Session Notes 10

Session 10: Achieving Meaningful Use: Public Health

4/13/11: 2:30 --4:00PM

Session Objectives

• Discuss how Direct can be used to meet meaningful use requirements for reporting to public health and immunization registries
  
  

Presenters/Panelists

• Emily Emerson, MIIC Manager/IT Unit Supervisor., Minnesota Department of Health
• Paul Tuten, VP Product Management, ABILITY

Introduction

• There are two MU requirements: submitting immunization data and submitting syndromic surveillance data. There will be additional, more robust requirements in stages 2 and 3.
• States will want to align with Medicaid and public health
• There are many reasons to use Direct for Public Health. It’s scalable, simple, usable, and will help you to meet meaningful use.

Presentation 1, Emily Emerson, Minnesota

• Some quick information about MN. MIIC is the statewide immunization system and has been live since May 2001. It has been very successful with 5.7 million clients/patients (greater than the number of MN citizens) and over 45 million immunizations covered. In addition, there are over 8,300 active users and a variety of providers and log-ins every day.
  • This is not just a repository.

• These 45 million immunization records come into the system in a variety of ways:
  • The bulk is through a batch file process (83%), while most are in flat file format, there are also some HL7 data

• MN does have agreements in place with its two HIOs (MN Health Information Exchange and CHIC, Community Health Information Collaborative). MN has performed pilots with both organizations and plans to use real time, HL7 messaging
• MN’s HIOs are not scheduled to be repositories themselves, they will be data aggregators for a one time use
• Three paths of EHR-MIIC Integration
  • #1: There are two clinical systems sending real-time HL7 messages (anywhere from 5-10 seconds). One is based in a large St. Paul clinic, the other is with a more rural clinic
  • #2: Provider feedback was that they didn’t want a two-step process to view immunization information. Now, however, there is the ability to click a tab/button on their desktop and it sends a query and it sends it to MIIC, which will respond with all of the patient’s immunization information. This has been integrated with three systems.
    • It should be clarified that this, unlike the HL7 messaging, is not real-time

• • #3 - True, bi-directional exchange remains unrealized

• MN hopes to have additional capabilities (e.g. HL7 2.5.1 and CVX codes) accepted soon
• The loading of immunization records is automated; getting the data to MIIC is more complicated. MIIC also uses a CDC software, which uses EBXML, to get the data.
  • MN received a recent grant from CDC to establish interfaces between EHRs and MIIC
  • This project will run from September 2010 - August 2012.
  • Three major components:
    • Implement HL7 version 2.5.1
    • Establish a secure, more automated standard method of exchanging HL7 messages
    • Implement a vaccine algorithm

• Direct project evolution:
  • The only automated way that MN had to receive data was through secure PHINMS communication standards as destination protocols.
  • Went live 1/12/2011
  • Currently receiving immunization batch files from Hennepin County Medical Center (HCMC) through Direct (PHINMNS on the MN side). It’s an excellent way for the HISP to meet state halfway. Still a rather simple system

• Future directions include increasing provider participation, encouraging use of HL7 standards instead of flat files, increased timeliness and completeness of immunization reporting
  • MN has been live for 9 years and providers are even more anxious for advanced reporting. This will enable them to use the data to improve clinical care for patients. Because of this, MN plans to make available advanced reports such as assessment and patient follow-up.
  • MN also hopes to develop true bi-directional exchange. Goal is to get exchange as real-time as possible.

• In January of this year, MN started using Direct to submit immunization records to MIIC.
• This has been a real group effort in MN.

Presentation 2, Paul Tuten, ABILITY

• ABILITY (formerly VisionShare) was involved in the Direct immunization pilot in MN.
• Although people often discuss public health, this doesn’t necessarily translate into action
• A key learning was that you have to deal with people where they are today, realistically look at the environment, and work from there
• In MN, the Hennepin Country Medical Center (HCMC) is on one side, the immunization registry (MDH/MIIC) is on the other end. ABILITY built a gateway, through Direct, from one point to the other.
  • It was fairly straightforward, although there were challenges (e.g., acknowledgements and other mappings)
  • For the county, they were already submitting immunization registries via a batch file. So ABILITY put them on a glide path to upgrade. Given where HCMC was, they chose to go from secure FTP to PHINMS.

• If you have a different HISP, it’s not a problem. That HISP can send a message to their HISP. With Direct, universal addressing is possible (i.e., as with from Comcast through other Internet providers).
• If a state can’t generate the HL7 message, there are options as well. HCMC can generate these messages, but HISPs are able to do this integration work. Either locally or in the cloud, the inter-standard development can work. Large providers are more likely to work locally, but smaller providers might use the HISP services.
• If a provider doesn’t have an EMR, in the case of MN, they have a direct portal entry. Not all states have this functionality, however, or there may be additional portals. It’s possible for HISPs or other HIE entities to build this into their work streams. ABILITY has this capability built out for MN and OK. What flows into one state may be different than what flows into another.
  • This shows that these types of registries benefit everyone. For instance, in FL, it is required that college students receive immunizations. This program can help those students.
  • Another possible use case is patient involvement in an EHR. This would allow a parent to access his/her child’s immunization records. This integration has been built into Microsoft Health Vault. Thus, users can get HL7 records and send them on to other relevant providers or public health organizations. Microsoft Health Vault also assists patients without an electronic record to get this information.

• Lessons Learned from the HISP perspective
  • Default to Direct for Provider -to-DoH exchange. Thus, you can leverage benefits from bi-directional routing and security. It also provides DoH side users with a single uniform edge
    • Recommends that states default to Direct.

• • Meet providers where they’re at. Direct is helpful here because it is flexible with respect to edge protocols. HISPs should also provide a range of options to meet provider needs and possibly offer paths to upgrade

• As a DoH, you should pick your protocol of choice and the HISP should be able to support that. There will always be some providers without the electronic means, all you can do is give them as much access as possible, for instance, a provider portal. HISPs could also deliver this functionality through portable applications.
  • Keep Direct direct. For providers, if there’s an EHR vendor that can serve this role, great. If not, however, there should be HISPs to fill this role.
  • Direct allows for providers to put patients first in a fairly simple way. Feels that this fits Einstein’s recommendation to “make everything as simple as possible, but no simpler”
  • Redwood MedNet has immunization reporting, as does the Health Information Network of South Texas.

• People are getting more and more interested in Direct, even Paul is getting daily calls asking for more information on Direct.
  
• Brian: Discussed how, if a provider has no capability of producing a VXQ they can contract with a HISP, but isn’t this bringing things to a new level?
  • Paul: There are many different services that a HISP can provide. One model is just connectivity. Another is the more advanced services. There are a lot of organizations currently contemplating becoming HISPs, a lot of the necessary legal framework is already in place. You must be concerned with how responsible the HISP is with responding to providers.

• Brian: Is this EHR functionality in production?
  • Paul: It’s in production, but HCMC hasn’t started sending records via Direct to a Health Vault. We plan for this to happen at some point, but we are currently working to inform and educate patients

FAQ Session

• Jim Daniels (ONC): I want to make sure that I understand your services. You can take a Direct message from a provider and drop it in to PHINMS? Yes. Can enable Direct to PHINMS be usable for other types?
  • It should be done for other types. The only questions are given any contracting requirements. What we’ve already built should be reusable. The “sent back” acknowledgements are a little bit of a challenge.
  • As long as there is no translation, do you think it could be used for any type of message? Paul: there’s nothing that I’m aware of that would make this difficult.
  • A word of caution relating to translation services...(Paul) we’re not really working with those in this pilot.
  • Question for Emily: Related to the bi-directionality, what exactly are you sending back to the providers? Structured data? How do you handle duplication?
    • HTML or XML, it’s as the screen appears in the registry. With this feature right now, we’re doing the most painless method. If it’s one-to-one match, it’s the full history. If more than one, they receive a message that they did not send the correct criteria. Clinicians are very happy, but it’s not perfect.

• Dave Perry (NM): Regarding physician-query, are you planning to replace that with Direct?
  • Emily: We haven’t gotten that far yet. HCMC would eventually like to be able to pick information that might not already be in the EHR. As a part of the grant, several experts got together to look at technologies (REST, SOAP, etc.) and SOAP rose to the top as the most useful methodology. They will still support PHINMS and Direct, but now they plan to implement SOAP.
  • Arien: I agreed with the majority in that panel on the benefits of SOAP. The goal of that transport panel was to support bi-directional, real time support in interfaces. Direct is only one tool, for the long-term, real-time, EHR, you could use Direct, but it might not work as well. The expert panel report makes it clear that this is not intended as a recommendation for only SOAP and also clarifies that Direct is often incredibly appropriate (push transactions, interim strategies, and point-to-point). No one in the immunization community, however, wants to stop with “push” transactions. This would leave a great deal of value on the table. If Direct, however, is how you can accomplish this, then use Direct. Immunization agencies are always happy to get data.
  • Brian: I think this underscores the point that Direct is one tool and is not necessarily in competition with other protocols. It’s one way of doing things, it’s often the simplest way, but there will be times that it is not the best option. Direct is complementary, it enhances, it does not undercut current plans.

• Mark (CT): Paul Tuten has been involved in their pilot as well. They have done a great job in their work.
• Dave Perry (NM): Regarding the SOAP technology, would you be willing to share?
  • Emily: I believe so, but the next step is for the workgroup to develop an implementation plan. I believe that the group is willing. It’s hosted by MDH IT Services, but the primary vendor is HP.
  • Paul: What we have developed should be usable across the states. Let us know if that would be of assistance

• Alix Goss (PA): How is this work that you are doing fall into that repurposing/retooling of public health elements. How does this work?
  • Emily: There’s a lot of work being done right now in getting local departments’ data to the overall DoH.
  • Alix: This may be more of a follow-up effort to ensure that these conversations are going.
    

Closing Remarks

• Brian: I’m really excited about this and about the potential for what this could mean for other states. Make sure that you are all connecting because there is a ton of potential here. Look how quickly this came together.
• Paul: If you represent a state HIE, you should talk to your DoH and align strategies for dealing with these types of transactions. Same for DoH representatives. There’s a lot of great work that could be done together. Regarding SOAP vs. Direct, one thing that’s really nice about Direct (and true standards) is that it gives a different attitude for healthcare. This is not a one off solution. This is the opportunity to ask those hard questions “should I build another interface or leverage what I have?” You can get down to a much smaller system and really leverage cost savings.
• Emily: MN appreciates the recognition of this work.