Standard Vocabulary Implementation Experience from CDC Partners and Programs PHIN Conference August 25, :30 a.m. – 12 noon

Standard Vocabulary and CDC’s National Healthcare Safety Network Daniel Pollock, Marla Albitz, Pavla Frazier, Jonathan Edwards, Ben Kupronis, Teresa Horan Surveillance Branch Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases CDC, Atlanta, GA

Acknowledgments Sundak Ganesan Rob Hausam Wenkai Li Kelly Peterson

Objectives Overview of CDC’s National Healthcare Safety Network (NHSN) Use of standard vocabulary in NHSN eSurveillance initiative Collaboration with Public Health Information Network Vocabulary Access and Distribution System (PHIN VADS) Lessons learned for other public health surveillance systems

Integrates legacy CDC systems for surveillance of nosocomial infections (NNIS), healthcare worker safety (NaSH), and hemodialysis (DSN) into a single web-based system Serves multiple purposes: infection control, prevention research, State-level public reporting, and national-level surveillance Data collection from a sample of U.S. healthcare facilities enables valid estimation of adverse events among patients and healthcare workers NHSN in a Nutshell

NHSN Components and Modules NHSN Component Patient Safety Component Healthcare Personnel Safety Component Research and Development Modules Blood/Body Fluid Exposure Vaccination Events Modules Device Associated Procedure Assoc. Medication Assoc. MDRO and CDAD High Risk Inpatient Influenza Vaccination eSurveillance HL7 Messages HL7 CDA Prevention research Component Biovigilance Modules Hemovigilance MDRO = Multidrug-resistant organism CDAD = Clostridium difficile associated disease HL7 = Health Level Seven CDA = Clinical Document Architecture

Am J Infect Control 2008;36:S21-6 NHSN eSurveillance initiative – Efforts are underway at CDC to foster greater use of electronic data stored in health care application databases for surveillance of healthcare-associated infections and antimicrobial use and resistance. These efforts... focus on standards- based solutions for conveying healthcare data and validation processes to confirm that the data received at CDC accurately reflect the data transmitted by health care facilities.

NHSN eSurveillance Projects Use HL7 Message and Document Standards NHSN Component Patient Safety Component Healthcare Personnel Safety Component Research and Development Modules Blood/Body Fluid Exposure Vaccination Events Modules Device Associated Procedure Assoc. Medication Assoc. MDRO and CDAD High Risk Inpatient Influenza Vaccination eSurveillance HL7 Messages HL7 CDA Prevention research Component Biovigilance Modules Hemovigilance MDRO = Multidrug-resistant organism CDAD = Clostridium difficile associated disease HL7 = Health Level Seven CDA = Clinical Document Architecture Data Transmission Standards - Messages for laboratory results, admission/discharge/transfer, and pharmacy data - Structured documents for infection reports, denominators, and process of care measures

HL7 Messages to Transmit Antimicrobial Use and Resistance (AUR) Data Healthcare FacilityCDC CDC Firewall eSurveillance Database Existing PHIN MS Infrastructure – specific AUR queue AUR Message Intermediary (assigns standard vocabulary/coding and formats to AUR HL7 2.5 spec) Secure Internet Transmission Facility Firewall Pharmacy Data Microbiology Data ADT Data New ETL System (automatically receives, validates, parses, and loads data from PHIN MS) Standard HL7 V2.5 Messages Source IT Systems Exception Reports PHIN MS Sender

HL7 CDA for Reporting Healthcare Associated Infection (HAI) Data Healthcare FacilityCDC CDC Firewall NHSN Database Entry of location mapping codes and monthly reporting plan Vendor system used to collect HAI data and create CDA document Facility Firewall Parsing and Validating CDA Document (HAI event and denominator records) NHSN Application Web-based data entry and access

Standard Vocabularies Used in NHSN LOINC SNOMED HL7 RxNorm ICD-9-CM UCUM

Use of Standard Vocabulary in NHSN’s HL7 V2.5 Laboratory Results Message OBR|1|""| ^UUHSC^ ^ISO| ^Clostridium difficile toxin A+B:ACnc:Pt:Stool:Qn:EIA^LN^65146^C.DIFFICILE TOXINS (A/B)by EIA^L||| ||||||||||||||| |||F||||| OBX|1|ST|6363-6^Clostridium difficile toxin A+B:ACnc:Pt:Stool:Qn:EIA^LN^65146^C.DIFFICILE TOXINS (A/B)by EIA^L|1|NEGATIVE||NEGATIVE|N^Normal (applies to non- numeric results)^HL70078^N^^L|||F||||||||| SPM|1| ^UPHSC^ ^ISO|| ^Stool specimen^SNM^^^L||||||||||||| | |||||||| |||| SNOMED LOINC HL7

Use of Standard Vocabulary in NHSN’s HL7 V2.5 Pharmacy Message RXE||198334^^RXNORM^SULF40080T^^L^3/01/2007^^Su lfamethoxazole + Trimethoprim SS mg TAB|1||{tbl}^tablets^UCUM^TABLET^^L|||||||||| |||||||||||||||||||||||||||6EICU^601^^^^1027-2&Medical critical care& &6EMedICU^^LWard& &6EMed^^L TQ1|1|1|q1D&&HL70335& &&Transmitter &2.5&&QDay|||| | RXR|PO^Oral^HL70162^PO^^L^09/21/2006 RxNormUCUM HL7

Standard Vocabulary in NHSN’s CDA Surgical Site Infection Report Signs & Symptoms □ Purulent drainage or material □ Pain or tenderness □ Localized swelling □ Redness □ Heat □ Fever □ Incision deliberately opened by surgeon SourceCode SNOMED NSHN termSS_pain NSHN termSS_locSwell SNOMED SNOMED SNOMED NSHN termSS_incision

NHSN Local Vocabulary in CDA Bloodstream Infection Report SourceCode NHSN termlab_path NSHN termlab_skincon NSHN termlab_noorg Laboratory □ Recognized pathogen from one or more blood cultures □ Common skin contaminant from > 2 blood cultures □ Blood cultures not done or no organisms detected in blood

Standard Vocabulary in NHSN’s Antimicrobial Susceptibility Report NHSN Concept SourceCode Coagulase- negative staphylococci SNOMED term Vancomycin susceptibility LOINC term Susceptible, Intermediate, Resistant, Not tested HL7 termS, I, R, N

NHSN Term Submissions to SNOMED: BSI and SSI NHSN ConceptSNOMED Concept SNOMED Concept Identifier Bloodstream infection Infection of bloodstream (disorder) Surgical site infection Surgical site infection (disorder)

NHSN Term Submissions to HL7: Healthcare Service Locations (Examples) Healthcare Service Location NHSN Code HL7 Code HL7 Hierarchical Level Intensive Care Unit − WardIN:ACUTE:WARD Medical Critical Care IN:ACUTE:CC:M Inpatient Medical Ward IN:ACUTE:WARD:M

NHSN Collaboration with PHIN VADS NHSN web-based application is bolted to PHIN VADS 2.3 Plans call for future migration to PHIN VADS 3.X PHIN VADS is the resource that implementers of NHSN message and CDA solutions will use for vocabulary access NHSN is informing PHIN VADS development by providing functional requirements and vocabulary content

Lessons Learned for Other Public Health Surveillance Systems Electronic message and document solutions for conveying surveillance data require concerted attention to vocabulary standardization Public health surveillance programs are well positioned to use and contribute to vocabulary standards Shared resources for developing, maintaining, and distributing vocabulary can yield important programmatic benefits

Thank You!