# Presentation: 475918

## Immunization Information Systems and Health Information Exchange:  The New York City ExperiencePresented to the American Health Information Community (AHIC) Population Health and Clinical Care Connections Workgroup

- Amy Metroka, MSW
- Director, Citywide Immunization Registry
- Bureau of Immunization, New York City Department of Health and Mental Hygiene
- April 3, 2008

## Overview

- Immunization Information Systems (IIS) and Health Information Exchange Networks (HIEN)
- New York City (NYC) IIS: Citywide Immunization Registry (CIR)
- CIR - Lead Integration: Master Child Index
- 2007: Data Reported and Shared
- 2008: Real-Time HL7 Web Services for Data Exchange with Electronic Health Records (EHRs)

## What is an Immunization Information System (IIS)?

- CDC Definition:
*Immunization information systems are confidential, computerized information systems that record, store, and provide access to children’s immunization records.*

## IIS Benefits

- Consolidates immunization records across providers
- Provides access to immunization histories and recommendations - reduces missed opportunities
- Identifies children in need of immunizations and facilitates reminder/recall to parents
- Monitors vaccine uptake and coverage - targets resources to areas of greatest need
- Helps control outbreaks - identifies people at risk
- Increases staff productivity - saves money
- Helps schools ensure compliance

## What can IISs contribute to HIENs?

- “Quick start” by leveraging existing data sharing
- Existing integrated data and population-based data
- Expertise: de-duplication, database management, Web applications, data exchange including HL7
- Existing relationships with many relevant stakeholders: providers, hospitals, health plans, professional associations
- Governance: experience in negotiating and implementing data sharing agreements

## The NYC IIS: The Citywide Immunization Registry (CIR)

- Operational since 1997; accessible via Internet (Online Registry) in 2002
- Mandatory reporting of all immunizations administered to individuals < 19 years
- Vital records loaded weekly (file includes birth certificates, corrections, infant deaths)
- Includes ~ 3.3 million records with over 33 million immunizations

## CIR - Lead Integration through the Master Child Index

- In 1999, decision made to integrate CIR and Lead Quest (LQ), the blood lead test registry
- Completed Master Child Index (MCI) in 2004
- Contains all patients in CIR and LQ
- Enables display of immunizations and lead test results in Online Registry
- Able to display other child health information (e.g., newborn screening results)

## 2007: Data Reported 

- Vital records: ~128,000 births
- Immunizing providers:
- Batch file transfer: 3.1 million (51%) immunizations
- Online Registry: 1.5 million (25%) immunizations
- Paper: 1.4 million (24%) immunizations
- New Jersey (NJ) IIS:  ~ 4,000 immunizations
- Laboratories: ~ 500,000 lead tests

## 2007: Data Shared

- 420,000 (25%) immunization records sent out via batch file transfer
- 375,000 (23%) lead records sent out via batch file transfer
- 27,000 (2%) immunization and lead records made available via phone/fax/mail
- 840,000 (50%) immunization and lead records viewed through the Online Registry

## Online Registry

- Went live on Internet in June 2002
- Designed for external use
- 	- Providers, health plans, schools
- Providers report immunizations (and lead results by June 2008) in real-time
- Providers, health plans, schools access immunization and lead screening histories - offers providers clinical decision support, auto-filled medical forms (day care, schools, camp)
- Dramatic increase in use in the last 2 years

## Online Registry Use: 2004 (to-date)

## Online Registry

## Impact of Data Sharing

- Lead coverage improvement:
- % of children with _>_ 1 blood lead level test before 3rd birthday increased from 84% in 2003 to 89% in 2006
- Immunization coverage improvement:
- % of children 19 - 35 months of age completing the 4:3:1:3:3:1 vaccine series increased from 72% in 2006 to 80% in 2007 (National Immunization Survey)
- % of children 10 - 12 months of age completing the 3:2:2:2:3 vaccine series increased from 33% in 2006 to 53% in 2007 (CIR)
- % of children with a NJ address completing the 4:3:1:3:3:1 vaccine series increased from 25% to 32% (CIR)

## 2008: Bi-Directional Data Exchange: Real-Time

- Build HL7 Web services to exchange data between CIR and:
- Provider Electronic Health Records (EHRs)
- Real-time reporting (eliminate duplicate data entry)
- Provide CIR’s consolidated immunization history and decision support back to EHRs
- Other IISs, e.g., New York  State, NJ
- Regional Health Information Organizations

## HL7 Web Services: Next Steps

- CIR Implementation
- Finish software development (May 2008)
- Test with EHR vendors (May - June 2008)
- EHR Partners:
- Change EHR to use Web services and display integrated immunization history and decision support
- Deploy integrated EHR
- Enhancements – replicate Online Registry experience in EHRs

## Challenges: Partners

- Difficult, until recently, to identify partners ready to use HL7
- Partners accustomed to batch file data exchange
- Real-time required for decision support
- Partners need to integrate, store, and display their information and CIR’s in their own application in a user-friendly way

## Challenges: Design

- HL7 standard is complex
- Difficult to learn to read/write messages
- Testing requires use of new tools
- Technical design very time-consuming
- Requirements gathering and technical design is complicated (many ways to solve some problems)
- IIS functions not 100% covered by HL7 messages

## Challenges: HL7 Variations

- Different HL7 versions
- 2.3.1 (NYC), 2.4 (NYS), 2.5 (Some EHRs)
- Commercial parser helps
- Variations from standard HL7 messages
- VFC eligibility by shot
- Use of custom HL7 message components called ‘z’ segments
- Use of different code sets (CVX, CPT)

## Lessons Learned

- Budget a lot of time: it’s worth the investment
- Complex process, logistics of getting 2 or more parties to agree on design
- Helpful to have a standard for everyone to code to (HL7)
- Development of a thorough HL7 Web services integration guide (available) has been very useful to partners

## Conclusions

- Based on NYC experience, IIS infrastructure can be successfully leveraged:
- As a platform for integration of child health information systems within public health (MCI)
- As a portal to child health records for health care providers, health plans, schools (Online Registry)
- For real-time, bi-directional sharing of child health information with provider EHRs, HIENs (Web services)

## Acknowledgements

- Jane Zucker, Assistant Commissioner, Bureau of Immunization
- Angel Aponte, Vikki Papadouka, Paul Schaeffer, Shirley Huie, Fritzner Paul, CIR
- Andrew Faciano, LQ
- Noam Arzt, Michael Suralik, David Lyons, Peter Sfiridis, Regina Hyder, HLN Consulting, LLC

## Contact Information

- Amy Metroka, MSW
- Director, CIR
- Bureau of Immunization
- NYC Department of Health and Mental Hygiene
- _[ametroka@health.nyc.gov](mailto:ametroka@health.nyc.gov)_
- Angel Aponte
- Computer Specialist, CIR
- Bureau of Immunization
- NYC Department of Health and Mental Hygiene
- _[aaponte@health.nyc.gov](mailto:aaponte@health.nyc.gov)_