1. Special Topics in Vendor- Specific Systems Unit 6 Vendor strategies for terminology, knowledge management, and data exchange

2. Objective Evaluate EHR strategies for terminology management, knowledge management and data exchange Component 14/Unit 6 Health IT Workforce Curriculum Version 1.0/Fall 2010 2

3. After this completing this unit, you should be able to: Define interoperability Describe vendor strategies for terminology and knowledge management, and how these impact interoperability Describe processes and requirements for exchanging data with personal health records Component 14/Unit 6 Health IT Workforce Curriculum Version 1.0/Fall 2010 3

4. Interoperability If I’m faxed a discharge summary which I can read, is that interoperable, since it’s human interpretable? If I’m sent an electronic note via email that notes “Allergy to MS”, is that interoperable? Of course MS could mean Morphine Sulfate, Magnesium Sulfate, or even Minestrone Soup. If I’m sent an electronic message which has an agreed upon format, a standard vocabulary, and a set of business rules which enable me to take action, is that interoperable? i.e. Your patient is allergic to medication NDC Code 123456789. Administration will cause a SEVERE reaction with HIGH CONFIDENCE. My e-Prescribing software could use this information to display a warning alerting me to the issue and could suggest an effective alternative medication. »John D. Halamka MD, MS, Chair, Health Information Technology Standards Panel (HITSP) Component 14/Unit 6 Health IT Workforce Curriculum Version 1.0/Fall 2010 4

5. Three Types of Interoperability: Technical Physical conveyance of a ‘payload’ Semantic Communication of consistent meaning Process Integration into actual work setting assuring the systems’ usability and usefulness Component 14/Unit 6 Health IT Workforce Curriculum Version 1.0/Fall 2010 5

6. Technical Interoperability If I’m faxed a discharge summary which I can read, is that interoperable, since it’s human interpretable? If I’m sent an electronic note via email that notes “Allergy to MS”, is that interoperable? Of course MS could mean Morphine Sulfate, Magnesium Sulfate, or even Minestrone Soup. If I’m sent an electronic message which has an agreed upon format, a standard vocabulary, and a set of business rules which enable me to take action, is that interoperable? i.e. Your patient is allergic to medication NDC Code 123456789. Administration will cause a SEVERE reaction with HIGH CONFIDENCE. My e- Prescribing software could use this information to display a warning alerting me to the issue and could suggest an effective alternative medication. »John D. Halamka MD, MS, Chair, Health Information Technology Standards Panel (HITSP) Component 14/Unit 6 Health IT Workforce Curriculum Version 1.0/Fall 2010 6

7. Technical Interoperability: Messaging Standards Health Level Seven (HL7) All-volunteer, non-profit organization involved in development of international healthcare standards HL7 and its members provide a framework (and related standards) for the exchange, integration, sharing, and retrieval of electronic health information Component 14/Unit 6 Health IT Workforce Curriculum Version 1.0/Fall 2010 7 MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4|200202150930||ORU^R01|CNTRL-3456|P|2.4 PID|||555- 44-4444||EVERYWOMAN^EVE^E^^^^L|JONES|19620320|F|||153 FERNWOOD DR.^ ^STATESVILLE^OH^35292||(206)3345232|(206)752-121||||AC555444444||67-A4335^OH^20030520 OBR|1|845439^GHH OE|1045813^GHH LAB|15545^GLUCOSE|||200202150730||||||||| 555-55- 5555^PRIMARY^PATRICIA P^^^^MD^^|||||||||F||||||444-44-4444^HIPPOCRATES^HOWARD H^^^^MD OBX|1|SN|1554-5^GLUCOSE^POST 12H FST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F

8. Semantic Interoperability Health Level Seven (HL7) All-volunteer, non-profit organization involved in development of international healthcare standards HL7 and its members provide a framework (and related standards) for the exchange, integration, sharing, and retrieval of electronic health information Component 14/Unit 6 Health IT Workforce Curriculum Version 1.0/Fall 2010 8 MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4|200202150930||ORU^R01|CNTRL-3456|P|2.4 PID|||555- 44-4444||EVERYWOMAN^EVE^E^^^^L|JONES|19620320|F|||153 FERNWOOD DR.^ ^STATESVILLE^OH^35292||(206)3345232|(206)752-121||||AC555444444||67-A4335^OH^20030520 OBR|1|845439^GHH OE|1045813^GHH LAB|15545^GLUCOSE|||200202150730||||||||| 555-55- 5555^PRIMARY^PATRICIA P^^^^MD^^|||||||||F||||||444-44-4444^HIPPOCRATES^HOWARD H^^^^MD OBX|1|SN|1554-5^GLUCOSE^POST 12H FST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F

9. Semantic Interoperability (cont.) If I’m faxed a discharge summary which I can read, is that interoperable, since it’s human interpretable? If I’m sent an electronic note via email that notes “Allergy to MS”, is that interoperable? Of course MS could mean Morphine Sulfate, Magnesium Sulfate, or even Minestrone Soup. If I’m sent an electronic message which has an agreed upon format, a standard vocabulary, and a set of business rules which enable me to take action, is that interoperable? i.e. Your patient is allergic to medication NDC Code 123456789. Administration will cause a SEVERE reaction with HIGH CONFIDENCE. My e- Prescribing software could use this information to display a warning alerting me to the issue and could suggest an effective alternative medication. »John D. Halamka MD, MS, Chair, Health Information Technology Standards Panel (HITSP) Component 14/Unit 6 Health IT Workforce Curriculum Version 1.0/Fall 2010 9

10. Semantic Interoperability: Terminology Standards How many ways to say “heart attack”? Easy for clinicians, hard for computer systems Communication among & within electronic systems  must speak common “language” Richness & variety of medical concepts are barriers to formulating standardized clinical terminologies: ICD-9 (International Classification of Diseases) [WHO]: Diagnoses & billing CPT-4 (Current Procedural Terminology) [AMA]: Procedures/billing SNOMED-CT (Systematized Nomenclature of Medicine) [College of American Pathologists]: Medical concepts LOINC (Logical Observation Identifiers Names and Codes) [Regenstrief Inst.]: Laboratory tests Component 14/Unit 6 10 Health IT Workforce Curriculum Version 1.0/Fall 2010

11. ICD-9 Codes Component 14/Unit 6 Health IT Workforce Curriculum Version 1.0/Fall 2010 11

12. Transition to ICD-10 October 1, 2013: ICD ‑ 10 CM (International Classifcation of Diseases, Tenth Revision, Clinical Modifcation) and ICD ‑ 10 PCS (Procedure Coding System) Will take effect, replacing the 30 ‑ year ‑ old ICD ‑ 9 system Will impact every paper-based system and software application, information system, and functional department that currently uses or generates ICD-9 codes Component 14/Unit 6 12 Health IT Workforce Curriculum Version 1.0/Fall 2010

13. LOINC Component 14/Unit 6 Health IT Workforce Curriculum Version 1.0/Fall 2010 13 MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4|200202150930||ORU^R01|CNTRL-3456|P|2.4 PID|||555- 44-4444||EVERYWOMAN^EVE^E^^^^L|JONES|19620320|F|||153 FERNWOOD DR.^ ^STATESVILLE^OH^35292||(206)3345232|(206)752-121||||AC555444444||67-A4335^OH^20030520 OBR|1|845439^GHH OE|1045813^GHH LAB|15545^GLUCOSE|||200202150730||||||||| 555-55- 5555^PRIMARY^PATRICIA P^^^^MD^^|||||||||F||||||444-44-4444^HIPPOCRATES^HOWARD H^^^^MD OBX|1|SN|1554-5^GLUCOSE^POST 12H FST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F

14. Process Interoperability If I’m faxed a discharge summary which I can read, is that interoperable, since it’s human interpretable? If I’m sent an electronic note via email that notes “Allergy to MS”, is that interoperable? Of course MS could mean Morphine Sulfate, Magnesium Sulfate, or even Minestrone Soup. If I’m sent an electronic message which has an agreed upon format, a standard vocabulary, and a set of business rules which enable me to take action, is that interoperable? i.e. Your patient is allergic to medication NDC Code 123456789. Administration will cause a SEVERE reaction with HIGH CONFIDENCE. My e- Prescribing software could use this information to display a warning alerting me to the issue and could suggest an effective alternative medication. »John D. Halamka MD, MS, Chair, Health Information Technology Standards Panel (HITSP) Component 14/Unit 6 Health IT Workforce Curriculum Version 1.0/Fall 2010 14

15. Process Interoperability (cont.) The most complex and difficult to achieve, but the most important for patients and clinicians Component 14/Unit 6 15 Health IT Workforce Curriculum Version 1.0/Fall 2010

16. Example: Cerner Nomenclature tool Permits creation & modification of nomenclature values & includes ability to use & link to standard vocabularies Rules Editor Allows creation of expert rules & can import standard based rule formats, e.g. MLMs Clinical knowledge sources Advanced clinical automation systems XML import tool for linking to external evidence based systems to supply expert rules &reminders Clinical Measurement Several levels of support, from Discern Expert (rules engine) to HealthFacts (aggregated client data) Component 14/Unit 6 16 Health IT Workforce Curriculum Version 1.0/Fall 2010

17. Example: Eclipsys Uses HL7 2.3 messaging to exchange messages with other systems containing results, documents, observations, & tasks Vocabulary manager module to map internal concepts to terminologies such as ICD-9, CPT-4, SNOMED Partnerships with third-party terminology solutions such as Multum (for medications) and Intelligent Medical Objects (for problems) Supports send/receive of patient summary information encoded using the HL7 Continuity of Care Document (CCD) standard Component 14/Unit 6 17 Health IT Workforce Curriculum Version 1.0/Fall 2010

18. Example: eClinicalWorks Semi-uniform structured data model that permits identification of common data elements across multiple installations Predefined mappings for internal codes to LOINC, ICD-9, CPT-4, NDC, etc. & manual mapping capability for custom added codes Uses CCR and CCD standards for clinical document sharing with health information exchanges (HIEs) Component 14/Unit 6 18 Health IT Workforce Curriculum Version 1.0/Fall 2010

19. Examples of Third-party Terminology Products Several vendors provide tools for managing & updating standard & localized medical terminology Intelligent Medical Objects, Inc. Health Language, Inc. Vendor systems specific to medication management First Databank Micromedex MediSpan Multum Component 14/Unit 6 19 Health IT Workforce Curriculum Version 1.0/Fall 2010

20. Personal Health Records Vendor-specific “patient portals” Google Health Microsoft HealthVault Dossia Electronic health records are beginning to support data exchange with personal health records Component 14/Unit 6 20 Health IT Workforce Curriculum Version 1.0/Fall 2010

21. Accuracy of EHR->PHR Data Component 14/Unit 6 21 Health IT Workforce Curriculum Version 1.0/Fall 2010

22. Benefits of PHRs PHRs may draw their information from a variety of sources sent by hospitals, pharmacies, and laboratories, insurers, etc. Supplying this information to patients has benefits: Greater sense of empowerment More engaged in their care Higher satisfaction Increased adherence to their care plans Better health outcomes Component 14/Unit 6 22 Health IT Workforce Curriculum Version 1.0/Fall 2010

23. Barriers to Linking EHR and PHR Data Logistics to work out to prevent misinformed patients Presentation of medical diagnoses, laboratory and radiology results before physician review Clinicians concerned that they would have to change they way they document Privacy concerns for patients, institutions Web-based applications Component 14/Unit 6 23 Health IT Workforce Curriculum Version 1.0/Fall 2010