Evolving Interoperability Across a State Public Health Immunization Registry and Electronic Health Records.

The critical need for system interoperability and robust information infrastructure in public health was highlighted during the COVID-19 pandemic. An assessment of the evolving interoperability between immunization information system (IIS) in a state-based public health agency and electronic health records (EHRs) including pandemic-driven evolution/use was conducted. The Minnesota Immunization Information Connection (MIIC), the IIS for Minnesota (US) supports interoperability with EHRs using HL7v2.5.1 standards-based queries. Structured interviews were conducted with 28 experts across 12 healthcare systems and public health clinics (n=286 sites) between April - July 2022. Though all reported use of MIIC, most (83%) had MIIC integration within their EHRs, and high EHR queries to MIIC (∼6 million/month), numerous organizational/technical barriers were identified including standard vaccine-naming need in EHRs, app access issues, limited resources and informatics-staff shortage in public health. Results underscore vital role of IIS, on-going interoperability evaluation to address issues and promote standards-based bi-directional EHR-IIS data exchanges.

Development and implementation of an interoperability tool across state public health agency's disease surveillance and immunization information systems.

Public health information systems have historically been siloed with limited interoperability. The State of Minnesota's disease surveillance system (Minnesota Electronic Disease Surveillance System: MEDSS, ∼12 million total reportable events) and immunization information system (Minnesota Immunization Information Connection: MIIC, ∼130 million total immunizations) lacked interoperability between them and data exchange was fully manual. An interoperability tool based on national standards (HL7 and SOAP/web services) for query and response was developed for electronic vaccination data exchange from MIIC into MEDSS by soliciting stakeholder requirements (n = 39) and mapping MIIC vaccine codes (n = 294) to corresponding MEDSS product codes (n = 48). The tool was implemented in March 2022 and incorporates MIIC data into a new vaccination form in MEDSS with mapping of 30 data elements including MIIC demographics, vaccination history, and vaccine forecast. The tool was evaluated using mixed methods (quantitative analysis of user time, clicks, queries; qualitative review with users). Comparison of key tasks demonstrated efficiencies including vaccination data access (before: 50 clicks, >2 min; after: 4 clicks, 8 s) which translated directly to staff effort (before: 5 h/week; after: ∼17 min/week). This case study demonstrates the contribution of improving public health systems interoperability, ultimately with the goal of enhanced data-driven decision-making and public health surveillance.

Stakeholder Use and Feedback on Vaccination History and Clinical Decision Support for Immunizations Offered by Public Health.

National initiatives on Electronic Health Records (EHRs) recognize the vital role of public health and recommend reporting to Immunization Information Systems (IIS) and access of its clinical decision support for immunizations (CDSi). The objective of this study was to collect stakeholder feedback on access and utilization of CDSi from the Minnesota Immunization Information Connection (MIIC), Minnesota's IIS. Input was solicited using a semi-structured questionnaire developed by experts, and from a sample of 17 key informants from February 2015 through May 2016. Analysis highlighted the appreciation of MIIC services, comprehensive vaccination history across providers and CDSi functionality, with public health users relying on MIIC. It also identified issues such as data entry due to read-only view, data quality and communications for improvement. These findings underscore the critical role of IIS, need to engage stakeholders, ensure CDSi updates, maintain good data quality, and promote bi-directional data exchanges across EHRs-IIS.

Direct and Electronic Health Record Access to the Clinical Decision Support for Immunizations in the Minnesota Immunization Information System.

Immunization information systems (IIS) are population-based and confidential computerized systems maintained by public health agencies containing individual data on immunizations from participating health care providers. IIS hold comprehensive vaccination histories given across providers and over time. An important aspect to IIS is the clinical decision support for immunizations (CDSi), consisting of vaccine forecasting algorithms to determine needed immunizations. The study objective was to analyze the CDSi presentation by IIS in Minnesota (Minnesota Immunization Information Connection [MIIC]) through direct access by IIS interface and by access through electronic health records (EHRs) to outline similarities and differences. The immunization data presented were similar across the three systems examined, but with varying ability to integrate data across MIIC and EHR, which impacts immunization data reconciliation. Study findings will lead to better understanding of immunization data display, clinical decision support, and user functionalities with the ultimate goal of promoting IIS CDSi to improve vaccination rates.

Characterizing the Access of Clinical Decision Support Offered by Immunization Information System in Minnesota.

BACKGROUND: Healthy People 2020 aims to improve population health by increasing immunization rates to decrease vaccine-preventable infectious diseases. Amongst the many strategies, role of immunization information systems (IIS) are recognized by studies and taskforce reports. IIS are unique in their offering of clinical decision support for immunizations (CDSi) which are utilized by healthcare providers. Federal initiatives such as Meaningful Use (MU) and Affordable Care Act (ACA) aim to improve immunization rates through use of technology and expanding access to immunization services respectively. MU, the Electronic Health Record (EHR) incentive program includes use of IIS CDSi functionality as part of Stage 3. It is essential to understand access and use patterns of IIS CDSi, so as to utilize it better to improve immunization services. OBJECTIVES: To understand the utilization of clinical decision support for immunizations (CDSi) offered by immunization information system in Minnesota and to analyze the variability of its use across providers and EHR implementations. METHODS: IIS in Minnesota (Minnesota Immunization Information Connection: MIIC) offers CDSi that is accessed through EHRs and branded as Alternate Access (AA). Data from MIIC and technical documents were reviewed to create details on organizations which implemented AA functionality. Data on EHR adoption in clinics and local health departments was obtained from Minnesota eHealth assessment reports. Data on access were tracked from January 2015 through mid-October 2015 through weekly specialized reports to track the queries by organization, volume and day of the week. Data were analyzed, findings were synthesized and reviewed with subject matter experts. RESULTS: Currently 25 healthcare systems/organizations which represent 599 individual provider sites have implemented the AA functionality. Analysis of their EHR platform pointed to two EHRs (Epic and PH-Doc) as dominant products in Minnesota for private and public providers respectively. Use of this function was even across study time period. The query volume correlated to size of the organization, with the exception of an outlier organization with huge query count. Query was able to successfully locate a single matching record for 59% of searches, could not find a record for 5% and 31% resulted in blank/error and the match rates varied across health systems. CONCLUSION: High EHR adoption offers a great opportunity to promote use of IIS CDSi at point of care. Analysis did not track use at individual clinic level and how the queries were being generated. Additional research is needed to understand the provider level use of this CDSi and other organizational and technical factors which influence access to IIS. This is essential for IIS as they execute projects to improve population-level immunization rates, plan provider outreach and prioritize their system enhancements to meet federal requirements.

Technological and Organizational Context around Immunization Reporting and Interoperability in Minnesota.

BACKGROUND: Immunization information systems (IIS) operate in an evolving health care landscape with technology changes driven by initiatives such as the Centers for Medicare and Medicaid Services EHR incentive program, promoting adoption and use of electronic health record (EHR) systems, including standards-based public health reporting. There is flux in organizational affiliations to support models such as accountable care organizations (ACO). These impact institutional structure of how reporting of immunizations occurs and the methods adopted. OBJECTIVES: To evaluate the technical and organizational characteristics of healthcare provider reporting of immunizations to public health in Minnesota and to assess the adoption of standardized codes, formats and transport. METHODS: Data on organizations and reporting status was obtained from Minnesota IIS (Minnesota Immunization Information Connection: MIIC) by collating information from existing lists, specialized queries and review of annual reports. EHR adoption data of clinics was obtained in collaboration with informatics office supporting the Minnesota e-Health Initiative. These data from various sources were merged, checked for quality to create a current state assessment of immunization reporting and results validated with subject matter experts. RESULTS: Standards-based reporting of immunizations to MIIC increased to 708 sites over the last 3 years. A growth in automated real-time reporting occurred in 2013 with 143 new sites adopting the method. Though the uptake of message standards (HL7) has increased, the adoption of current version of HL7 and web services transport remains low. The EHR landscape is dominated by a single vendor (used by 40% of clinics) in the state. There is trend towards centralized reporting of immunizations with an organizational unit reporting for many sites ranging from 4 to 140 sites. CONCLUSION: High EHR adoption in Minnesota, predominance of a vendor in the market, and centralized reporting models present opportunities for better interoperability and also adaptation of strategies to fit this landscape. It is essential for IIS managers to have a good understanding of their constituent landscape for technical assistance and program planning purposes.