul><ul><li>IIS reporting capable: 82% </li></ul><ul><li>IIS not yet capable: 13% </li></ul><ul><li>Can your IIS electronically generate recall </li></ul><ul><li>notifications? </li></ul><ul><li>IIS reporting capable: 84% </li></ul><ul><li>IIS not yet capable: 11% </li></ul>
    10. 10. HL7 V2 Communication is Point-to-Point Point to point: Hub: Bus:
    11. 11. HL7 V2 Economics <ul><li>Approximately 75 U.S. IIS </li></ul><ul><li>Completely connected point-to-point IIS network: 74 * 75 / 2 = 2775 connections </li></ul><ul><li>Assume 200 regional provider EHRs per IIS: </li></ul><ul><li>200 * 75 = 15,000 connections </li></ul><ul><li>Each connection costs $10K-$30K per side </li></ul><ul><li>Approx $40K each * $711,000,000 total </li></ul><ul><li>And that’s just for immunization data </li></ul>
    12. 12. And that’s just for immunization data <ul><li>Labs </li></ul><ul><li>Meds </li></ul><ul><li>Problem Lists </li></ul><ul><li>… etc. </li></ul><ul><li>Intra-enterprise communication </li></ul><ul><li>Provider-to-Provider communication </li></ul><ul><li>Provider-HIE communication </li></ul><ul><li>... </li></ul>
    13. 13. HL7 V2 Depends Upon Common Codesets <ul><li>Canada Health Infoway Panorama project found they needed to address: </li></ul><ul><ul><li>60 reference codesets (i.e. LOINC, SNOMED) </li></ul></ul><ul><ul><li>461 Panorama codesets </li></ul></ul><ul><ul><li>1,000 vocabulary domains </li></ul></ul><ul><ul><li>1,600 drop-down lists </li></ul></ul><ul><ul><li>495,763 drop-down options </li></ul></ul>
    14. 14. Example: Canada Health Infoway
    15. 15. What Can Be Done? <ul><li>HL7 V2.5 Implementation Guide aims at reducing customization by more accurate specification of codesets </li></ul><ul><li>Service-Oriented Architecture and Structured Document Approaches may offer a better direction </li></ul>
    16. 16. Computing in the Cloud (Service-Oriented Architecture) Services Other Service Security Data Transform 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
    17. 17. Clinical Decision Support Service <ul><li>Immunization Decision Support Service </li></ul><ul><ul><li>Takes immunization history and other medical conditions as input </li></ul></ul><ul><ul><li>Returns evaluated immunization history and recommendations </li></ul></ul><ul><ul><li>Includes contraindications and precautions </li></ul></ul><ul><ul><li>Can support reminder and recall functions </li></ul></ul><ul><ul><li>Demo </li></ul></ul>
    18. 18. Advantages <ul><li>Accessible from anywhere </li></ul><ul><ul><li>Massachusetts example: immunization forecast accessed from Personally Controlled Health Record (PCHR) </li></ul></ul><ul><ul><li>Described in AMIA article by Kenneth Mandl MD, James Daniel MPH and others at Harvard, Children’s Hospital and State Dept of Public Health </li></ul></ul><ul><ul><li> </li></ul></ul><ul><li>Rules directly loadable into web service </li></ul><ul><ul><li>Offers possibility of AAP-CDC direct update </li></ul></ul><ul><li>De-identified </li></ul><ul><li>Accepts more medical history </li></ul><ul><li>Where to get that history? </li></ul>
    19. 19. Immunization Web Service IIS Sites <ul><li>Massachusetts, San Diego County </li></ul><ul><ul><li>Software Partners Immunization Decision Support Service </li></ul></ul><ul><li>Rhode Island KIDSNET </li></ul><ul><ul><li>service-enabled immunization algorithm service-enabled by HLN Consulting. Could be expanded for EHR systems to access as well </li></ul></ul><ul><li>New York City CIR </li></ul><ul><ul><li>immunization query/response and update for EHR systems to send/receive histories and recommendations - service-enabled by HLN Consulting </li></ul></ul><ul><li>Texas, Utah </li></ul><ul><ul><li>Web service version of IZ forecast used by Scientific Technologies (STC) system </li></ul></ul>
    20. 20. Documents and Repositories <ul><li>Human-readable part </li></ul><ul><ul><li>.xslt </li></ul></ul><ul><li>Structured data part </li></ul><ul><li>Clinical authentication </li></ul><ul><li>Wholeness </li></ul><ul><li>Persistence </li></ul>
    21. 21. Document Examples <ul><li>Continuity of Care Document (CCD) </li></ul><ul><ul><li>Particular type of medical summary doc </li></ul></ul><ul><ul><li>CDA and Continuity of Care Record </li></ul></ul><ul><ul><li>Based upon V3 Care Provision standard </li></ul></ul><ul><ul><li>Increasing adoption of CCD and other Care Record variants </li></ul></ul><ul><li>IHE Cross-Enterprise Document Sharing (XDS) </li></ul><ul><li>IHE Immunization Content (IC) </li></ul><ul><ul><ul><li>Based upon V3 Care Provision standard </li></ul></ul></ul><ul><li>,english </li></ul>
    22. 23. Identification Service <ul><li>Commonly referred to as eMPI </li></ul><ul><li>Cross-references identifiers for the same person, enabling complete medical record to be retrieved </li></ul>
    23. 24. Identification Service
    24. 25. Benefits of SOA and Documents <ul><li>Handles complete medical record, not just immunizations </li></ul><ul><li>Direct AAP access to decision support rules </li></ul><ul><li>Economies of bus architecture (one hop to bus) </li></ul><ul><li>User can glean value from human-readable documents even if codesets not 100% compatible </li></ul><ul><li>Works with existing HL7 V2 infrastructure </li></ul><ul><li>Workflow optimization (“agility”) </li></ul><ul><li>Ability to create security layers </li></ul><ul><li>Compatible with HITSP standards and direction </li></ul>
    25. 26. SOA implemented or planned in other IIS <ul><li>San Diego County – most IIS functions </li></ul><ul><ul><li>Decision support, HL7 V2, patient identification and official immunization card </li></ul></ul><ul><li>Massachusetts – statewide SOA initiative </li></ul><ul><li>10 states with STC implementations </li></ul><ul><ul><li>HL7 V2 and WIC web service interfaces </li></ul></ul><ul><li>Contra-Costa County, CA – prototyping </li></ul><ul><li>MI- WIC IZ status and planned expansion </li></ul><ul><li>MN- using in DOH, planned expansion </li></ul><ul><li>KS- WIC IZ status </li></ul><ul><li>NYS- HIE grant, Electronic death registry </li></ul><ul><li>AZ- looking at for HITECH </li></ul>
    26. 27. 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
    27. 28. Discussion of ARRA Opportunities