depicting ehrs immunization capability hl7 wgm - may 8, 2006 immunization storyboard project...
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Depicting EHR’s Immunization capability
HL7 WGM - May 8, 2006
PeDS SIG Immunization Storyboard projectStoryboard Subgroup
Milestones 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
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)
EHR-S DSTU
ID Functionality
DC.2.2.1.2 Support for context-sensitive care plans, guidelines, protocols
DC.2.3 Medication and immunization management
DC.2.3.1 Support for medication and immunization ordering
DC.2.3.2 Support for medication and immunization administration or supply
DC.2.5 Support for Health Maintenance: Preventive Care and Wellness
DC.2.5.2 Notifications and reminders for preventive services and wellness
DC.3.2.5 Communication with medical devices
S.1.1 Registry Notification
S.2.2 Report generation
S.3.1.2 Encounter specific functionality
S.3.3.2 Eligibility verification and determination of coverage
S.3.3.6 Health service reports at the conclusion of an episode of care.
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
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.
Patient State/Local RegistryClinic EMRPhysicianRN
Prepares pt record for review
Initiates immunizationrecord retrieval
No immunization record
Generatesrecommendations
using decision support
Sends immunizationhistory to Clinic EMR
Populates immunizationdata in patient record
Searches forImmunization history
Requests immunizationrecord from registry
Populates newImmunization data
Administers shots
Orders immunization
Hx and PE; reviewsPx record and
recommendations
Unique patient identifier: Query
Unique patient identifier, Immunization record: Send
Accepts/Updates new Immunization information
to patient record
Prints updatedImmunization record
for patient
Updates immunizationInformation in EMR
Unique patient identifier, Update immunization record: Send
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.
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.
Patient State/Local RegistryClinic EMRPhysicianRN
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.
Prepares pt record for review
Initiates immunizationrecord retrieval
No immunization record
Populates immunizationdata in patient record;
displays recommendation
Sends immunization history and
Recommendations (using decision
support engine) to Clinic EMR
Searches forImmunization history
Requests immunizationrecord from registry
Populates newImmunization data
Administers shots
Orders immunization
Hx and PE; reviewsPx record and
recommendations
Unique patient identifier: Query
Unique patient identifier, Immunization record, Recommendations: Send
Accepts/Updates new Immunization information
to patient recordPrints updated
Immunization record for patient
Updates immunizationInformation in EMR
Unique patient identifier, Update immunization record: Send
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.
Alternate Flow 1
Patient State/Local RegistryClinic EMRPhysicianRN
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.
Prepares pt record for review
Initiates immunizationrecord retrieval
No immunization record
Generatesrecommendations
using decision support
Sends immunizationhistory to Clinic EMR
Populates immunizationdata in patient record
Searches forImmunization history
Requests immunizationrecord from registry
Withholds immunization
Hx and PE; reviewsPx record and
recommendations
Unique patient identifier: Query
Unique patient identifier, Immunization record: Send
Patient waits for next shot schedule
Prints updatedImmunization record
for patient
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.
Alternate Flow 2
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
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
Pediatric Immunization (DOPC ST000030)
Pediatric Immunization (DOPC ST000030)
Road to HL7 Standard Dev’t Process
Storyboard Text UML Storyboard Activity Diagram Domain Glossary
UML Domain Analysis Model Static Model Cross-Reference (to HL7 RIM)
SIG
HL7 Engineers
Domain Experts
TC
PeDS SIG Immunization Storyboard
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?
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?
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
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
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