The Arizona Department of Health Services (ADHS) provides a range of health services to the citizens of Arizona. When the federal government required that all state health departments facilitate interoperable information exchange between public health partners, ADHS adopted the Partner Healthcare Electronic Data EXchange (PHEDEX), a data integration solution powered by Microsoft® BizTalk® Server 2006 R2, from The Simi Group. With its new solution, ADHS was able to quickly comply with federal regulations, eliminate paper from its lab reporting process, increase the quality of data reported, and increase public safety. By eliminating manual data entry, ADHS staff members are more productive and efficient, and can focus on quality data analysis. The department saved an estimated U.S.$2 million and years of development time by acquiring a commercial solution instead of building its own.
The Arizona Department of Health Services (ADHS) maintains a number of programs that preserve and promote the health of Arizona citizens, addressing disease monitoring and prevention, mental health, child and teen health, senior health, pregnancy care, family planning, vital records, immunizations, and more. The department is based in Phoenix, Arizona, and employs 2,200 people.
||Using PHEDEX, built on the Microsoft Application Platform, saved us the $2 million that it likely would have cost to create a data exchange in-house and establish individual partner connections.
Acting Chief Information Officer, Arizona Department of Health Services
The United States government, through the U.S. Centers for Disease Control and Prevention (CDC), requires that state health departments collect lab reports from hospitals and labs across their states and share infectious-disease information with the CDC to support its national disease surveillance efforts. An Arizona State statute requires hospitals, labs, and county health agencies to submit many other types of data to various program groups within the state health department.
In Arizona, dozens of healthcare partners are involved in this information exchange: hospitals, commercial laboratory companies, county health departments, and multiple program groups within ADHS. Although hospitals and labs maintain patient data in electronic lab information management systems, their various systems generally are not capable of generating industry-standard data exchange messages.
That left ADHS and its many healthcare partners with the cumbersome task of using paper to transfer data. Lab personnel printed reports and sent them to the state, where state personnel typed the data into state systems and often faxed the reports to affected county health departments. ADHS tracks approximately 26,000 health cases annually, and for each case there are multiple tests performed, causing perhaps hundreds of thousands of reports to be exchanged each year.
Health occurrences that require immediate reporting are handled expeditiously in compliance with state statutes and rules; however, the everyday process was not very efficient. “In the best case, we received disease data from hospitals and labs on a weekly basis, but often we received the data every few weeks or months since it was easier for them to batch the paperwork,” explains Paula Mattingly, Acting Chief Information Officer for the Arizona Department of Health Services.
Receiving reports quickly was key, due to the state’s need to identify public health problems early on. When problems were identified, the department needed to respond and know if the measures that it was taking were effective. This was difficult to do when it took a month for lab reports to arrive. Manually keying data from paper reports into the state health department’s systems added to the time lag.
In 2005, the CDC updated the Public Health Information Network (PHIN) requirements aimed at speeding emergency response. These requirements established that all states create an electronic information system that would support interoperable data sharing between public health partners—essentially mandating that states eliminate paper exchanges. Since then, public health agencies around the country have been scrambling to develop PHIN-compliant electronic lab reporting (ELR) systems that can accept data in any format, from any partners.
With the clock ticking on compliance with the CDC policy, the Arizona Department of Health Services evaluated a range of options for meeting the new regulation. ADHS had already used Microsoft® BizTalk® Server 2006 to address data exchange needs with a few healthcare partners, such as the state veteran’s hospital; however, maintaining multiple customized BizTalk Server connections was staff-intensive. In addition, ADHS believed it would be costly to sustain the support required for each partner participating in data exchange. With an estimated 200 hours required to establish a single connection and dozens of partners, the rollout and maintenance could overwhelm the project.
“We realized that it would cost $2 million to establish all the needed connections, plus an additional $250,000 annually to manage and maintain them,” says Deborah Littlejohn, Project Manager for the Arizona Department of Health Services. “We needed to identify a straightforward process to establish and maintain the many types of data exchanges with our healthcare partners.”
Data Exchange Automation
ADHS researched products offering automated data exchange and became interested in an integration solution offered by The Simi Group of Sacramento, California. The Simi Group develops products to facilitate the exchange of data between healthcare and public health organizations. ADHS had experience with Simi products and felt comfortable entrusting the firm with its data exchange requirements.
||The combination of BizTalk Server and SQL Server provided the most highly integrated solution but also the most flexible from a development standpoint.
Acting Chief Information Officer, Arizona Department of Health Services
The Simi Group had created a product called the Partner Healthcare Electronic Data EXchange (PHEDEX), which enables public health organizations to establish connections with trading partners in a security-enabled, scalable manner. PHEDEX integrates BizTalk Server 2006 R2, BizTalk Server Accelerators for HIPAA and HL7, Microsoft SQL Server® 2005 data management software, Microsoft Office SharePoint® Server 2007, and the Windows Server® 2003 R2 operating system with Active Directory® service. PHEDEX organizes exchanges among diverse applications and data types while ensuring that transactions are audited and backed up. Electronic lab reporting was one of the first supported business transaction sets.
The ADHS healthcare partners use shared workspaces in Office SharePoint Server 2007 to set up and manage connections, check the status of exchanges, and troubleshoot any transmission failures. PHEDEX is also integrated with the Simi SRA-Gateway product to provide a complete role-based access solution for partner provisioning and administration. The total package provides consistent data and information exchange, and it frees staff members from having to create and maintain workflows that are specific to each partner and connection.
“PHEDEX was easy to configure and would not require custom coding every time we wanted to connect a new healthcare partner,” Mattingly says. “The Simi Group really made us aware of the power of BizTalk Server. Many of the other integration products required a great deal of customization. The combination of BizTalk Server and SQL Server provided the most highly integrated solution but also the most flexible from a development standpoint. In addition, there are many more development resources available for BizTalk Server than for other alternatives.”
Although the work of connecting healthcare partners is ongoing, The Simi Group worked with ADHS to implement PHEDEX in just 45 days. ADHS now uses PHEDEX to exchange data electronically with lab information management systems. When hospitals and labs submit data to the state, PHEDEX determines which internal programs and counties also need to receive the data and transmits it automatically.
Instead of having confidential patient data on paper faxes in state and county offices, the data is now encrypted for transmission and only accessible by authorized personnel. “We’re in the infancy of enrolling healthcare partners; however, we have enrolled several of Arizona’s largest labs, which has enabled us to make major inroads in reducing the flow of paper,” Mattingly says. Users at ADHS required minimal PHEDEX training because they were already familiar with Office SharePoint Server 2007 through using Simi’s extranet environment.
To establish a connection to ADHS, healthcare partners collaborate briefly with ADHS to specify type of connectivity and data format, and then they submit a test file. PHEDEX takes care of implementing security features and routing the data to appropriate programs and personnel. The solution supports multiple versions of laboratory standards (HL7 2.3.x, 2.4.x, 2.5.x, and 3.0), including the management of laboratory-defined mapping tables for data standardization (vocabularies such as CPT, ICD, LOINC, and SNOMED). These data validation and mapping components are important to ensure compliance with the CDC PHIN requirements. Maintenance of vocabularies is simplified and exposed in Office SharePoint Server 2007, which further reduces the cost of technical support.
The Simi Group also made PHEDEX scalable and extensible so that it can accommodate far more than lab results data. ADHS is in the process of using PHEDEX to exchange lab orders, pharmacy orders, emergency medical services data, and many other types of healthcare data.
SOA Foundation for Partner Integration
PHEDEX employs a service-oriented architecture (SOA) approach to deliver its partner integration benefits. The service orientation modularizes IT resources, creating loosely coupled business processes that integrate information across business systems.
||Microsoft turned BizTalk Server 2006 R2 into an enterprise-class messaging platform that separates security, validation, and other aspects of integration…. This enables multiple development groups to focus on separate parts of a business problem.
President and Chief Executive Officer, The Simi Group
“When we were developing PHEDEX, we realized that managing partner connections would be the limiting factor for our BizTalk Server 2006 R2 skill set,” says Dan Desmond, President and Chief Executive Officer of The Simi Group. “We knew that we needed to create a framework on top of BizTalk Server that enabled our customers to easily provision partners and manage partner relationships.”
“Microsoft designed BizTalk Server to be extensible, whereas other integration solutions—such as Orion Rhapsody, Quovadx Cloverleaf, and eTransX eTX HEMI—solve only one problem,” Desmond continues. “Also, Microsoft turned BizTalk Server 2006 R2 into an enterprise-class messaging platform that separates security, validation, and other aspects of integration into distinct skill sets. This enables multiple development groups to focus on separate parts of a business problem. BizTalk Server 2006 R2 also includes a wide range of adapters that enabled us to solve business problems rather than build tools.”
By adopting a flexible and interoperable data exchange solution, ADHS was able to quickly meet the CDC requirements and has been able to increase public safety through the timely exchange of information for analysis and response. As the timeliness has improved, data volumes, quality, and security have also improved. With the reduced need for data entry, patient data is more secure, and staff members are more productive. ADHS estimates that it saved more than $2 million and two years of development time by purchasing a commercial solution rather than developing its own and establishing individual partner connections.
Increased Public Safety
With PHEDEX providing fluid electronic connections between partners, ADHS now receives lab reports on the same day that the labs complete them. “The sooner we get the data, the faster we can report outbreaks and equip regional health centers with needed vaccines and other response preparedness,” Mattingly says.
For example, when a health threat occurs, such as the nationwide concern about salmonella in peanut products in early 2009, there is huge public pressure to identify the origin of the problem. This effort requires data. When paper lab reports have to make their way from labs to local health departments, state health departments, and finally to the CDC, valuable time is lost. “The more time we can cut out of this information relay, the more we can improve public health,” Littlejohn says.
Improved Data Quality
Because lab data is now so much easier to submit, labs and county agencies are submitting many more reports and much more data. When reports were faxed, ADHS received 1,700 lab reports annually from major labs, or about seven a day. After it implemented the electronic data exchange solution, even without all partners signed up, the department started receiving approximately 375 reports a day—91,000 annually. “We aren’t sure why the number of reports has jumped so dramatically, but we have to wonder if all the reports that should have been submitted to us were being submitted,” Mattingly says. “Perhaps all the work required inhibited some labs and agencies from doing the paperwork that they should have been doing. The more data we get, the more accurately we can pinpoint trends.”
There has been an equally staggering increase in the completeness and quality of the data submitted. Initial partner data feeds are demonstrating a dramatic increase in the amount of laboratory data reported on each report. This increase is due to the fact that data is transmitted directly from system to system rather than collected and transcribed by hand.
Savings of More Than $2 Million
“Using PHEDEX, built on the Microsoft Application Platform, saved us the $2 million that it likely would have cost to create a data exchange in-house and establish individual partner connections, plus an additional $250,000 annually to maintain all the connections,” Mattingly says. Also, the department obtained a working solution at least two years sooner than it would have taken to create one in-house, Mattingly estimates. Given the labor and time savings, the department IT staff can now concentrate on solving business problems rather than having to develop and maintain complex, custom data paths.
The time to implement a new partner connection using the PHEDEX solution is 10 percent of what it takes the department to create individual BizTalk Server connectors to partner systems. “It takes alternative solutions weeks, months, and even years to connect labs to the state; with PHEDEX, the entire process, from gathering the provisioning information to establishing the first data feed, takes days,” Desmond says.
Improved Staff Productivity
Because data is submitted electronically and automatically, ADHS professionals no longer spend time performing mundane data entry; they are focused on spotting trends and serving the community. “Previously, our epidemiologists were hampered by the poor timeliness and quality of the data,” Mattingly says. “By automating data exchange between our healthcare partners and ADHS, we are enhancing the effectiveness of epidemiologists statewide by increasing the volume and quality of healthcare data and maximizing the time they focus on elevating public health.”
Extended Healthcare Partner Collaboration
Electronic healthcare reporting and collaboration can now be extended to the Native American tribes within Arizona, while maintaining the security and privacy of the data being shared. “Offering PHEDEX connections provides a way to bring remote health clinics into our wider reporting net and perform broader disease surveillance,” Mattingly says.
ADHS is also using PHEDEX to exchange data with its epidemiology counterparts in Mexico, Arizona’s close neighbor. The department shares some health data with the Mexican state of Sonora, and health officials there can use the electronic data exchange solution to submit lab reports to ADHS so that Arizona can track infectious diseases across shared international boundaries.
“International providers are very willing to connect with Arizona, because Arizona can accommodate many types of data files,” Desmond says. “The Microsoft BizTalk team participates in international standards organizations, relieving our customers of that burden. Other states have to pay labs in other states and countries to send them data, and even then the states require that those labs adopt their product-specific data format. By offering flexible options to laboratory partners, Arizona makes the connections possible. [The state has] emerged as a real leader in ELR.”
According to Desmond, Arizona was one of the first states in the country to create a complete ELR exchange that addresses all required laboratory needs, not just reports. Many states are still working to resolve a myriad of data compatibility issues.
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