Clinical Decision Support for Immunization (CDSi)

Clarity, Consistency, and Computability

Stuart Myerburg

National Center for Immunization & Respiratory Diseases Immunization Information Systems Support Branch

Translating ACIP Recommendations

Advisory Committee on Immunization Practices (ACIP)

Clinical Immunization Recommendations

CDS Engine

 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

Bridging the Gap

Advisory Committee on Immunization Practices (ACIP)

Clinical Immunization Recommendations Logic Specification Computable Logic

CDS Engine

    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”

Expert Panel Facilitation Approach

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

Logic Specification for ACIP Recommendations

ACIP Recommendations . Schedules Supporting Data Logic Definition Technical Framework Test Cases Testing Methodology Business Rules Decision Tables Process Models Domain Model EHR . IIS . HIE SOFTWARE

  

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

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) Haemophilus Influenzae (Hib) Rotavirus

Out of Logic Specification Scope

Item



Non-ACIP published rules



State law differences



Rules published by other organizations

 

Rules published in other countries Local school schedules Notes

Not addressed specifically, however configuration data – known as supporting data in this model – could be adjusted to cover      

Adult vaccines Underlying conditions High/increased/special risk series (e.g. HIB past 5 years, MCV HIV series) Travel vaccines Vaccine shortages Non-FDA approved vaccines (e.g. used in clinical trial)

Currently excluded from scope, but candidate for future consideration

Logic Specification Components

Supporting Data Supporting Data Technical Framework Technical Framework

  

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

Supporting Data (2012 ACIP Rules) Logic Definition Technical Framework

Dynamic vs. Static

Supporting Data (2013 ACIP Rules) Supporting Data (2013 State Rules)

Sample Logic Definition Content: Text



4.2 S KIP T ARGET D OSE 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.

Sample Logic Definition Content: Figure

Sample Logic Definition Content: Decision Table

DECISION TABLE 4 - 2 CAN THE TARGET DOSE BE SKIPPED?

CONDITIONS RULES Date Administered < Trigger Age Date?

Yes No

OUTCOMES

The Target Dose cannot be skipped. The Target Dose can be skipped. Target Dose status is Skipped.

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

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

Make / Publish Recs

“As-Is” Process

Communication re

“ACIP Recs”

  IIS programs IIS vendors   EHR HIE

Implementers

INDIVIDUAL INTERPRETATION of ACIP LOGIC Support Schedule Questions

“To-Be” Process

Communication re

“ACIP Recs”

Make / Publish Recs

Implementers LOGIC SPEC TEST CASES

Support Schedule /

Logic Spec

Questions Communication re

“Logic Spec” Update / Publish Logic Spec CDC IISSB

Communication re

“New Recs”

and

“Logic Spec”

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

What’s Next?

 Publication of Logic Specification –

October 29 th

 Training Delivery –

November 12 th – 23 rd

   Introduction Supporting Data Tables Testing Aids  Support through [email protected]

Project Contacts

Eric Larson – [email protected]

Stuart Myerburg – [email protected]

Jennifer Wain – [email protected]

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: [email protected] Web: www.cdc.gov

National Center for Immunization & Respiratory Diseases Immunization Information Systems Support Branch