Jim Greene, MD, MSDeputy Director

Center for Health Statistics and InformaticsCalifornia Department of Public Health

Neal RosenblattChief

Informatics BranchCenter for Health Statistics and Informatics

California Department of Public Health

Jeremy PineChief

Information Technology SectionChronic Disease Surveillance and Research

Branch Center for Health CommunitiesCalifornia Department of Public Health

James P. Watt, MD, MPHChief

Division of Communicable Disease Control Center for Infectious Disease

California Department of Public Health

Public Health 2035 &

Ecosystem of Data Sharing

Connecting the Dots

What’s in interoperability for CDPH ?

Progressive capability maturity to integrate population health management data with healthcare delivery systems data, making

data and information more easily accessible as a means to improve

community health throughout California.

Thank you!

We look forward to collaborating with you!

The How of Interoperability: CDPH

Interoperability Primer & Roadmap Planning Toolkit

– A Strategy for Interoperability, Assessment, Implementation, and Data

Sharing

Objectives • Strategic Approach • Governance • Implementation • Output

Neal Rosenblatt

Chief, Informatics Branch

Center for Health Statistics and Informatics

California Department of Public Health

2017 – 2022

Presentation Topic & Contents

The How of Interoperability: The Interoperability Primer & Roadmap Planning Toolkit− A CDPH Strategy for Interoperability Assessment, Implementation, and Data Sharing

• Objectives & Strategic Approach– Registries/Surveillance Systems Forum, June

2016– Business, Data, and Technology

• Governance– Organizational Structure

• CHSI Informatics Branch– Information Management Services

• EODS Steering Committee– Workflow

• RME Toolkit & Implementation• Output

– As-Is/To-Be Requirements Documentation– Interoperability Strategic Plan

Topic Presentation Contents

Objectives

From the CDPH Planning for the Future of Registries & Surveillance Systems Forum, June 22, 2016:• Identify needs and opportunities for registries and surveillance

systems as we plan the future of data sharing and interoperability• Understand CDPH’s individual registries and data system priorities

for business, data, and technology needs including:1. Linking common identifiers for sharing information; 2. Collaboration with hospitals and providers; 3. Leveraging data lessons learned from other states; 4. Agreement of a common data dictionary; 5. Using data to educate the public – “tell our story”; 6. Data agreements with outside sources; 7. Identifying Centers and Offices with similar goals to work together.

Objectives upon which the RME

Toolkit development process was

founded

Identify needs and opportunities

Understand CDPH’s individual registries and data system priorities

Linking common identifiers Collaboration with hospitals and providers

common data dictionary

Data agreements

EODS STRATEGIES FOR INTEROPERABILITY AND DATA SHARING

CDPH Registries, Surveillance Systems, and Business Support Systems

• 2.1 ADOLESCENT FAMILY LIFE PROGRAM (LODESTAR)

THE CENTER FOR FAMILY HEALTH (CFH)

• 2.2 BLACK INFANT HEALTH PROGRAM (ETO)

THE CENTER FOR INFECTIOUS DISEASES (CID)

• 2.3 CALIFORNIA BIRTH DEFECTS MONITORING PROGRAM (CBDMP)

• 2.4 CALIFORNIA IMMUNIZATION REGISTRY(CAIR)

• 2.5 CALIFORNIA OFFICE OF REFUGEE HEALTH

• 2.6 CALIFORNIA REPORTABLE DISEASE INFORMATION EXCHANGE (CALREDIE)

THE CENTER FOR HEALTHY COMMUNITIES (CHC)• 2.7 CALIFORNIA CANCER REGISTRY (CCR)

• 2.8 CHILDHOOD LEAD POISONING PREVENTION BRANCH (RASSCLE II)

• 2.9 DCDC CALIFORNIA LABORATORY INFORMATION MANAGEMENT SYSTEM (CAL-LIMS)

• 2.11A ELEVATED LEAD VISUAL INFORMATION SYSTEM (ELVIS)

• 2.11B WORK-RELATED ASTHMA PREVENTION PROGRAM (WRAPP)

• 2.11C OCCUPATIONAL PESTICIDE ILLNESS PREVENTION PROGRAM (OPIPP)

• 2.11D FATALITY ASSESSMENT AND CONTROL EVALUATION PROGRAM (FACE)

• 2.10A NEWBORN SCREENING DISORDER REGISTRY

• 2.10B CHROMOSOME REGISTRY

• 2.10C NEURAL TUBE DEFECTS REGISTRY

• 2.12A CALIFORNIA HIV SURVEILLANCE SYSTEM

• 2.12B HIV CARE DATABASE (ARIES)

• 2.12C HIV PREVENTION DATABASE (LEO)

• 2.13 FLUORIDATION & ORAL HEALTH SURVEILLANCE SYSTEM (FLOHSS)

• 2.14 PARKINSON’S DISEASE REGISTRY

• 2.15 CALIFORNIA STROKE REGISTRY

• 2.16 CALIFORNIA SMOKER’S HELPLINE

THE CENTER FOR HEALTH STATISTICS AND INFORMATICS• 3.1 CALIFORNIA INTEGRATED VITAL RECORDS SYSTEM (CAL-IVRS)

• 2.17 CALIFORNIA BIOBANK PROGRAM

• 3.2 WIC MANAGEMENT INFORMATION SYSTEM (WIC-MIS)

1.1 Working Definition of a Public Health RegistryThe California Department of Public Health (CDPH) does not have a unified definition of a public health registry. For purposes of this report, a registry is defined “as a database of identifiable entities containing a clearly defined set of health and demographic data collected for a specific public health purpose.”

1.2 BackgroundThe California Department of Public Health (CDPH) currently supports 27 identified public health registries and surveillance systems at varying phases of development. These registries vary by purpose, scope, function, funding source, technical capabilities, implementation, case definition and case-finding (ascertainment) procedures, determination of data elements, data collection and processing procedures, data access policy, and a framework for dissemination of registry data and findings.

LEGEND:• Grouped by CDPH Centers• Indexed to California Department of Public Health Registries: A Report for the Directorate (2015)

THE CENTER FOR HEALTH CARE QUALITY (CHCQ)• X.X LICENSING AND CERTIFICATION PROGRAM (HFCIS)

Governance Structure

Directorate

DO-ITCommittee

PolicyCommittee

EODS Steering

Committee

B/F WGJim Greene / Alex

Haq, Co-Chairs

O & CEllen Badley, Chair

DS/DQ WGNeal Rosenblatt,

Chair

LPS WGJim Greene, Chair

Tech WGYasser Lahham / Neal Rosenblatt,

Co-Chairs

Oversight is provided by DS/DQ and Technical Workgroup Leads EODS Info Mgt Services & Analytics

Services Unit

Research Data Supervisor II

VACANT581-223-5734-909

(916) XXX-XXXX

Eyobe AkoRDS II

581-223-5758-909

(916) XXX-XXXX

Chelsea ScheiberRDS II

581-223-5758-909

(916) XXX-XXXX

Marisa ReyITS II

580-151-1414-909

(916) XXX-XXXX

Vonda LongITS II

580-151-1414-909

(916) XXX-XXXX

Predictive Analytics Services Team

(P.A.S.T.)

Analytics Services Unit

E O D S

Rebecca FeinCID ContractorXXX-XXX-XXXX-

XXX(916) XXX-XXXX Program

SpecialistCHCQ

Latonia Richardson

CHCQ SupportXXX-XXX-XXXX-

XXX(916) XXX-XXXXProgram

SpecialistCAIR/CalREDIE

Giselle LauITS II

580-151-1367-909

(916) XXX-XXXX

Information Management Services

Team (I.M.S.T)

Info. Mgt Lead/

EODS 3.0

Colin ChewRDA II

581-223-5731-909

(916) XXX-XXXX

IT Dev/Ops/SDLC

Scott Fujimoto, MD, MPHPHMO II

580-223-7722-001(916) 324-6376

Ryan BealRS III

580-223-5594-909

(916) 552-8041

Laura LundRS III/Branch Lead580-223-5605-001

(916) 552-8113

David DauphineRS II

580-223-5582-003

(916) 552-8224

Michael RodrianRDM III (RDA)580-223-5740-

901(916) 872-5866

Mayra CanoHPS I

580-223-8338-002

(916) 650-6895

Research Scientist Supervisor I

VACANTTony Agurto, CEA (Acting)

580-223-5651-904(916) 552-8100

Science AdvisorEODS

Neal RosenblattRS III

580-222-5594-909

(916) 621-1540

Victoria DaherRDS II

580-223-5758-001

(916) 552-9873

Cal-IVRS

Let’s Get Healthy California / Open Data

Angel ValdezAGPA

580-223-XXXX-XXX

(916) 552-9978

DS/DQ WGNeal Rosenblatt,

Chair

Technical WGYasser Lahham

Neal Rosenblatt, Co-Chair

Oversight is provided by DS/DQ and Technical Workgroup Leads

EODS Steering Committee

EODS Steering CommitteeEODS Information

Management Service/ Analytics Services Unit(Within CHSI Informatics Branch)

Information Management Service Function Between CDPH Data Coordinators and EODS Information Management Services

Team

Data CoordinatorsCDPH

Centers/Offices

CID CHSI

CHC

CFH CEH

CHCQ

OHE EPO

Inclusion Criteria = Data Collecting, Sharing, Exchanging Entities

Depicts requirements information flow

ToolkitImplementatio

n/ Requirements

Gathering Process

• Interoperability “Readiness” Assessment

• Requirements Gathering

• Strategic Planning

• Interoperability Solutions• Predictive Analytics Service• Data Standards/Data Quality• Data Privacy/Security• Governance• Data Curation• Information & Data Management/ EODS 3.0

Minor Reorganization2018

Data Coordinators& Workflow

EODS INFORMATION MANAGEMENT SERVICES TOOLKIT

3 Components• Manual• Workbook• Training Guide

AssessmentRequirements

Gathering Process

Information Management Services Toolkit

Interoperability Readiness Assessment

• Interoperability Primer• Worksheet Series

– Business Case for Interoperability

– Goals + Objectives

– Strategic Planning

• Section 1.0– Business Case for

Interoperability– Worksheets 1.5 – 1.6

• Section 2.0– Goals + Objectives– Worksheets 2.1 – 2.2

• Section 3.0– As-Is/To-Be Strategic

Planning– Worksheets 3.1 – 3.8

User Manual Workbook Training Guide

EODS Planning History

Roadmap Exercise + Objectives

Business + Data + Technology Strategic Approach

Toolkit Development + Alignment

Interoperability Primer

Toolkit Contents + Exercises

Roadmap Toolkit Content Areas: 1.

2.

3.

Three (3) key steps to defining how to get from a current As-Is state to a desired future To-Be state

TABLE 3. ROADMAP PLANNING TOOLKIT LIST OF WORKSHEETS

Roadmap Toolkit Implementation:

1 Day StrategicPlanning Workshop

Strategic PlanningPrep Work

TABLE 3. ROADMAP PLANNING TOOLKIT LIST OF WORKSHEETS

Toolkit Workflow

As-Is / To-Be Specifications Output to Roadmap Vendor

6 – 8 week implementation process

RME Toolkit Alignment with State and National Initiatives, and Federal Policy

Aligns with:21st Century Cures Act (2016)ARRA HITECH Act (2009) MACRA (2015) U.S. DHHS ONCAHIMA Data Standards CAHIE/CTENCHHSA 2016 Information Strategic Plan CHHSA 2012-2014 HIE Plan CHHS Master Data Management StrategyPublic Health 2035 Vision

Federal

National

Statewide

California Association of Health Information Exchanges (CAHIE)

CAHIE Founding:• $38.8M State HIE Cooperative

Agreement Grant (2011)o Provisioned by HITECH (2009) through

ONCo CHHS Initial Administrator

• CAHIE formed as 501(c)3 (2013)CTEN: California’s inter-organizational health information exchange CIC: A committee of CTEN participants. Upholds set of policies and procedures for trusted exchange CalDURSA: California's multi-party data sharing agreement for trusted statewide health information sharing; compatible with DURSA in partnership with ONC’s eHealth Exchange

CALIFORNIA ASSOCIATION OF HEALTH INFORMATION EXCHANGES OBJECTIVES:

1. PROMOTE A REGULATORY ENVIRONMENT IN CALIFORNIA THAT ENABLES PROVIDERS, CONSUMERS, AND

OTHER STAKEHOLDERS TO EXCHANGE AND APPROPRIATELY ACCESS HEALTH INFORMATION.

2. CREATE A COLLABORATIVE ENVIRONMENT THAT FOSTERS AND SUPPORTS COOPERATION AMONG OUR

MEMBERS AND OTHER STAKEHOLDERS TO SOLVE DIFFICULT PROBLEMS AND SHARE LESSONS LEARNED IN

HEALTH INFORMATION EXCHANGE.

3. FOSTER THE ADVANCEMENT AND GROWTH OF ELECTRONIC INFORMATION EXCHANGE THROUGH

CREATING AND SUPPORTING INFORMATION EXCHANGE INITIATIVES.

4. ENABLE AND SUPPORT HIGH-VALUE INFORMATION EXCHANGE AMONG UNAFFILIATED COMMUNITIES.

5. PROVIDE SERVICES IN SUPPORT OF STATEWIDE HEALTH INFORMATION EXCHANGE ACTIVITIES AND

INITIATIVES.

Founding, Structure, Policies & Procedures

California HIE LandscapeCAHIE CTEN Membership:

• 11 Community HIOs• 6 Enterprise HIOs• Other Point-to-Point Exchange• 38 of 58 Counties have Community HIO

presence

ONC Trusted Exchange Framework and Common Agreement (TEFCA)

Qualified Health Information Network (QHIN) Structure and Roles

How the Trusted Exchange Framework Works

To-Be Interoperability Solution for the Roadmap Planning ExerciseIn Alignment with CAHIE CTEN and ONC TEFCA

CalDURSA

Alignment with State and National Interoperability Initiatives and Federal Policy

When completed, Roadmap Toolkit output will provide the following information by CDPH Center/Office and by Program data collection system:

• A brief overview of the registry, surveillance system, or business support system

• Its current and envisioned future state • Mission and Value statements • SMART goals and objectives statements • SWOT Analysis

o Identifies proposed pathways to get from a current “As-Is” state to a desired future “To-Be” state

o Informs RME vendor of business, data, and technology requirements• Opportunities to engage State and National interoperability

initiatives and directly address federal policy

Thank You!

Neal Rosenblatt

Chief, Informatics Branch

Center for Health Statistics and Informatics

California Department of Public Health

3701 N. Freeway Blvd, Sacramento, CA 95834

Email: Neal.Rosenblatt@cdph.ca.gov

Contact Information

Interoperability Use Case

Electronic Pathology ReportingJeremy PineInformation Technology Section ChiefChronic Disease Surveillance and Research BranchCenter for Healthy CommunitiesCalifornia Department of Public HealthJanuary 7, 2019

California Caner Registry

The Path Forward

• What – Recent Legislative Change• How – Program Execution• The Future – Where we are headed• Why – Define the purpose

California Cancer Registry

• 1987 - First statewide data collection year – Hospital generated cases– Manually abstracted by Certified Tumor Registrar

(CTR) staff

• 180,000 New Patients per year– 200,000 new tumors, 240,000 hospital cases

• 2001 – First implementation of electronic Pathology Reporting

Introduction

• CA State Assembly Bill 2325 – Introduced in February of 2016 by

Assemblywoman Susan Bonilla, 14th District - Contra Costa, Solano Counties

– Approved and signed by Governor Jerry Brown on September 14, 2016

Assembly Bill Text

This bill, on or after January 1, 2019, would, among other things, require a pathologist diagnosing cancerto report cancer diagnoses to the department by electronic means, including, but not limited to, either directly from an electronic medical record or using a designated Internet Web portal provided by the department.

CA Health and Safety Code 103885

Assembly Bill Text (Cont.)

3 (C) A pathologist shall not be responsible for acquiring missing or inaccessible patient demographic information not provided to him or her beyond the content of the required cancer-specific data elements

CA Health and Safety Code 103885

Many Large Parts to the Plan

• Communications • Data Standards• Technical Support• Software/Hardware/Network Development• Testing/Implementation Support• Operational Process Changes

Milestones

January 15, 2017

July 1, 2017

January 1, 2018 January 1,

2019June 8, 2018

September 14, 2016

Path to Implementation

Registration Process

• Registration with the California Cancer Registry is required for electronic pathology reporting

• A Laboratory or institution may register a single time on behalf of all of its pathologists

• https://pathreporting.ccr.ca.gov/registration/

Data Elements• Required

– Patient Information (First, Last)– Ordering Physician Information (First, Last, Provider NPI, CA License

Number, Address)– Ordering Facility (Facility Name, NPI, Address)– Principal Result Interpreter (Last, First, CA License Number)– Cancer Diagnosis (Order Filler Number, Date Specimen collected, Date

results reported, Report Text)• Required if available

– Patient Information (14 fields)

Data Format

• HL7 v2.5.1 ORU_R01 - CDC National Standard NAACCR Volume V:– Simple Narrative– Synoptically Structured – Synoptically Structured using College of American

Pathologists (CAP) Electronic Cancer Checklist (eCC)

• SDC XML – CAP eCC Structured Data Captured(SDC)– IHE QRPH SDC Rev. 2.1 Trial Implementation

Required Data ElementsElectronic HL7

• California HL7 v2.5.1 Constraints Document• Fields are designated as required or required if accessible• Specific constraints including:

– Identifier Type – CCR wants Medical Record Number (MR) or Social Security Number (SSN)

– Producer’s reference – CCR wants the CLIA number of the Lab

Transmission Methods

• CCR will accept electronic pathology reports through four methods of transmission:

1. Web Services (SOAP, REST)2. Minimal Lower Layer Protocol (MLLP)3. Secure File Transfer Protocol (SFTP)4. Direct Data Entry Web Portal

Current State of Implementation

• 537 Reporting entities have registered• 198 Reporting entities have completed onboarding• 239 Reporting entities are actively within the process

of onboarding– 210 via a new interface– 28 to report via the Direct Entry Portal

• 100 Registered entities have yet to initiate onboarding

What does the future look like?

• Support transition of interfaces off of HL7 v2.5.1– Move away from customized interfaces and data

constraints

• Towards HL7 v3– Consolidated Clinical Document Architecture (C-CDA)– Clinical Document Architecture (CDA) based reporting

What is in HL7 v3 C-CDA?

CDA Document Types (9 Common Types)

Continuity of Care Document

Consultation Notes

Discharge Summary

Diagnostic Imaging Reports

Clinical History and Physical

Operative Note

Progress Note

Procedure Note

What is in a CDA Document Type?

Continuity of Care Document (CCD) Templates

Header Medications

Allergies Immunizations

Problems Medical Equipment

Procedures Vital Signs

Family History Functional Stats

Social History Results

Payers Encounters

Advance Directives Plan of Care

What is CDA on FHIR?

• FHIR – Fast Healthcare Interoperability Resources – Structured and Standardized constraints – Blueprint for a shared message structure– Enables direct query and response

Why are new standards important to CCR?

• Timeliness of Data• Data Curation Cycle of 24 months to 6 months

or less• Near-time access to data for researchers and

clinicians

Cancer based CDA Implementation

HL7 CDA ® Release 2 Implementation Guide: Reporting to Public Health Cancer Registries from Ambulatory Healthcare Providers, Release 1, DSTU Release 1.1 – US Realm

What’s next for CDA and Cancer Reporting?

• Reporting to Public Health Cancer Registries from the Pubic Health Case Report (eICR)

• Reporting to Public Health Cancer Registries from Clinical Oncology Treatment Plan and Summary

What can CCR do with CDA based data?

• Genetic Data guides cancer treatment decisions in today’s world– Central Cancer Registries should start to stratify

surveillance data on genetic profiles and associated treatment decisions in near-time

– Focus towards use of CCR data in clinical environments

Future of a Central Cancer Registry

• 21st Century Central Cancer Registry– Near-time Surveillance– Clinical Decision Support– Clinical Research Evaluation

• Leverage technology and emerging health information data exchange standards

Improving Public Health through Electronic Case Reporting

James Watt, MD MPHChief

Division of Communicable Disease Control

January 7, 2019

Presentation flow

• Overview of Electronic Case Reporting (eCR)• Overview of the Digital Bridge• Update on eCR implementation in California

Electronic case reporting (eCR)

• Automated generation and transmission of case reports from electronic health records to public health agencies

• Automated communications from public health agencies to health care providers

eCR flow

Provider EHR Decision Support

IntermediaryPublic Health

Provider

enters information into the EHR

as part of regular

workflow

sends an electronic

report based on a set of standard triggers

reviews report,

determines reportability

and forwards to appropriate

public health agency

receives report and

acts to protect

public health

receives confirmation

of report and

information from public

health agency

Benefits of eCR

• Public health– Improved timeliness and quality of disease reports– Improved data for public health action– Increased efficiency of communications to health care

providers• Providers

– Increased efficiency of reporting to public health– Reduced uncertainty of reporting requirements– Improved communication flow from public health– Compliance with meaningful use requirements

The Digital Bridge: A partnership of health care, health IT and public health organizations

• Goal: improve our nation’s health through bidirectional information flow between health care and public health

• A forum for sharing ideas• An incubator for innovative projects • Initial focus: eCR, leveraging investments by

CDC, CSTE and APHL

C

He

Governing Organizations

Funders Project Management Office

Digital Bridge organization

• Governance body– Health care networks– Health IT vendors– Public health agencies

• Program management office• Workgroups

– eCR implementation– Evaluation– Legal and regulatory– Strategy

Digital Bridge approach

• Leverage the APHL Informatics Messaging Services (AIMS) platform built for electronic laboratory reporting (ELR)– Hosted on Amazon Web Services– Uses standardized, EHR system agnostic transmission

• Utilize a decision support intermediary (Reportable Conditions Knowledge Management System—RCKMS)– Provide a library of reporting triggers for use by EHRs– Review, validate and route case reports

• Provide national coordination, tools, training and technical assistance for eCR

Digital Bridge pilot sites

Digital Bridge progress

• Houston Methodist/Epic• Production date: Nov. 14, 2018• Able to trigger on problem list –SNOMED• SNOMED translated to ICD-10 when diagnosis is not triggered• As of December 7, 2309 eICRswere received and processed by RCKMS with 69 determined as reportable and sent along to the Houston Health Department.

• Utah Intermountain Health/Cerner

• Successful end-to-end workflow testing• IMH pushed eICR/ triggering functionality to production without sending messages through the firewall to AIMS– Within one week –3,000 eICRs generated for 1,800 unique patients for five pilot conditions

Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 June 2019 July 2019 Aug 2019 Sept 2019 Oct 2019 Nov 2019 Dec 2019

Digital Bridge eCR Implementation Timeline - 2019 DRAFT

New York State SiteProduction

New York State Site Connectivity/Onboarding/Testing

Anticipate discussion of how eCR onboarding will be opened up as part of eCR transition

New York City SiteProduction

Kansas SiteProduction

New York City Site Connectivity/Onboarding/Testing

Kansas Site Connectivity/Onboarding/Testing

California SiteProduction

Michigan SiteProduction

California Site Connectivity/Onboarding/Testing

Michigan Site Connectivity/Onboarding/Testing

California eCR status:• Pilot testing initiated• Production transmission planned for early 2019• Evaluation of pilot planned for mid 2019

eCR next steps

• Legal arrangements for HIPAA compliant data transmission to AIMS

• Evaluation of pilot activities– System impacts– Data quality, completeness, timeliness

• Ongoing communications with stakeholders

Questions?

• www.digitalbridge.us• www.cdph.ca.gov/Programs/CID/DCDC/Pages

/Electronic-Case-Reporting-eCR.aspx