2012 AAP NCE – Selected Short Subject

1. 2012 AAP NCE – Selected Short Subject Tracking Immunizations In Your Practice and Community October 22, 2012 Stuart T. Weinberg, MD, FAAP Vice Chair, AAP Council on Clinical Information Technology (COCIT) Assistant Professor Departments of Biomedical Informatics and Pediatrics Vanderbilt University School of Medicine stuart.weinberg@vanderbilt.edu

2. Faculty Disclosure Information • In the past 12 months, I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. • I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation

3. Objectives • Understand how recent efforts to bar-code vaccine products will assist in recording patient information. • Describe how vaccine data is shared through importing from and exporting to existing immunization registries. • Visualize methods to reconcile vaccine data from multiple sources. • Describe examples of practice workflow where vaccine data is compiled and assessed prior to a visit. • Learn about immunization assessment/forecasting web services and the potential role they can play in adding functionality to electronic medical records.

5. Definition of Biomedical Informatics • “The scientific field that deals with biomedical information, data, and knowledge—their storage, retrieval and optimal use for problem-solving and decision making.” (Shortliffe) • The discipline dealing with the structure, organization, utilization, and communication of health-related information. • Pertinent to clinical care, research, education, and administration.

6. What is Bioinformatics? “Bioinformatics is the study of how information is represented and transmitted in biological systems starting at the molecular level”--Altman Bioinformatics Medical Informatics

7. Information Technology and Informatics Information technology centers on the technical tools – hardware and software Clinical informatics highlights people, process, technology. There are several peer-reviewed journals AND on Sep 22, 2011, Clinical Informatics became a Board-Certified Medical Subspecialty, sponsored by the American Board of Preventive Medicine.

9. Vaccine Barcodes – What is the Workflow? A CDC 2D Vaccine Barcode Pilot began in August, 2012, involving 10+ States/CDC immunization program grantees, 220 Immunizers (public, private, and commercial), and 1-3 vaccine manufacturers . More info at: www.2dbarcodepilot.com As of August, 2D barcoded vaccines currently shipping were Menactra, Pediatric DT, and adult HAVRIX. Future distribution was planned for Adacel, Fluzone, Daptacel, Tenivac, IPOL, and Pentacel. Barcodes are on the vials, *not* the packages. May have implications for vaccine inventory. Different workflows for practices with and without EHRs?

10. Vaccine Barcodes – The Pilot Process Participating manufacturers will place a 2D barcode, containing the vaccine type (GTIN/NDC), the expiration date, and the lot number, onto a vaccine vial’s primary packaging (label); Upon vaccine administration, immunizers will scan the vaccine barcodes; Immunizers’ electronic medical record system, or other records system, will be automatically populated with the three vaccine data items, and; Data will be transmitted to the participating grantee immunization information systems (IIS) using the existing transmission method. Data that is transmitted will be used to assess the ability to improve the efficiency of immunization record keeping, as well as the availability and accuracy of immunization information in the IIS. Source: www.2dbarcodepilot.com/pilot_overview/

11. Immunization Registries July, 2010: The Task Force on Community Preventive Services recommends immunization information systems on the basis of strong evidence of effectiveness in increasing vaccination rates. Evidence is considered strong based on the findings from 71 published papers and 123 conference abstracts showing that IIS are directly related to increasing vaccination rates and reducing vaccine-preventable disease. FOR PROVIDERS: Communication with immunization registries could provide a more complete vaccination history Access may be an issue. Is it through a portal or is immunization information integrated with your site’s existing EHR?

12. Tennessee Immunization Registry Overview • ‘TWIS’ (Tennessee Web Immunization System) technically refers to the web portal for the ‘SIIS’ (State Immunization Information System) • Overseen by the Tennessee Immunization Program (TIP), located in the Communicable and Environmental Disease Services (CEDS) section of the Bureau of Health Services in the TN Department of Health. • Medical Director of TIP is Kelly Moore, MD, MPH. • Established in 1994 • TN birth certificates automatically uploaded to create a demographic record (low birth weight, preterm births, sealed birth certificates excluded). • State law specifically authorizes voluntary participation by healthcare providers (allows them to share these data with the state) • Opt out provision for parents who notify TDH to remove or block child’s record.

13. TN Registry HL7 Message Exchange Status • At present, the following methods are available for data exchange with the registry: - Batch (2,000 messages or less) - Fast Batch (negotiable) - [not real-time] • GSA Contractor is creating a method to convert flat files to HL7 message to assist nontraditional providers who would not have or be expected to have HL7 established (or those who would not benefit from meaningful use, e.g., pharmacists).

14. Current Vanderbilt – TN Registry Process Overnight, a batch request is electronically sent to the state for all patients scheduled in selected clinics for the next *3* days (whose records have not already been requested). This request is processed by the state and the results are retrieved by Vanderbilt and stored *separately* from Vanderbilt’s electronic immunization records. During the day, at 20-minute intervals, small batches of requests (no more than 20) are electronically sent to the state to handle newly-scheduled and walk-in patients. Responses are usually available within 20 minutes – by the time the next request is made. The status of the immunization request from the state is displayed on an electronic outpatient whiteboard for each clinic. [P- pending; n/m – no match; D – done successfully; H – hold on administering vaccines as there are records from the state that do not match any in our system] Clicking on the status in the whiteboard will display an integrated view of imm records from both Vanderbilt’s EHR and the state registry.

15. Interfacing with Immunization Registries • Interoperability and Reuse of Data…. • Medical Communication Standards: -- HL7 (Health Level 7) -- DICOM (Digital Imaging and Communications in Medicine) -- CCD (Continuing Care Documentation) • HITECH was passed by Congress in 2009 to support the adoption and use of Electronic Health Records (EHRs) to achieve significant improvements in care through meaningful use of EHRs by health care providers. Interoperability is a key component of ‘meaningful use’. FOR HOSPITALISTS: • Can external charts be incorporated not only in an electronic form but a *computable* form. Example: Importing lab results not as a PDF but as discrete elements that can be graphed among existing lab work? • Can preparations for transport include a mechanism to generate documents and images that can be electronically sent to the receiving facility?

18. The Electronic Outpatient Whiteboard • Developed in-house, initially for Pediatric and Adult Cancer Centers to facilitate workflow and communication. Placed in production Summer, 2005. • Pediatric Primary Care was an early adopter and has used the OPWB since October, 2005. • Apache/MySQL/PHP app which lives within the EMR environment and is integrated w/ other apps • Sep 2012 statistics: ~2,400 users per day across 130+ clinics in the Vanderbilt enterprise, tracking room movements of as many as 5,500+ patients per day.

20. Vendor’s Consortium: 18 People From 11 Vendors: • Allscripts (2) • Athenahealth (2) • Cerner Corporation (1) – 1 MD • e-MDs (2) – 1 MD • Epic Systems Corporation (1) – 1 MD • GE Healthcare (1) • McKesson (1) – 1 MD • NextGen (2) • OptumInsight (3) – 1 MD • Physician’s Computer Company (2) • Sage Software (1)

29. CDC Survey Assessing Variability Among Immunization Information System (IIS) Vaccine Forecasting Algorithms • Presented at the National Immunization Conference, April 21, 2010 • 9 test cases submitted to 44 of 56 IIS grantees which met forecasting functional standard • Response rate: 36/44 • Of the 36 IIS forecasting algorithm tools testing the nine cases, 19 (53%) IIS forecasted the next dose due > 5 days before the minimum age for at least one test case or more.

31. Objectives - Revisited • Understand how recent efforts to bar-code vaccine products will assist in recording patient information. • Describe how vaccine data is shared through importing from and exporting to existing immunization registries. • Visualize methods to reconcile vaccine data from multiple sources. • Describe examples of practice workflow where vaccine data is compiled and assessed prior to a visit. • Learn about immunization assessment/forecasting web services and the potential role they can play in adding functionality to electronic medical records.

32. Questions? Contact Information: Stuart T. Weinberg, MD FAAP 615-936-4239 stuart.weinberg@vanderbilt.edu http://medschool.vanderbilt.edu/dbmi/people/weinberg