Depicting EHR’s Immunization capability

1. Depicting EHR’s Immunization capability Immunization Storyboard projectStoryboard Subgroup HL7 WGM - May 8, 2006

2. May 2005 WGM Storyboard project scope June 2005 Topic selection Definition of Storyboard vs. Use case July 2005 Storyboard/Activity diagram Webinar (Dan Russler) CHCA Sharepoint August 2005 IZ topic selection Storyboard iterations Activity Diagram building September 2005 WGM Presented IZ storyboard and activity diagram at WGM October 2005 Glossary Webinar (Dan Russler) November 2005 Glossary iterations Scoping for future directions HL7 v3 IZ project (Pharmacy SIG) December 2005 Storyboarding strategy January 2006 WGM Official engagement with HL7 v3 IZ project Submitted project to Patient Care TC Storyboard Activity diagram Glossary Milestones

3. Immunization Storyboard topic • Domain experts within PeDS SIG • Public Health • Public Health Data Standards Consortium – presence of existing standards • American Immunization Registry Assn (AIRA) • CDC • Primary Care • CCHIT • PeDS SIG • High Impact factor • EHR-S DSTU (context)

4. EHR-S DSTU

5. Depicting EHR’s Immunization capability • Focus on function than patient scenario • immunization registry connectivity of EHR • Four basic functions from EHR-S DSTU • Storage of IZ data • Retrieval of IZ data • Connection to the state/local registry • Decision support capability (EHR or registry) • High level representation • Consensus building • Room for expansion • Allow broad-based input

6. PeDS SIG Immunization Registry Storyboard iteration #4 Precondition: Billy Newpatient is 4 years old. He has been seen at other clinics in the state. However, he is a new patient at Dr. Shotz’s clinic. He is there for a pre-school physical. Dr. Shotz's clinic EMR is able to interface with state/local immunization registry. The state/local immunization registry conforms to CDC Minimal Functional Standards for Immunization Registries. The clinic EMR conforms to HL-7 EHR-S Functional Model. The state/local registry is able to locate the patient’s immunization record. Storyboard: Billy has previously been seen at other clinics in the same state. The caretaker does not have his immunization record. In preparing his new patient record for Dr. Shotz to review, the nurse initiates the clinic EMR to query the state immunization registry. The immunization registry finds and sends data to clinic EMR. The clinic EMR populates Billy’s patient record with that data. The clinic EMR generates immunization recommendations using a decision support engine. Alternate Flow #1: The state registry uses a decision support engine and sends recommendations along with Billy’s immunization data. Dr. Shotz reviews the record and notes (amongst other data) Billy’s immunization record (or its absence thereof) and recommendations. After taking history from the caretaker and performing physical exam, she orders immunizations. The nurse administers the shots and documents them in the clinic’s EMR. The clinic EMR sends the message about the new immunizations to the state registry which updates its record. The nurse also prints an updated paper record of Billy’s immunizations. Alternate Flow #2: Dr. Shots determines that Billy does not require or decides to withhold immunizations at this stage. No updates are made to the immunization history in the patient record. No data is sent to the registry. Post-condition: The state registry has successfully sent Billy’s immunization history. The state registry has successfully recorded Billy’s new immunizations. The clinic EMR has an updated immunization record. The patient has an updated immunization record.

7. Patient RN Physician Clinic EMR State/Local Registry No immunization record Prepares pt record for review Requests immunization record from registry Searches for Immunization history Initiates immunization record retrieval Unique patient identifier: Query Populates immunization data in patient record Sends immunization history to Clinic EMR Hx and PE; reviews Px record and recommendations Generates recommendations using decision support Unique patient identifier, Immunization record: Send Administers shots Orders immunization Accepts/Updates new Immunization information to patient record Updates immunization Information in EMR Populates new Immunization data Prints updated Immunization record for patient Unique patient identifier, Update immunization record: Send

8. Patient RN Physician Clinic EMR State/Local Registry Alternate Flow 1 No immunization record Prepares pt record for review Initiates immunization record retrieval Requests immunization record from registry Searches for Immunization history Unique patient identifier: Query Sends immunization history and Recommendations (using decision support engine) to Clinic EMR Populates immunization data in patient record; displays recommendation Hx and PE; reviews Px record and recommendations Administers shots Orders immunization Unique patient identifier, Immunization record, Recommendations: Send Updates immunization Information in EMR Accepts/Updates new Immunization information to patient record Prints updated Immunization record for patient Populates new Immunization data Unique patient identifier, Update immunization record: Send

9. Patient RN Physician Clinic EMR State/Local Registry Alternate Flow 2 No immunization record Prepares pt record for review Initiates immunization record retrieval Requests immunization record from registry Searches for Immunization history Unique patient identifier: Query Populates immunization data in patient record Sends immunization history to Clinic EMR Hx and PE; reviews Px record and recommendations Generates recommendations using decision support Unique patient identifier, Immunization record: Send Prints updated Immunization record for patient Patient waits for next shot schedule Withholds immunization

10. Lessons learned • Significant domain expert involvement • Considerable iterations • Constant communication during the build • Balance between level of detail and granularity vs. degree of consensus vs. work effort • Requires a standardized building approach

11. Updates • 1st Immunization Storyboard deliverable • HL7 Immunization project – Scott Robertson • Part of submitted IZ projects • HL7 Version 3 Standard • Previously included in the Care Provision domain for May ballot; for “information only” • Now formally part of the Care Provision DSTU - see the Care Provision Domain-Storyboard Section. • Not attached to specific immunization messages • http://www.hl7.org/v3ballot/html/welcome/environment/index.htm

12. Pediatric Immunization (DOPC ST000030) Pediatric Immunization (DOPC ST000030)

13. Road to HL7 Standard Dev’t Process Domain Experts • Storyboard Text • UML Storyboard Activity Diagram • Domain Glossary • UML Domain Analysis Model • Static Model Cross-Reference (to HL7 RIM) PeDS SIG Immunization Storyboard SIG TC HL7 Engineers

14. Next Steps • Scope of future project (focus on Immunization) • Breadth – requires more domain expertise • Depth – requires more technical expertise (i.e., informatics, engineers, developers, etc.) • Pediatric focus? • PeDS SIG resources • Clinicians • Registry experts • Public health • Informaticians • Vendors? • International?

15. Examples of Breadth • Information System and Registry communication • Hospital • Military • Health systems (i.e., Indian Health Service) • School health systems • RHIO • Surveillance system • Registry to Registry communication (high level) • HL7 Continuity of Care Document • Harmonization of CCR and CDA • Immunization section • Others?

16. Examples of Depth • EMR process • EMR queries registry • EMR receives info from registry • EMR updates registry • EMR updated by registry • EMR IZ decision support processes • EMR and Registry • Process map for indications to withhold IZ (contraindications, previous disease, etc) • Inventory information exchange between registry and EMR • Reporting of adverse reactions • Sending batched requests from registry • Registry processes • Registry receives query for a client from a registry or other IS • Registry receives answer to query for client info • Registry receives unsolicited update of a client record • Registry receiving batched request for a number of patients

17. Next Steps • Divide and conquer • Breadth? • Depth? • Engage with HL7 IZ project • Follow-up Patient Care TC • Follow-up leading to message definitions • Pursue evidence of tangible impact/contribution within HL7 development process • Begin project documentation (storyboarding process) • Publish • Guidebook

18. Process documentation for the storyboarding activities • Storyboarding • How to choose topic • Priorities • How to choose domain experts • How to update versions (group editing process/procedure) • How to add granularity • Activity Diagram • Glossary build