Along with most of Ontario’s family physicians, I was thrilled to hear the newly-elected Conservative government’s announcement on June 20 that the implementation of the portion of the Immunization of School Pupils Act (ISPA) mandating immunization reporting to public health units would be paused. This legislation was flawed from the outset, and was opposed by both physician groups as well as public health units who all spoke out against it to the Standing Committee of the Legislative Assembly in April/May 2017. The basis for the concern was not opposition to the concept of integration of patient medical records, but rather that in the absence of integration with current electronic medical records, that this would add an unreasonable burden of work to both family physicians and public health units (since without seamless integration with EMRs, physicians would still likely fax records to the health units, duplicating work for both). The previous Liberal government had set an arbitrary implementation date of July 1, 2018, despite the fact that the complete technological solution to implementation has yet to be finalized. With this pause in implementation, we can now work to ensure that the proper supports are in place before immunization reporting becomes mandatory.
So how close are we to a solution? Thankfully a lot of work has already been done in this space, and I will try to give you an explanation of the landscape as we stand right now. I am currently a member of the Digital Health Immunization Repository Clinical Advisory Working Group (DHIR CAWG) as an unpaid member. This working group consists of members which represent the MOHLTC, eHealth Ontario, public health, physicians, nursing, and other stakeholders.
The Digital Health Immunization Repository (DHIR) is the centralized repository of standardized electronic immunization data. This is already in place and operational.
Public health units access the DHIR through an interface called Panorama, which has been operational for many years now. The 36 medical officers of health in the province are the Health Information Custodians (HIC) for the immunization data. It is the public health units that act as the curators of the immunization data before it enters the DHIR to ensure quality control, through a system called the Public Health Information Exchange (PHIX). This quality control is important to avoid patients or providers entering incorrect or duplicate vaccine information.
From the patient’s standpoint:
ICON-Public (Ontario’s Digital Yellow Card) is the online portal where patients can view their immunization data stored in the DHIR, securely submit vaccination information to the DHIR, and receive email notification confirming that information has been accepted into the DHIR. This is operational in 33 of 36 health units right now. To log in, they require their health card number, their Stock Control Number (on back of health card), their date of birth and postal code. They pick a secure PIN which they will need to log-in during subsequent sessions.
CANImmunize is a bilingual mobile application where patients can track their immunizations on their smartphone. It gives them information on what immunizations are due or upcoming based on their age, and provides a ton of information about vaccinations, activities for kids, and outbreak information based on geography. The goal is that this will sync with the DHIR (but not clear whether this will be bi-directional or unidirectional).
For clinicians:
ICON-HCP is the online portal where health care providers can view their patient’s immunization data and manually submit vaccination to the DHIR (both vaccinations covered by the IPSA legislation and those outside the legislation). HCPs can also access clinical decision support for which vaccines a patient is due for, which are coming up as due in their forecast, and a future iteration will include specific vaccines for high-risk individuals. HCPs log in to ICON-HCP using their oneID login information. ICON-HCP is currently in a pilot stage was scheduled to be ready for provincial rollout on July 1.
Following me so far?
So while all of the above innovations are fantastic for patients, and necessary for health care professionals without an EMR, ICON-HCP is simply not a practical tool for physicians with an EMR. We have invested significant time and money into having high-functioning EMRs, and to expect us to enter immunization data into our EMR, then to log into a separate portal to enter that same information again, simply is not practical.
What is required is a seamless process, where entering immunization data into the EMR is automatically submitted to the DHIR. OntarioMD is currently working on setting the standards that EMR vendors would need to meet for submitting data to the DHIR, and my understanding is that these standards should be finalized by early fall. The individual vendors would then work on their own solutions for rolling out to physicians. My own personal hope Is that this includes both pushing out of information to the DHIR at the time of vaccination, as well as a pull mechanism for vaccine information from the DHIR, similar to how OLIS operates right now.
Once we have reached a point where vendors have been given sufficient time to implement a functional integration with the DHIR, then the IPSA legislation dealing with mandatory reporting can be un-paused. Those with EMRs will have a functional system to work with, and those without EMRs can use ICON-HCP to submit their immunization data (and yes, they should be required to submit via ICON-HCP; they are being paid to administer vaccines, they cannot silo themselves indefinitely).
One issue I hope is looked at critically is the requirement for express consent from patients for clinicians accessing information from the DHIR. This creates a tremendous barrier for clinicians who are undertaking quality improvement work in their practices to ensure patients are completely vaccinated (running custom searches using EMRs), and many physicians would simply abandon this type of work rather than chase down every single patient to obtain consent. Many physicians do not have an electronic means to contact patients, and either calling patients or bringing them in for consent is simply not practical for practice-wide initiatives.
Overall, I am pleased with the steps the Conservative government has taken to pause the implementation of the mandatory reporting, and I hope they continue to build on the infrastructure work that is so close to providing an integrated electronic immunization system that works for both patients, physicians, and public health units.
Dr. Mario Elia 