Stuart Myerburg

Clinical Decision Support for Immunization (CDSi)

Clarity, Consistency, and Computability

National Center for Immunization & Respiratory Diseases

Immunization Information Systems Support Branch

Translating ACIP Recommendations

Clinical Immunization

Recommendations

Advisory Committee on Immunization Practices (ACIP)

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

Computable LogicClinical

Immunization Recommendations

Logic Specificatio

n

Advisory Committee on Immunization Practices (ACIP)

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”

CDS Engine

Expert Panel Facilitation Approach

40 industry experts

American Immunization Registry Association

(AIRA)

American Academy of Pediatrics (AAP)

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”

Three working groups

Logic Specification for ACIP Recommendations

ACIPRecommendations . Schedules

EHR . IIS . HIE

SOFTWARE

BusinessRules

Decision Tables

Process Models

Domain Model

Testing Methodology

Supporting Data

Logic Definition

Technical Framework

Test Cases

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 ScopeItem Notes Non-ACIP published rules

State law differences Rules published by other

organizations Rules published in other

countries Local school schedules

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

  

Technical Framework

Logic Definition

Supporting Data

Logic Specification Components Abstracted attributes and values

Standard data table definitions Antigen specific values Static definitions Dynamic values

Supporting Data

Technical Framework

Functionality for evaluation/forecasting Thin process models Decision tables Business rules Static Technical “glue” Activity diagrams Static

Logic Definition

Dynamic vs. Static

Technical Framework

Logic Definition

Supporting Data(2012 ACIP Rules)

Supporting Data(2013 ACIP Rules)

Supporting Data(2013 State Rules)

Sample Logic Definition Content: Text

4.2 SKIP TARGET DOSE 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

CONDITIONS RULES

Date Administered < Trigger Age Date?

Yes No

     

OUTCOMESThe Target Dose cannot be skipped.

The Target Dose can be skipped. Target Dose status is Skipped.

DECISION TABLE 4 - 2 CAN THE TARGET DOSE BE 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

“As-Is” ProcessCommunicationre “ACIP Recs”

ImplementersMake / Publish

Recs

Support Schedule Questions

· EHR· HIE

· IIS programs· IIS vendors

INDIVIDUAL INTERPRETATION of ACIP LOGIC

“To-Be” ProcessCommunicationre “ACIP Recs”

Communicationre “Logic Spec”

ImplementersLOGIC SPEC

TEST CASES

CDC IISSB

Update / Publish

Logic Spec

Make / Publish

Recs

Support Schedule / Logic Spec Questions

Communicationre “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 29th

Training Delivery – November 12th – 23rd

Introduction Supporting Data Tables Testing Aids

Support through NIPInfo@cdc.gov

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

Eric Larson – vev5@cdc.gov Stuart Myerburg – jyz0@cdc.govJennifer Wain – jua7@cdc.gov

National Center for Immunization & Respiratory Diseases

Immunization Information Systems Support Branch

Project Contacts