Immunization Connect

Transport

2010-10-14T17:16:00.003-05:00

Things are going crazy in the immunization registry world. EHR vendors are now implementing HL7 messages and doing them quite well. Transport has now become the major issue. The CDC has not specified the method of sending HL7 data. The HL7 language was charted to specifically avoid transport issues and so this is left to each state and vendor to figure out. (Personally I would love to see a national standard, but there isn't one so we have to figure it out on our own.)

Here are the transport options I see being done right now:

File upload directly to registry
Users login to registry and upload HL7 files that have been exported.
Benefit: Easy for users to load data.
Drawback: Manual process that stops if the user forgets to load data.

File upload to secure FTP directory
User uses third-party application to load HL7 file into SFTP/FTPS location.
Benefit: fairly easy to setup.
Drawback: Normally a manual process, although it may be automated.

PHIN-MS
Sender and state install PHIN-MS and applications on both ends transfer file.
Benefit: PHIN-MS is free software provided by CDC.
Drawback: Not a simple application, takes a certain level of effort to install and configure. May not be supported on all platforms, or be accepted by all sending systems.

HTTPS method
Simple HTTPS method is used by several states and some EHR systems.
Benefit: Simple to implement by vendors so it can be automated.
Drawback: only limited supported in the industry.

Web Services method
Uses HTTPS.
Benefit: Industry standard and is fairly easy for EHR vendors to implement.
Drawback: There is not a standard web services definition that has been adopted by state registries so this still has to be negotiated with each vendor.

I personally like the simple HTTPS method, because, well it's simple. Besides that I think the Web Services is probably the best solution for the nation, if we can just get it standardized.

Everything's Amazing

2010-04-22T17:53:00.005-05:00

I am writing this post from 38,018 feet over Arkansas. This is the first time I have used WIFI while in an airplane. This reminds me of this clip Everything's Amazing and Nobody's Happy.

It is so easy to forget how amazing everything is. When we do our job right in public health, nobody notices. And this is how it should be. So it was a great opportunity to attend the the National Immunization Conference and to see what everyone has accomplished.

There is so much more to do. I'm now excited to go back to work and to complete my goals for this year.

MIROW Ad-Hoc Meeting

2010-04-19T14:14:00.002-05:00

Just attended a MIROW Ad-Hoc Meeting to discuss topics that need to be covered in the coming years. The Modeling of Immunization Registry Operations Workgroup has met every year to create a recommendation documentation that registry managers can use to implement improvements. These documents have proven to be an invaluable start in many areas.

We started the meeting by discussing how the documents have been used. The Data Quality Assurance document has been the most used. Some time was also spent discussing MOGE Status, especially now that it's evident that there are two kinds of MOGE: provider and jurisdictional. I will write more about this later.

Next the subject for this year's MIROW was discussed: IIS & VFC Integration. This document will hopefully be out in the Fall, barring another pandemic like H1N1.

Then the meeting was opened up to brainstorming. Ideas were given about what the next MIROW meetings could be about. Some of the ideas:

User training. This would be a continuation of the presentations given yesterday.
MOGE - determining denominator
Inventory. Improving data quality as it relates to inventory.
AFIX.
New healthcare act. How will this change VFC?
Lead, BMI, Newborn hearing. How should registries approach this?
EMRs
Patient deduplication. Hasn't been dealt within the past because it is not registry specific and could be a real can-of-worms.

National Immunization Conference

2010-04-16T12:14:00.002-05:00

I am preparing to attend the National Immunization Conference in Atlanta, GA. I will be there for the entire conference.

Sessions I plan to attend:

Monday 2:00 PM: Exploring Scanning as a Method of Data Capture
Monday 3:30 PM: Assessing MOGE Status Through National Change of Address Data
Tuesday 11:00 AM: Enhancing Immunization Surveillance Through Data Exchanges
Tuesday 4:00 PM: Immunization Information Systems: Evaluating Performance and Standards Adoption
Wednesday 9:00 AM: Immunization Information System Interoperability with Public Health Systems
Wednesday 2:00 PM: Growing Pains: Lessons Learned during Immunization Information System Software Transition
Thursday 10:30 AM: Immunization Information System Provider Feedback

I will also be attending an AIRA workshop on Sunday, and the AIRA AD HOC meeting on Monday. Look forward to seeing you there!

Public Health Project Tracking

2010-04-15T10:49:00.002-05:00

Keeping track of public health projects is critical. I have been using a personal system for the past 3 months to dramatically increase my productivity and reduce my stress. I designed the system after reading Getting Things Done by David Allen. Since my work is entirely electronic my system is built to work in that world.

I am now working on allowing access to this same system to my colleagues. It is currently still in Beta testing, but my plan is to eventually offer this as a free service to all Public Health professionals.

My hope is that this system will improve the capacity of these professionals so they can make a bigger impact on public health.

HL7 Transport Protocols

2010-04-14T08:06:00.002-05:00

When HL7 was created in the late 1980's the computer world was a very different place. The global Internet was in it's infancy, web pages had not yet been created, and email stayed within the organizations network. Every organization had it's own proprietary network protocols. For this reason the HL7 committees did not want to dictate what kind of network to use, but instead allow each organization implement their network/transport layer as they needed.

Fast forward to 2010 and you now find that all networks support the standard Internet protocol, TCP/IP. In the 1990's, HL7 did develop the Minimum Lower Level Protocol (MLLP). Although MLLP is not an official HL7 standard it has become so widely used that it is commonly referred to as a TCP/IP connection. While the MLLP is a great protocol, it does not support encryption, so it is not good for use on the global Internet.

Which is why today, many Immunization Registries will accept HL7 messages but use a variety of transport protocols to accept them.

New HL7 Guide

2010-04-13T12:07:00.006-05:00

Health Level Seven (HL7) was designed to help hospitals and other health organizations transmit health information in a standard way. Immunization registries use a subset of HL7 messages for sending vaccination information. The goal is that if all registries and all medical record systems use the same standard it will improve the process of creating new interfaces.

What HL7 has done so for immunization registries:

Created a common message structure.
Standardized code sets.
Delineated business use cases.

What HL7 does not yet address:

Vaccine program specific information.
Specific state requirements.
Message transport.

Because of these gaps, AIRA has been working with the CDC to create a new Immunization Guide that addresses the gap in the HL7 standard. The new guide is due out this Spring.

Working Remotely

2010-04-09T07:54:00.003-05:00

In the past 10 years I have transitioned from working in a traditional office environment, to working in a distributed office environment, to working from a home office, to working while traveling. In the process I have been able to create a system that helps me work effectively no matter where I am. Here are four things I would recommend for working remotely:

(1) Make sure you have two ways to connect the Internet. I would recommend standard DSL/Cable and an Spring/Verizon/AT&T wireless Internet connection. The DSL/Cable is fast and good when you are at home, and the wireless can serve as your back at home or your primary when you are traveling. Having a backup Internet connection will mean that you will not break a sweat when your DSL goes out and the phone company says it won't be fixed until tomorrow.

(2) Pay for a software such as GoToMeeting or WebEx. This will allow you to start your own web meetings. You can usually find plans for less than $50 a month. I have been using GoToMeeting ever since I worked from home and would never be without it.

(3) Use a good time tracking system to keep track of what you are doing at every minute or at the very least every 15 minutes. I use a tracking system that allows me to switch between projects, write notes, set action items, and review history. In this way I naturally keep my time as I'm working. At the end-of-the month I can generate reports with details of how much time I spent and what I did.

(4) Once you start tracking your time don't be surprised to find that a full and productive day is now between 6-7 hours. A productive 8 hour day in the office probably has about an hour or so of wasted time. Once you start tracking your time closely you will see this. Working from home can be very productive so it is important that your performance is not measured by the hours you work but by what you are able accomplish.

Livescribe Pen

2010-04-08T13:35:00.003-05:00

One of my most favorite gadgets is my Lifescribe Pulse smartpen. I bought it last year and used it quite a bit, but have not really started to use it consistently until now.

It is essentially a ball point pen that can record audio as your write. Then when you want to hear the audio again you simple touch the word on the page with the pen it repeats back what it heard when you were writing the information. This is great because if I miss something in a meeting I can simply go back and listen to it again, using my notes to cue the pen to the right place.

Even better I can sync it with my computer and it transfers all the notes to the computer. I can listen to the audio there or search for a word or phrase I have written.

Starting Again

2010-04-06T10:11:00.002-05:00

I am back after a long hiatus. My work has kept me so busy that I didn't have time to write. This all changed in December when a friend recommended that I read "Getting Things Done" by David Allen. This book has increased my productivity and decreased my stress. I will write more on this later.

My plan now is to write a little every day about Public Health and Immunizations from the perspective of a software developer. Some of the topics I am looking to cover:

HL7 Messages
Immunization Forecasting
Electronic Medical Records
Immunization Registries
Productivity Improvements

My job is to improve Public Health... I love my job!

Barcode Scanners

2009-02-23T15:40:00.009-06:00

I am currently evaluating barcode scanners for a project to improve data collection at provider practices. I have purchased 4 different barcode scanners to get a handle on how they work and understand what will work the best. I am looking at the following scanners:

ID Tech EconoScan - $74
I purchased this several weeks ago. This is the first barcode scanner I have ever purchased or used. It has a keyboard "wedge" which means that computer essential sees it as another USB keyboard, what it scans are sent as keystrokes and whatever application currently has focus receives the data. Installation and configuration were easy but the scanner has to be aimed just right to get a scan.

Symbol LS2208 - $134
Just arrived today in my office. This seems to be the low budget model. The spec listed tolerances for roll, pitch and skew; so it gives me hope this will be better at scanning than the EconoScan; which did not even list these attributes in its spec. Which makes me think the EconoScan was not built for tolerance for these things. I bought this one with an RS232 cable, as I think this will be final solution. The keyboard "wedge" solution requires that the target software application remain in focus to work properly. The installation I'm looking at will not support this.

Unitech MS120 - $85
The wand format is the orginal barcode technology and one I remember my library having when I was a kid. The format might not be exactly what I'm looking at but the low cost made it necessary that I look to see how it works. The orginal wands would just output the light levels it saw and your software would have to decode the barcode as it was swipped. This model has a built in decoder so I should be able to get regular ASCII data out of it. I'm not looking to write a barcode decoding software.

Symbol CS1504 - $110
This is the one I am most interested it. It has been built to be given to end consumers so they can scan barcodes in promotional and marketing materials. It was built to be operated from a keychain and stores the scans in memory. Afterwards it is docked and the scans downloaded. It can also be run in a tethered mode. I'm particularly interested in this because of it's portable nature and the likelyhood that it is very good at scanning codes. This might work very well in the office environment.

A.I. Med

2009-02-23T13:31:00.005-06:00

I just received a response from Acrendo Software.

1. Describe how your software handles vaccinations.

Yes, with active and passive for children 0-18 via CDC (when opening a chart, and during searches for ALL patients meeting age)

2. Can your software recommend when vaccinations are due for a given patient record?

Yes, based on age, and past injections via CDC chart

3. Has your software ever connected with or submitted data to an immunization registry? If so, please describe.

Yes, TX, FL, CA, WA via upload file for registry.

I asked for more clarification and received the following responses:

1. What format do you support for sending data to registries? Are you sending flat-file or HL7?

Flat tab separated file

2. I know that Texas does not support HL7, and that Washington supports both HL7 and flat-file. California has several registries. Do you submit to one or more of their regional registries?

We submit the same file with all the data, they take what they can use

3. As for you vaccination recommendations, do you support the CDC catch-up schedules as well?

We have the catch up sheet, but it is not scanned when we do the standard 0-18yrs. They can view the sheet on screen and print it only.

While the national standard is to submit data via HL7, submitting data in a flat-file format is accepted by most registries.

SpringCharts

2009-02-23T12:52:00.005-06:00

Just received a quick reply from Spring Medical Systems, Inc. They are CCHIT Certified 2006. Here are their answers to my questions:

1. Describe how your software handles vaccinations.

SpringCharts EHR has a specific area for recording and displaying vaccination records. You can download a full working copy of our software if you would like to see how vaccination records are entered and displayed.

2. Can your software recommend when vaccinations are due for a given patient record?

Yes. We have a feature called Chart Evaluation that will indicate when vaccinations are due for groups of patients. Once the guidelines are input, the system notifies the staff automatically for each patient.

3. Has your software ever connected with or submitted data to an immunization registry? If so, please describe.

Not yet. This is on our enhancement list but we would like to see some standards before we commit significant resources to programming our output.

This again confirms that one of the biggest obstacles to connecting with registries is that registries have not communicated well with vendors in explaining the CDC standards for connecting to registries.

alloFactor

2009-02-09T07:21:00.003-06:00

alloFactor is an online billing system with support for a range patient management functions. I contacted them via their web page and received a very prompt and helpful response.

While they do support enter vaccination information they do not yet forecast vaccination recommendations. They have not yet connected with an immunization registry, but they indicated that they would like to know more about it. Since billing is a core piece of alloFactor they will probably find submitting to a registry is pretty easy.

Selecting an EMR

2009-02-06T08:36:00.003-06:00

Although this was written a few years ago, I think it provides a good roadmap for selecting an EMR:

Medscape Today
How to Select an Electronic Health Record System

Posted 03/29/2005
Kenneth G. Adler, MD, MMM

Introduction

So you've decided to purchase an electronic health record (EHR) system, and your initial research reveals that more than 200 companies claim to make an EHR. You've barely started looking, and already you feel overwhelmed. A natural tendency might be to call a few vendors that you've read or heard about and ask them for a demo. Stop. Unless you want the vendors to control the selection process, you need a plan. Remember, the EHR will have a huge impact on your practice, going to the very heart of how you practice medicine. A rushed or ill-informed decision could make your life miserable.

This article is designed to help you develop that plan. By adhering to a logical and systematic selection process, you'll be able to make a high-quality decision about which EHR to choose. The process described below is based on my experience and research as an EHR committee chair for an 86-physician group. Although my group is large, I work in an office of three physicians, and I believe the following steps will apply to practices of all sizes.

Read full article (free registration required)

AIRA making progress on guide

2009-02-06T08:19:00.004-06:00

Yesterday I participated in an ARIA workgroup call. We discussed the current tables used in the CDC Implementation Guide and tried to decide which codes we could remove from the guide.

This is very important work. Overtime, implementations such as this get larger and larger. And the complexity can weigh it down. By removing old, unused codes, the guide can become lighter and much more focused on immunizations.

My hope is that the new guide that will be coming out, will help vendors understand exactly how to write for an immunization registry.

Eclipsys PeakPractice connects with two registries

2009-02-06T08:14:00.003-06:00

Just received good news from Bond Medical about Eclipsys PeakPractice:

Beginning this month, the Colorado and Georgia immunization registries will be available! Based on user requests, these two states have been added into the upcoming release.

The Georgia Immunization Registry (GRITS) uses the WIR-based system.

TEPR+

2009-02-06T07:52:00.002-06:00

I just did some research on Towards the Medical Patient Record (TEPR+) Conference, which has been held by Medical Records Institute (MRInstitute) since 1984. Just by coincidence, this conference was actually held this week in Palm Springs, CA.

The MRInstitute website offers audio cast and other content, most of it available for a fee. It seems that they are currently very focused on cell phone based healthcare applications. Which sounds like a very interesting idea.

Most interestingly they offer an EMR Compare section were the EMR vendors have self-reported their system and this has been placed in a spreadsheet for rapid comparison. I took a quick look, there are 21 EMRs represented and two questions about recording immunizations. Not surprisingly there is no mention of immunization registiries.

MedPlexus EHR

2009-02-06T07:47:00.004-06:00

I received the following response from MedPlexus EHR:

1. How does MedPlexus EHR handle vaccinations?

Our EHR system significantly improves vaccination/immunization
rates. The system alerts for vaccinations and immunizations
through clinical guidelines. The system provides opportunity to
vaccinate through reminders/alerts during the visit as well as
analyzing the patient population on parameters set by the user.

2. Can MedPlexus EHR recommend when vaccinations are due for
a given patient record?

Yes and the default is CDC, but user can build their own
vaccinations through guidelines if they want to customize.

3. Has MedPlexus ever connected with or submitted data to an
immunization registry? If so, please describe.

Yes we can; we do it in different ways bays on the needs of the
client.

It is great to hear that MedPlexus is focused on improving immunization rates. It sounds like they offer a forecast and reminder/recall to accomplish this.

Eclipsys PeakPractice from Bond Medical

2009-02-05T12:12:00.004-06:00

I recently contacted Bond Medical by email and I received a very quick and complete response. I remember speaking with them a couple of years ago for a different project and they were very responsive at that time as well. Since then there have been a few changes. Bond Clinician has been renamed as Eclypsis PeakPractice and the system is now CCHIT 2008 certified.

Here is Bond Medical's reply to my questions:

Immunization Handling

We've taken Pediatrics seriously, and I think you'd find the immunizations fascinating! Immunizations are recommended within the software based on our direct work with Bright Futures to develop the guidelines for patient visits, including the immunizations. Additionally, the Supply Chain Manager portion of the software recognizes the visit type when the appointment is booked and checks to ensure inventory is available. If not, an order is generated and awaits approval from the Office Manager. Each practice can determine reorder levels and staff assignments during implementation. Lot numbers for immunizations can be stored as well--which sure make contacting patients easy in the event of a recall! Of course, immunization records can be printed, faxed, or transmitted on request. Educational materials on immunizations (and everything else) are available for printing at checkout, or for the patients/caregivers to review at home via the Patient Portal.

Immunization Recommendations

Our Disease Care Reviews set triggers in the system to do several things. If a patient arrives for a visit (perhaps a sick visit) and is behind on an immunization, the provider will be flagged during the visit so that it can be taken care of or scheduled. Additionally, the system can be set up to trigger automated emails to patients/parents or alerts to staff to call/send cards, based on just about anything--age, last visit date, etc.

Immunization Registry

We're currently connected to Florida SHOTS and Ohio's immunization registry. We'd love to add more and are pursuing as clients request this very useful integration.

As you can see, we're more than enthusiastic about our pediatric software. We won first place the last several years at the TEPR conference, an award presented by Medical Records Institute and the American Association of Pediatrics. The Supply Chain Manager product also won the Hot Products award at the same conference. We were chosen by Microsoft and the American Academy of Pediatrics to be the host application for the AAP's Pediatric Office of the Future exhibit as well. The software has received 5 stars, 5 years straight from the Anderson Consulting Group annual EHR software survey.

Ecipsys PeakPractice appears to have very good support for immunizations and for registries. Their vaccine lot support looks very robust. The ability to track by lot numbers is very critical, and I'm glad to see that their system will support a recall project.

ChartConnect

2009-02-02T07:52:00.003-06:00

Two weeks ago I participated in a demo of the ChartConnect system. I was impressed by their vaccination data entry screens and by their good support of standard vaccination fields. ChartConnect is based in Yakima, Washington and is currently working to interface with the Washington registry: CHILD Profile. From a recent press release:

ChartConnect currently has 18 communities where its medical hub and community health record are deployed along with other applications. Several of these communities have an 85% provider participation rate.

This same press release announces that Noteworthy has acquired ChartConnect and Mars Medical Systems.

The new company will retain the name Noteworthy Medical Systems and will serve a combined customer base of more than 1,200 practices, 5,700 healthcare providers and 12,000 users across 43 states, with company locations in Cleveland, Ohio; Phoenix, Arizona; Yakima, Washington; and Pocatello, Idaho.

More details in the press release.

MedLink EHR

2009-01-30T09:58:00.005-06:00

MedLink TotalOffice is CCHIT 2008 Certified and supports immunization practice in several ways:

Forecasts based on the ACIP schedule to give alerts to physicians about what immunizations are due on a particular patient.
MedLink can sent immunization updates using a Continuity of Care Record (CCR).
MedLinks is looking to do bi-directional HL7 with registries but are hampered by lack of support by their client's registries.

The last point is very important to note. MedLink is very interested in working with registries and would like to add better support. But they are being held back because registries are not ready to work with them. MedLink is not alone in facing this problem. Here are some of the issues I've seen:

There are some registries that still do not support HL7. And many of those that do have significant functional limits.
There are local variations on what messages mean, how they are constructed, how they are interpreted, and how they are transported.

These problems are not insurmountable. The commonalities between registry interfaces is actually quite high but most vendors do not have enough registry knowledge to determine what is a local variation and what is done in the rest of the US. This is probably something that AIRA needs to address.

MedAptus not EMR

2009-01-29T07:16:00.003-06:00

MedAptus sent me an email saying that they are not an EMR, and that they do not support immunization tracking or reminders. Medaptus supports coding and billing. website

Registry data

2009-01-28T15:37:00.002-06:00

Getting data back from the registry is very important to vaccination providers. While state registries usually concentrate their effort on collecting data they can sometimes forget the importance of sending data back.

The demand for data back is currently low because most vaccination providers do not have systems capable of processing that data. But those who can expect to be able to get data back.

It is important that registries do the following:

Allow providers to receive immunization updates for their patients, as determined by the registry.
Provide a support for the providers EMR.

Registries who do support this process will see greater buy-in and participation from providers.

PCC Partner

2008-11-20T07:43:00.008-06:00

I just received information from Physician's Computer Company (PCC) about their Partner practice management software. They support entering vaccinations in three different ways:

A nurse can enter in a vaccination that was administered complete with lot number, manufacturer, site, and other details. PCC Partner also tracks inventory so the nurse does not have re-enter lot number each time. The nurse can also document vaccinations that are refused.
The vaccination may be entered into billing. This tracks that the vaccination was given but does not support lot number, etc.
Historical vaccinations may be entered.

PCC Partner can generate a forecast and indicate if the patient is behind or not. Forecast includes the flu shot. PCC Partner can also has a reminder/recall program. This is the same application that is used to follow-up on individuals who are due for their annual physicals.

PCC Partner has connected with over 24 regional and state-wide regsitries around the country. They can provide an initial "dump" of all patient records for a given practice, which they can limit by age or zip code. After that the provider can submit any new immunizations given. The data can be formatted in a variety of ways including HL7.

I have never worked with PCC Partner but am excited that they have connected with so many immunization registries. Their vaccination tracking system seems to be quite complete and if used properly by physicians should allow them to run a full vaccination program.

Consent and PD1-12

2008-11-19T15:53:00.003-06:00

Consent status can be transmitted in PD1-12. Currently there is some conflict as to the value that should be placed in this field. The CDC Immunization Guide indicates that Y - Yes should indicate that the patient is consented to be in the registry. The HL7 guide indicates that Y - Yes should indicate that the patient has requested to be protected from sharing and so should NOT be included in the registry. Obviously these two standards are in conflict.

There are also some questions about how two registries should communicate. Should they indicate their own consent status, or the other system's consent status? Should a record that is not consented be sent at all?

These issues are now being discussed by AIRA and resolution should be reached soon.

Medtuity EMR

2008-11-19T14:22:00.009-06:00

I just received information about Medtuity EMR. They seem to have good support for recording and recommending vaccinations for patients.

Introduction

Medtuity EMR operates on a subscription basis; providers pay per encounter. There are no fees for other services such as suport and training. Providers can have multiple users which can edit patient records concurrently. Meduity appears to have an orientation towards ease of entry and supports multiple ways to enter data including voice-recognition. Vaccinations are supported in various locations in their software.

Vaccination Process Support
Here is a walk through of the vaccination process in Medtuity EMR:

The physician can review recommendations for which vaccinations are next, based on age range, gender, and which doses have already been given, and order the appropriate vaccinations.
The nurse can immediately see the vaccination order and draw the vaccination even before a physican is finished seeing a patient.
The nurse can then document that it was given and this information is pulled directly into the patient's health maintenance information and their vaccination sheet.

A screenshot of the vaccine screen is shown on the right. The lot number and other common information is saved so that when the same vaccine is picked again the nurse does not have to reenter them, they are automatically populated.

Another unique feature is that the vaccination record can be faxed with a click of a button to a school that is requesting it.

Immunization Registry Support

Medtuity supports HL7 for several different interfaces for labs and practice management systems but Medtuity reports that demand for immunizations registry connections is surprisingly light. Interestingly Medtuity EMR can export and import data using a Continuity of Care Record (CCR) which can include vaccination information. Medtiuty appears to have the expertise and willingness to interface with registries if this were asked for.

Vaccination Codes

One of the continual maitenance issues is keeping the vaccine codes (CPT or CVX) up-to-date. Out-of-date codes lead to errors in recording vaccinations. Medtuity solves this process by providing a centralized table of manufacturers and vaccines that the local EMR applications can download updates from.

Summary

Overall it appears that they have a good system for supporting vaccination practice. The data entry screens are optomized for easy data entry and for capturing the most important information.

Vendor talks about immunizations

2008-11-18T15:15:00.003-06:00

Last week I received an email from a vendor explaing their support of immunization data. I include a paraphrase of what he wrote because it typifies the perspectives of many vendors:

Their system supports immunizations.
They perceive a major disconnect between what individual states are doing, what immunization departments are doing, and what providers are actually doing.
Doctors are not willing to enter data twice.
Concerned about how a registry operates and if it would be able to match patient data.

There is a great need to standardize how registries operate such that vendors may understand them well enough to create interfaces for them. Right now vendors are largely ignorant of the needs of providers who give immunizations, especially when it comes to accessing functionality available from the registry.

Medisoft

2008-11-18T13:26:00.002-06:00

I have tried to contact Medisoft in the past to get information about connecting to registries and I was asked to talk to one of their resellers. Medisoft seems to be concentrating on their core product and allowing resellers to do special interfaces.

The resolution we came to a few years ago was to use their report menu to export the data and then import it as a flat file. This process has the following benefits:

Does not require custom programming.
Does not require installation of software.
Will work across software upgrades.
Not too hard for a regular user to do on a regular basis.

There are a few downsides:

Not automated. Requires clinic user to run report.
Only a limited number of data columns can be exported because of some kind of line length restriction. (It is enough to report patient records and immunizations.)
Requires installation of a custom report.
Data is exported in a non-HL7 format.
Requires clinic user to upload data to the registry.

The ideal solution would be a module that supports exporting vaccination updates. I have sent an email to Medisoft but have not gotten a response. I will give more details as I get them.

MUMPS or Caché?

2008-11-18T08:12:00.003-06:00

Yesterday I spoke with InterSystems about Caché. Previousily it was called MUMPS. Caché is an integrated programming language and database. There are several different versions out there but many of them have been purchased by InterSystems.

There are a lot of health care applications that use MUMPS/Caché, including RPMS (used by Indian Health Services), Epic Systems, and VaVISTA.

New Immunization Guide

2008-11-11T10:22:00.002-06:00

AIRA is making a solid effort to create a new immunization guide. The current guide has been very successful but it now needs to be updated and expanded. Anyone who has experience with the immunization guide is encouraged to give their feedback and suggestions. Here is the post on the AIRA website:

AIRA is collaborating with the CDC on updating the IIS HL7 implementation guide. We are seeking input on your issues and concerns. The AIRA Data Exchange Standards Steering Committee will review each submission to determine the appropriate resolution.

Please take a moment and post any issues or changes you would like in the immunization guide.

e-MDs now supports consent and VFC

2008-11-11T10:18:00.004-06:00

Good news, e-MDs has made some recent improvements to their HL7 interface. They can now record and report consent status for patients. They also have limited support for patient VFC status and will report if the patient is Native American/Alaskan, Uninsured, or Medicaid.

openEMR

2008-11-04T16:09:00.002-06:00

I found an open source EMR called openEMR. I wrote to get more information about 2 weeks ago, but have not heard back. I called the contact number but the phone is not working.

Perhaps this project is not currently active.

I went ahead and downloaded the software. Appears to be written in PHP.

Sevocity

2008-10-21T15:08:00.003-05:00

Just spoke on the phone with Sevocity. They use an ASP model and are very comfortable with creating interfaces. HL7 has never been a problem for them and they currently connect with the Texas immunization registry, ImmTrac. Which is great news! They are also working on interfaces with a few other registries.

Their software model is to provide a monthly service based on the number of physicians and users. This keeps the costs constant. Everyone gets the same set of improvements, no one has to pay for extra add-ons.

More information is coming.

Cerner PowerWorks

2008-04-15T15:26:00.006-05:00

I just spoke with a developer with Cerner PowerWorks who is working to create an interface for a particular state registry. He explained to to me that Cerner PowerWorks does not have a standard interface, instead it they build interfaces as they are requested for each registry.

Nightingale Physicians Workstation

2008-04-15T14:51:00.001-05:00

I just finished speaking with a software developer with Nightingale who is adding some new features to their EMR, Physicians Workstation (PWS). They have been successfully connected to the Wyoming immunization registry for the past few years and now are working on a bi-directional interface. My contact at Nightingale also indicated that they are currently working with other state registries and that they can offer this same interface to any of their customers in the US.

The software currently uses HTTPS to submit the message following the old-CIRSET HTTPS transmission guide that was developed several years ago.

e-MDs New Immunization Interface

2008-04-15T11:08:00.001-05:00

Last week I received an email from e-MDs about their new immunization interface. The email was addressed to state registries and asked for feedback on their new messages. Here is a summary of what I found in their messages and what they indicated in their email:

1. They will not be able to support Opt-In states that require patient consent to be recorded by the provider and then submitted as part of the HL7 message. They assume that states will be able to filter the messages themselves.

2. e-MDs will only export the data out to a user defined directory. It will be the responsibility of the provider to upload the file to the state registry.

3. They put the account number (MRN) in PID-3 and in PID-2. The PID-3 field repeats and the PID-2 field doesn't . This way they figure state registries that don't like repeating fields can read the account number out of PID-2.

4. They qualify their account number (MRN) with the designation "PI" and place it in the first repetition. The SSN is sent in the second repetition and also in the old location PID-19 for backwards compatibility.

5. They send the ORC segment before sending the RXA segments. This is a little unusual as most VXU implementation I have seen do not send this. While this field is required in HL7 version 2.5 it optional according to the CDC guide. Some registries may not expect this field and may not handle it properly. This field is sent by e-MDs to indicate that the vaccination was ordered.

6. They do not have guardian information, instead they are sending guarantor information in GT1 segments. Immunization registries should accept this message but may or may not ignore these segment. My recommendation would be to read these as if they were guardians if the relationship indicates them to be so. Most state registries use guardian information for matching and do not have a strict definition of guardian. For most cases the person identified as the guarantor will work sufficiently well as a guardian.

Overall their messages looked very good and thoroughly put together. e-MDs seems to have made a very good effort to put together an accurate and complete HL7 message.

State-to-State Sharing

2008-04-11T15:19:00.000-05:00

Now that many state of immunization registries they are starting to work towards connecting with each other to share appropriate information. Americans are very mobile and move often, sometimes to new states. The question that many registries are now asking is, how can we handle this? What can be done to connect states together?

First it is important to understand that data is only transferred in state-to-state connections for specific patients who have indicated that their records are out-of-state. A physician or physician's staff asks the registry to query the other registry for the immunization registry. The querying registry sends the patient information, asking for matching record(s) to be sent back. There is no batch transfer of records on regular intervals.

This process worked very well for families displaced by Hurricane Katrina who needed their shot records in Houston. The Houston health department went to the Astrodome and helped families standing in line by quering the Louisiana registry for their immunization records. These children could then be enrolled in school without requiring re-vaccination.

The second important thing is that these queries and data transfer are only being done because of the need to provide service to a patient. Such a transaction is allowed under HIPAA rules, as long as the process was done securely and the information is going to a physician who is providing care to this patient.

HL7 Transport

2008-04-11T15:05:00.000-05:00

Health Level Seven (HL7) is a reference to the OSI model of ideal networks. Back in the 1980's hospitals were working to "network" various computer system together so that they could communicate. Remember that this was before the "Web" and "Email" as we know it today. Many different companies offered "network" solutions and these were different and incompatible standards. The OSI model was created to explain the theoretical model of how networks should work.

The HL7 standards organization wanted to avoid implementation specifics of what kind of network was being used by limiting the discussion to the 7th (top) layer of the OSI model. Which simply means that HL7 would define how to format the message but not how it should be sent.

The advent of the modern Internet was made possible by an adoption of a standard networking protocol TCP/IP. The old proprietary protocols still exist but they are not hidden under standard TCP/IP protocols. Still HL7 Version 2 standards preserve the divide and do not specify transport standards.

HL7 Version 2 does provide a possible transport solution for TCP/IP networks called Minimum Lower Level Protocol (MLLP), and this has become the industry standard. Again, because HL7 is not supposed to move beyond message format, this is just a possible way to transport messages. But in practice it is so widely used that it is normally referred to and known as "TCP/IP".

This defacto standard has one flaw - it is not well suited to the Internet as it does not provide for security. This is why exchanging HL7 across the Internet has become clumsy and difficult, because there are no agreed upon national standards for doing so.

What is HL7?

2008-04-11T14:54:00.000-05:00

Health Level Seven (HL7) is a messaging standard that created in the late 1980's by hospitals and vendors interested in creating an common standard for exchanging health information. The context was health but more specifically hospitals.

HL7 comes in two main flavors Version 2 and Version 3. These versions have entirely different formats and are different development tracks. Standards work is still be done on both versions. Most legacy HL7 systems support Version 2 while many newer non-Hospital systems are beginning to to support Version 3. Systems that speak one version normally do not speak the other version.

The CDC has asked immunization registries to support HL7 Version 2 messages that pertain to immunizations. Standardization work is being done for immunizations for Version 3 but none of this is yet recommended by the CDC. Many immunization registries are still working on their HL7 Version 2 support and are unlikely to support Version 3 any time soon.

Here is a sample HL7 Version 2 message:

MSH|^\&|||||20080320102346||VXU^V04|20080320102346.693458||2.3
PID|1||505^^^^MR||MOUSE^MICKEY^^^^L|19281128|M|
RXA|0||20080319|20080319|90715|

This is very basic but shows a patient by the name of "MICKEY MOUSE", born "11/28/1929", who received a vaccination with CPT code '90715' on '03/19/2008'.

Consent

2008-04-10T08:14:00.000-05:00

Most registries are opt-out while some are opt-in. This depends on the state law that governs the registry. Opt-out registries have processes to remove patients from the registry who do not want to be in the registry, and Opt-in registries have processes to include patients who want to be in the registry. The patients decision, as to whether be in the registry or not is generally called "consent". In opt-out registries consent is assumed to be given, and in opt-in registries consent is assumed to not be given.

How to send consent in HL7 messages

Consent can be sent in PD1-12 Protection Indicator. Here is the description from the CDC guide:

This field will be used by immunization registries to indicate whether or not consent has been given (or assumed) for record sharing. It can have 3 values with the following meanings:
"" : Null will indicate that patient/guardian has not yet been asked to give consent to share or has not responded
Y : Sharing is allowed (patient has given consent or consent is implied)
N : Sharing is not allowed (patient has refused consent)

For opt-out registries do not populate this field for patients that are assumed to be consented. The registry will already assume the patient has consented. For patients that have explicitly requested to not be included in the registry send the value 'N'. The value 'Y' should only be sent if the patient explicitly indicated they wished to be part of the registry. It should not be set as default. If the patient has not consented to be in the registry then the data may or may not be sent to the registry depending on state policy. Some opt-out states have formal processes for removing all related patient records when a patient opts out and so require that the opt-out information be sent to the registry so this process can be completed properly. Other registries may require that these opt-out patients be not sent.

For opt-in registries record the patients decision to be in the registry in this field. Depending on registry policy this patients record may or may not be sent based on this status. Some registries will require that non-consented records be sent so that all related records can be removed from the registry. Others will require that the non-consented records should not be submitted.

For all registries it is important to verify that they support this field as you expect. Because of the name of this field many registry system may not realize that consent may be reported here and may not have processes in place to handle non-consented data. Sending systems may be required to filter out non-consented data.

How to Connect to Registries

2008-04-10T07:54:00.000-05:00

Vendors who wish to connect to registries have to solve two problems: (1) message format and (2) message transmission. The message format is pretty well defined by HL7 but the message transmission varies from registry to registry. Here are a few pointers to help in this process.

Message Format

HL7 defines the Unsolicited Vaccination Update (VXU) as the message of choice for submitting data to registries. The CDC requires that all registries support this format and have created the Implementation Guide for Immunization Data Transactions using Health Level Seven (HL7) Standard Protocol (download). Writing your interface to match this guide will insure the best support nationwide.

Message Transmission

HL7 informally defines a TCP/IP method (MLLP) to transmit HL7 data and this is widely supported by traditional HL7 applications. Many state registries do not support this method as it requires using a custom VPN connection in order to make the transmission secure. Instead registries provide various other methods including FTP(S), HTTPS, PHIN-MS and secure emails. Most also have a process for manual submission either through FTP(s) or by uploading via a web page.

It is recommended that vendor systems have the ability to export VXU messages and save them to a file. This minimum ability will work in most situations.

The various methods for automating will be discussed in a future post.

Setting Up Blog

2008-04-05T10:03:00.000-05:00

It's Saturday morning and I'm just setting up the Immunization Connect blog. This will be used as a common clearing place for data about immunization systems. The focus will be initially how to connect private providers to registries. All information obtained about private provider systems will be kept here.