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Query Health Concept-to-Codes (C2C) SWG Meeting #6 January 17, 2012 1.

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Presentation on theme: "Query Health Concept-to-Codes (C2C) SWG Meeting #6 January 17, 2012 1."— Presentation transcript:

1 Query Health Concept-to-Codes (C2C) SWG Meeting #6 January 17,

2 Today’s Agenda TopicTime Allotted Quick Review of Updated Timeline and Future Meeting Times 2:30 – 2:35 Presentation by Subject Matter Experts Shaun Shakib – 3M 2:35 - 3:00 Zeshan Rajput- RELMA (Regenstrief LOINC Mapping Assistant) 3:00 – 3:30 David Baorto – NY Presbyterian Terminology Services 3:30 - 4:00 2

3 Proposed Timeline 3 TODAY Coordinate offline activities to summarize approaches and develop draft deliverable from presentations Meeting 1 – Dec 6 Meeting 2 – Dec 13 Meeting 3 – Dec 20 Meeting 4 – Jan 03 Meeting 5 – Jan 10 Meeting 6 – Jan 17 Meeting 7 – Jan 24 Meeting 8 – Jan 31 Meeting 9 – Feb 7 Meeting 10 – Feb 14 Tasks Preliminary review of presentation summaries and Draft Deliverable Presentation I2b2 (Cont.) Intermountain Health DOQS (Data Warehousing / Mapping) Tasks Introductions Scope Proposed Approach Identify SME and presentation timeline for next few meetings Meeting times extended from 2:30-4:00pm Presentation hQuery i2b2 Presentation DOQS (Data Warehousing / Mapping) Cont. PopMedNet NLM Presentation Ibeza CDISC SHARE Tasks Review of presented concept mapping frameworks to select a proposed approach Begin Consensus Voting process Presentation RELMA (LOINC) 3M NY Presbyterian Hospital Vocab Team Tasks AHIMA LexEVS and CTS2 NQF Tasks Consensus Voting Finalized

4 Announcement – Follow up Questions from 1/3 DOQS presentation by Rick Biehl Document posted under Presentation / Reference Materials Work+Group%29

5 5 3M Health Information Systems, Inc. Concept Mapping Approach 3M Healthcare Data Dictionary Shaun Shakib, MPH M Health Information Systems

6 6 3M Health Information Systems, Inc. History: HELP System Developed by Dr. Homer Warner, first chair of the University of Utah Department of Medical Informatics, with Dr. Allan Pryor and Dr. Reed Gardner, and others Origin goes back to 1954 (in the LDS Hospital’s Cardiovascular Laboratory), but the system is first described in 1972 The vision was not only to acquire and present data, but also to interpret data so as to “help” the physician in patient care Integrated database Data dictionary Decision support Functional applications Interfaces and data capture Reports © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

7 7 3M Health Information Systems, Inc. Example: HDD in support of a CDR Interface Engine Presentation Layer © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

8 8 3M Health Information Systems, Inc. A system that organizes, defines, and encodes concepts A practical, enterprise solution for implementing and maintaining reference terminology and knowledge A critical data governance tool A metadata repository that defines the logical structure of instance data to make it computable What is the 3M Healthcare Data Dictionary? HDD Lab, Rx, Radiology, Dental, Demographics, etc. 2.4 million concepts 26 million representations 15.9 million relationships Lab, Rx, Radiology, Dental, Demographics, etc. 2.4 million concepts 26 million representations 15.9 million relationships © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

9 9 3M Health Information Systems, Inc. Manage Complexity in the 3M HDD Content Encode data – Crosswalk between any code/term (standard or legacy) Query, analyze and reason – Sharable logic Exchange data – Semantic interoperability Customize or extend content – Support local needs Standardization, Simplicity and Flexibility for End Users 733 A AM Ampicillin ContextsRepresentationsConcepts Mapping Relationships Penicillin *NCID Penicillin *NCID Has Child *NCID = 3M HDD’s Numerical Concept Identifier Cloxacillin *NCID Cloxacillin *NCID Hospital A Interface Code Hospital A Interface Code Hospital A Name SNOMED CT ID SNOMED CT Full Name SNOMED CT Full Name RxNORM RxCUI RxNORM Name Ampicillin (Substance) Ampicillin (Substance) 2625 CLOX … Antibiotic *NCID Antibiotic *NCID Staphylococcus *NCID Staphylococcus *NCID Treatment For Ampicillin *NCID Ampicillin *NCID …… Data Standardization Using the 3M HDD © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

10 10 3M Health Information Systems, Inc. Concept Mapping Defined Process of building links among concepts to integrate various vocabularies Context: the purpose of the map Are these drugs being mapped for inventory, allergens, or as clinical drugs? Matching technologies/tools/process to avoid duplicate concepts and increase consistency and efficiency String comparison mapping and semantic mapping Requires subject matter expertise Herpesvirus 3, Human C (UMLS ID) 3M HDD Herpes-zoster Virus Display 2 Chickenpox Virus Display 1 Varicella-zoster Virus (3M HDD ID) VZV 243 = Ft Hood Lab Interface Context Healthcare Data Dictionary Concept Mapping SMEs, Expert Tools © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

11 11 3M Health Information Systems, Inc. Semantic Mapping for Drugs © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

12 12 3M Health Information Systems, Inc. HDD Mapping Result – Rosetta Stone Manages ongoing updates from standard terminologies as well as local additions and changes from health care facilities Translates/transforms an enterprise’s data to standards such as LOINC®, so it can be interpreted by all other systems using standards Moves Syntactic Interoperability to the level of Semantic Interoperability and enables Meaningful Use HDD ID Protime Concept 3M HDD ID LOINC® Code Fort Sill Interface Code DoD Long Name Protime DoD Short Name PT Camp LeJeune Interface Code © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

13 13 3M Health Information Systems, Inc. 3M HDD and HL7 Common Terminology Services HL7 CTS provides functional specifications to query terminology servers in a standard way HL7 CTS frees the application developers from the constraints of the terminology service. If the EMR applications are CTS compliant, they can work with any CTS compliant terminology service HL7 CTS v1 query only HL7 CTS2, adds distributed authoring and versioning capabilities © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

14 14 3M Health Information Systems, Inc. HL7 CTS Application Programming Interface... Modified From HL7 Service-Oriented Architecture SIG, OMG Healthcare Domain Task Force, January 2008 Applications Interface Services Data CTS © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

15 15 3M Health Information Systems, Inc. HL7 CTS Application Programming Interface Applications Interface Service Data Find all the children of “Units of Measure” Modified From HL7 Service-Oriented Architecture SIG, OMG Healthcare Domain Task Force, January M HDD Vocabulary Browser CTS 3M HDD Terminology Server select * from rsform, rsform_context, concept_relation where concept_relation.CONCEPT_RELATION_NCID=1110 and concept_relation.RELATIONSHIP_NCID=363 and concept_relation.CONCEPT_NCID=rsform.NCID and rsform.RSFORM_ID=rsform_context.RSFORM_ID and rsform_context.CONTEXT_NCID=2000 and rsform_context.PREFERRED_SCORE=0; © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

16 16 3M Health Information Systems, Inc. Exchanging Standard Codes Two Implementation Strategies - Comparison Encode with the identifiers of standard terminologies *CDR Patient: John Doe Lab Result: *CDR=Clinical Data Repository**HDD=Healthcare Data Dictionary Encode with internal identifiers, “translate” to standard codes for external exchange **HDD Internal code: 1234 LOINC®: *CDR Patient: John Doe Lab Result: 1234 © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

17 17 3M Health Information Systems, Inc. The Mapping Challenge SNOMED Target 1 SNOMED Target 1 Source LOINC Target 2 LOINC Target 2 HDD Source LOINC SNOMED Mappings = 15 Adding 1 source adds 2 maps Adding 1 target adds 9 maps Mappings = 9 Adding 1 source adds 1 map VS. © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

18 18 3M Health Information Systems, Inc. NDC Shift the Meaning of a Standard Code Encoding Data Using Standard Codes Before July 2002 CDR Patient: John Doe Medication: Liposyn (Fat Emulsions), 10%, IV Solution, IV, Abbott Hospital, 200ml Bag After July 2002 CDR Patient: John Doe Medication: Paclitaxel (Paclitaxel, Semi- Synthetic), 6mg/ml, Vial, Injection, Abbott Hospital, 5ml Vial © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

19 19 3M Health Information Systems, Inc. Shift the Meaning of a Standard Code Encode With Internal Identifiers, Map to Standards (HDD Approach) Before July 2002 CDR Patient: John Doe Medication: After July 2002 CDR Patient: John Doe Medication: HDD ID Active NDC Liposyn (Fat Emulsions), 10%, IV Solution, IV, Abbott Hospital, 200ml Bag Inactive NDC Liposyn (Fat Emulsions), 10%, IV Solution, IV, Abbott Hospital, 200ml Bag Concept Permanence © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

20 20 3M Health Information Systems, Inc. Removal of a Standard Code Encoding Data Using Standard Codes Before December 31, 2003 CDR Patient: John Doe Procedure: 0002T After December 31, 2003 CDR Patient: John Doe Procedure: 0002T CPT 0002T Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; aorto-uni- iliac or aorto- unifemoral prosthesis ? © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

21 21 3M Health Information Systems, Inc. Removal of a Standard Code Encode With Internal Identifiers, Map to Standards (HDD Approach) Before December 31, 2003 CDR Patient: John Doe Procedure: After December 31, 2003 CDR Patient: John Doe Procedure: HDD ID Inactive CPT 0002T Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; aorto-uni- iliac or aorto- unifemoral prosthesis Active CPT 0002T Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; aorto-uni- iliac or aorto- unifemoral prosthesis Concept Permanence © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

22 22 3M Health Information Systems, Inc. LOINC® April 1995 Database 6,500 lab results from the master data files of 7 U.S. labs December 2004 Database 28,000 lab results + 14,000 clinical observations Updates 2000: Feb, June 2001: Jan, Jul 2002: Jan, Feb, Aug, Sep 2003: May, Oct Updates 2000: Feb, June 2001: Jan, Jul 2002: Jan, Feb, Aug, Sep 2003: May, Oct Lack of Comprehensive Standard Codes Encoding Data Using Standard Codes © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

23 23 3M Health Information Systems, Inc. Frameworks 3M Healthcare Data Dictionary Overview and Current Status How do you define concept mapping within your system (e.g. are you mapping in between standards, or are you mapping from standards to your local data dictionary)? Mapping to local data dictionary = centralized concept mapping; not point-to-point Are there any internal mechanism? Quality Control? – Inter-rator agreement; internal terminology models; db triggers and constraints; business logic in domain specific tools Do you use any external tools?We do use external technologies, but all our tooling is in-house Are you able to maintain the integrity of the original data in its native form (i.e. data as collected and not modified)? Yes Integration and Infrastructure How can you integrate with external tools for mapping? JavaScript library? Java? Web Services API? Web services API = CTS v1.2 How do you see your framework integrating with the QH Reference Implementation solution? Native integration or through the API Alignment to Query Health Where does the mapping occur? Is it at the Data Source level? Or at the Information Requestor level? Or Both? Both; Local terminologies (terms and codes) are integrated with standards through concept mapping Can it be easily implemented elsewhere?Yes Maintenance Who maintains your concept mapping tool? Domain specific mapping tools maintained by a Development team Who maintains the mappings and how often are they released? A team of nearly 30 SMEs with domain specific clinical expertise and informatics training What is the associated cost with maintenance?N/A © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE C2C Questions for Consideration

24 24 3M Health Information Systems, Inc. Questions? © 3M All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

25 Clinical Concept Management Mapping For Flexibility David Baorto, MD, PhD New York Presbyterian Terminology Service Query Health Working Group Meeting January 17,

26 Terminology Management at NYP At NYP, terminology management began over 20 years ago with “the MED” (Medical Entities Dictionary) developed by Jim Cimino. Still have that tool, but it has developed into a “Terminology Service” that serves the multi- hospital system. 26

27 How do you define concept mapping? Tasks: –Local to local codes. –Local to standard codes. –Standard to Standard. Types: –Equivalency. (HR = Heart Rate) –Hierarchical. (“Attending Physician Cardiology Consult Note” is a subclass of “Cardiology Consult Note”) –Relational. (“What LOINC codes test for this SNOMED code”) Concept Mapping need not always mean finding equivalency. 27

28 How do you view criteria for concept mapping? Goal – oriented. –“I want to plot T3 (triiodothyronine) values from different labs on a single graph.” –“Please show me all testing for RSV on a patient.” The supporting concept maps for these 2 use cases have different requirements. Flexible. –To support different goals. –To support changes to evolving standards. –To support updated information about local codes. 28

29 K + 1 = 4.2 K + 3 = 3.3 K + 2 = 3.2 K + 1 = 3.0 K + 4 = 2.6 Retrieving Results Individually

30 K + 1 = 4.2 K + 3 = 3.3 K + 2 = 3.2 K + 1 = 3.0 K + 4 = 2.6 Do you Retain the Integrity of the Original Data? Yes, by Retrieving Results according to Class K#1 K#2 K#4 K Original Data is retained at the granularity of the source system. Semantics about the data are maintained in the central terminology system.. K#3 30

31 1.POSITIVE FOR STREPTOCOCCUS GROUP B, NEGATIVE FOR YEAST, LISTERIA, N. GONORR. 2.NYH LAB TERM: STREPTOCOCCUS AGALACTIAE 3.NYH LAB TERM: STREPTOCOCCUS GROUP B (STREPTOCOCCUS AGALACTIAE) 4. NYH LAB TERM: POSITIVE FOR STREPTOCOCCUS GROUP B. 5.MESSAGE: POSITIVE FOR STREPTOCOCCUS GROUP B. 6.MESSAGE: BACTERIAL ANTIGEN POSITIVE FOR STREPTOCOCCUS GROUP B 7.ME TERM: STREPTOCOCCUS AGALACTIAE (GROUP B)...or retrieving Results by Sematics Decision Support for Infection Control Lab Results Group B Strep Results Result 2. Result 6. Result 7. Result 1. Result 3. Result 4. Result 5. Microorganisms Group B Strep SNOMED ID: Reported By Result 31

32 Architecture? Data Terminology EHRs Data Stores Reporting Central Termino- logy The MED c onnects in real time for production queries to certain systems, and provides batch interval results for other vendor systems. 32

33 How does mapping occur? Serum Total T3 Tests (MCNC) LOINC: Intravascular Total T3 Tests Intravascular Thyroid Test Triiodothyronine Intravascular Chemistry Test CPMC Laboratory Test: T3 Total Cerner ME DTA: Triiodothyronine, T3 (E) CPMC Laboratory Test: Triiodothyronine,T NYH Lab Procedure: Triiodothyronine Cerner ME DTA: Triiodothyronine Entity Measured 30 – Pharmacologic Substance 33 - Hormone WebCIS Thyroid Display Is Display Parameter of Mapping does not occur at data source level, nor at information requestor level, but at the level of a dedicated terminology server – Columbia LabTest 33

34 Example of Use Case Outside Scope of Standard Serum Total T3 Tests (MCNC) LOINC: Intravascular Total T3 Tests Intravascular Thyroid Test Triiodothyronine Intravascular Chemistry Test CPMC Laboratory Test: T3 Total Cerner ME DTA: Triiodothronine, T3 (E) CPMC Laboratory Test: Triiodothyronine,T NYH Lab Procedure: Triiodothyronine Cerner ME DTA: Triiodothyronine Entity Measured 30 – Pharmacologic Substance 33 - Hormone New - Serum Total T3 Tests ng/dl New - Serum Total T3 Tests ng/ml Don’t graph here! Graph at this level! 34

35 Example of how to support Version changes of Standards Document Class: Endocrinology Consult Note LOINC: “Endocrinology Consult note“ Eclipsys West Campus Document: PEDIATRIC ENDOCRINOLOGY CONSULT Eclipsys East Campus Documents: Ped endocrinology Attending Consult Note NEW – Document Class: Pediatric Endocrinology Consult Note LOINC: “Pediatric Endocrinology Hospital Consult Note“ 35

36 Example of how to support Version changes of Standards Intravascular Rubella IgG Antibody Tests LOINC: “Rubella virus IgG Ab [Presence] in Serum“ Cerner ME DTA: Rubella Antibody IgG NYH Lab Procedure: RUBELLA AB, IGG NEW – Intravascular Rubella IgG Antibody EIA Tests LOINC: “Rubella virus IgG Ab [Presence] in Serum by Immunoassay“ X X 36

37 Mapping Tools Internal tools – task specific Lexical, synonymy, hierarchy and semantics. Terminology team builds some tools (perl) –Frequently more ‘service’ than ‘tool’. –Sometimes need to be creative, but often tedious. –Sufficient information about source and target codes critical. (No tool will map without it). => phone and . External tools Available crosswalks. –Standards: ICD – CPT; ICD9 – ICD10 –Local: Legacy system maps. RELMA for LOINC 37

38 Content Provision Tools All homegrown. Web-based MED browser. Active memory versions for real time interaction with clinical information system. (Java web serv and C API) Perl scripts for regular pre-determined queries. 38

39 Maintenance Slow accrual -> easy –Once a terminology has been incorporated, maintenance consists of regular updates. Local sources average 20 weekly changes. New terminology -> difficult –Ex., 2 independent laboratories merged into single laboratory information system. –Importance of terminology issues often unrecognized by source systems at outset. Communication and Information Critical for knowledge management. Costs: 3 FTEs and 2 unix servers. 39

40 Zeshan Rajput RELMA (LOINC) 40

41 Introduction to RELMA Objectives –Overview of LOINC and RELMA - Very Brief! –Demonstrate the concept mapping functionality in RELMA Disclaimer –Contractor to ONC to support S&I Framework (Standards Development support team Informatics Lead) –Any opinions are my own and not those of ONC, Accenture, etc. For More Information –LOINC.orgLOINC.org –The Current Lab LOINC TutorialLOINC Tutorial 41

42 The Point of this Presentation Show how (some) concept mapping is done currently RELMA is an example of a class of concept mapping tools –These tools facilitate translation of a local set of concepts into a standard language Tools like RELMA can help query composers create queries –But as one off tools, may be better to consume the underlying data structure and combine for uses like QH

43 Background State of the Art in Concept Mapping? –From codebooks to tools like RELMA to terminology services LOINC - Logical Observation Identifiers Names and Codes Use to code questions in healthcare –Lab Questions (e.g., "What is my patient's hemoglobin?" ) –Clinical Questions (e.g., "How far can my patient walk in 6 minutes?" ) Answers are represented using other standards –Value + UCUM –SNOMED –etc.

44 RELMA Overview Tool distributed with LOINC –Same free use (see license) Provides manual and automated mapping functions –User creates file of local term/names and codes –RELMA tools help assign a LOINC term to local test/battery code Features –"Common Tests" subset –"Google-Like" search functions 44

45 Four Ways to Present Local Codes Direct entry into LMOF from within RELMA (painful) –Local master observation file (in case you were wondering) Create an access table that mimics LMOF structure (less painful but tedious) Create a delimited ASCII file from your local test catalog (good) Load directly from HL7 v2.x messages (best) –Pulls data from OBR and OBX segments –Stores NTE segment data 45

46 Demonstration Run LOINC Load LMOF One or two manual searches Help file Auto mapper and conflict reconciliation 46

47 Tips for Improving Mapping Success Expand Abbreviations Standardize Colloquial Terms ("ABG" for arterial blood gas) Ignore "Administrative" Terms Standardize Time References RELMA has built in tools for these 47

48 Answering the QH C2C Questions How does your tool function? –Take any of four sources of local observations and map them to LOINC using automated or manual (facilitated) approaches Are you able to maintain the integrity of the original data in native format? –Since you have to get your information into LMOF format (in one way or another), the mapping would not affect the original data as long as you don’t delete your original data after conversion to LMOF 48

49 Answering the QH C2C Questions How can your tool be leveraged? External APIs? How can QH use this tool? –No API or interface (as far as I’m aware) –Representative of tools (another is RxNav) that facilitate adoption of a single standard Tools tend to be one off, but critical in their role For measure/query composers, tools like RELMA can facilitate making sure you ‘ask the question’ specifically and in a language your targets likely understand –LOINC also distributed with.mdb Could be directly imported into another interface and used to facilitate query composition, interpretation, or response 49

50 Answering the QH C2C Questions Where does the mapping occur? –Probably at both the query composer and data source –Query composer – makes sure the right question is being asked –Data source – makes sure the question is translated into local terms Can the mapping be easily implemented elsewhere? –The point of RELMA is to facilitate implementation of the LOINC standard –Constant improvements to its ease of use –Freely available for download 50

51 Answering the QH C2C Questions Who maintains the tool? –Regenstrief Institute and multiple partners around the world Who maintains the mappings? –The mappings are created by each user of RELMA –The tool is updated with LOINC, twice yearly Associated cost of maintainence –RELMA makes mapping easier, but still requires concept dictionary curation and some ‘elbow grease’ 51


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