Clinical Decision Support for Immunization (CDSi ) Clarity, Consistency, and Computability

1. Clinical Decision Support for Immunization (CDSi)Clarity, Consistency, and Computability Stuart Myerburg National Center for Immunization & Respiratory Diseases Immunization Information Systems Support Branch

2. Translating ACIP Recommendations • Translation of scientific language to technical logic is complex and time-consuming • Uniform interpretation is challenging: • Mostly happens independently within each health information system • Significant variance in system outputs • Outputs frequently don’t match expectations of clinical SMEs Clinical Immunization Recommendations Advisory Committee on Immunization Practices (ACIP) CDS Engine

3. Bridging the Gap Logic Specification Clinical Immunization Recommendations Computable Logic Advisory Committee on Immunization Practices (ACIP) • Increase the accuracy and consistency of immunization evaluation and forecasting • Improve the process of accommodating new and/or changed ACIP recommendations • Make it easier to develop and maintain immunization evaluation and forecasting products • Ensure patients receive proper immunizations “The right immunization at the right time” CDS Engine

4. Expert Panel Facilitation Approach Three working groups 40 industry experts American Immunization Registry Association (AIRA) American Academy of Pediatrics (AAP) Indian Health Service (IHS) Facilitated remote and in-person sessions Electronic Health Record (EHR) Vendors Immunization Information System (IIS) Vendors Consensus-based decisions “I can live with and support that” IIS Programs Academic Institutions

5. Logic Specification for ACIP Recommendations

6. The Logic Specification Is … • Documentation of current ACIP recommendations (and clarifications of those recommendations) for healthy children from birth to 18-years-old • A single, complete source for implementer clarification • Computable and implementation-neutral The Logic Specification Is Not … • Modification of existing ACIP recommendations • Replacement for the role of ACIP • National evaluation and forecasting application or other product • Replacement for current software applications

7. In Logic Specification Scope • Vaccine groups routinely recommended for perfectly healthy children ages 0 to 18 • Hepatitis A (Hep A) • Hepatitis B (Hep B) • Diphtheria, Tetanus, Pertussis (DTaP, Tdap, TD) • Pneumococcal Disease (PCV) • Poliomyelitis (Polio) • Meningococcal Disease (MCV) • Mumps, Measles, Rubella (MMR) • Varicella • Influenza (Flu) • Human Papillomavirus (HPV) • HaemophilusInfluenzae (Hib) • Rotavirus

8. Out of Logic Specification Scope

9. Logic Specification Components • Abstracted attributes and values • Standard data table definitions • Antigen specific values • Static definitions • Dynamic values • Functionality for evaluation/forecasting • Thin process models • Decision tables • Business rules • Static • Technical “glue” • Activity diagrams • Static

10. Dynamic vs. Static

11. Sample Logic Definition Content: Text 4.2 Skip Target Dose • There are certain times where a Target Dose can be skipped. In most settings, this occurs when a patient is behind schedule and the total number of doses needed to reach presumed immunity can be reduced. In cases where a Target Dose does not specify Skip Target Dose attributes, the Target Dose cannot be skipped.

12. Sample Logic Definition Content: Figure

13. Sample Logic Definition Content: Decision Table DECISION TABLE 4 - 2 CAN THE TARGET DOSE BE SKIPPED?

14. Logic Specification Audience and Uses • Those with or without immunization evaluation and forecasting engines • Refine, clarify, troubleshoot, and verify • Develop • Organizational roles • Program managers • Business analysts • Technical developers • Similar to HL7 Implementation Guide • CDC version • State-specific, local versions

15. Sustainability Process • Ensures long-term viability of the Logic Specification and Test Cases • Features • Project liaison to clarify ACIP Recommendations • NIPInfo to address logic specification and testing aid inquiries • Planned participation in ACIP working groups • All materials available on the web with updated FAQs • Regular communication and training opportunities related to logic specification updates

16. “As-Is” Process

17. “To-Be” Process

18. Challenges • Timely updates to the specification • Expanding the specification to include currently out-of-scope topics, such as the adult schedule • Marketing and communication of resources to potential users, particularly in the EHR community • Setting the expectations of potential users as to what the resources are • Continuing the liaison relationship and establishing one with ACIP

19. What’s Next? • Publication of Logic Specification – October 29th • Training Delivery – November 12th – 23rd • Introduction • Supporting Data Tables • Testing Aids • Support through NIPInfo@cdc.gov

20. Project Contacts Eric Larson – vev5@cdc.gov Stuart Myerburg – jyz0@cdc.gov Jennifer Wain – jua7@cdc.gov National Center for Immunization & Respiratory Diseases Immunization Information Systems Support Branch