1. AHLTA: How Physicians See Our Lab(s!) Now Society of Armed Forces Medical Laboratory Scientists (SAFMLS) Boston, 28 February 2007 Michael P. Fitch, Lt Col, USAF (ret), BSC mike_fitch@chcsii.com

2. Purpose Full disclosure First AHLTA presentation to lab professionals Presented from a laboratory (i.e., CHCS, CoPath, DBSS, and eventually PathNet®) perspective Share knowledge Gather feedback 02/28/20072

3. 3 Objectives Learn the concepts behind AHLTA Understand the basic interactions between CHCS Lab and AHLTA Order entry Result reporting Become aware of its most significant differences relative to CHCS Lab Discuss strategies to take advantage of AHLTA to enhance our lab business model and improve communication

4. 02/28/20074 AHLTA Concepts AHLTA in its present form is a longitudinal electronic medical record (EMR) a clinical documentation tool 02/28/20074

14. 14 AHLTA Concepts AHLTA in its present form is a longitudinal electronic medical record (EMR) a clinical documentation tool a single database for clinical events (CDR) a CHCS front-end for direct-care providers a whole enterprise, not just a single product NOT a replacement for laboratory or other ancillary functionality 02/28/200714

15. 02/28/200715 How CHCS Works with AHLTA Nightly data collection Table synchronization Delta data capture Data mapping through the Health Data Dictionary (HDD) 02/28/200715

16. Overview of Lab/CHCS- AHLTA Architecture 16 CHCS CoPath HDD CDR Clinics (AHLTA Workstations) Labs CoPath CHCSDBSS Facility 2 Facility 1Montgomery, AL

17. Purpose of the Health Data Dictionary (HDD) NCID 20947395 DISA Megacenter HDD Purpose: To provide a Common Medical Vocabulary of standardized medical terminology, where applicable, for linking multiple like concepts to a single concept AHLTA uses the 3M Health Information Systems Healthcare Data Dictionary® as the Common Medical Vocabulary Fort Bragg SGOT Portsmouth AST Minot AFB Aspartate Aminotransferase Aspartate Aminotransferase CHCS I Lab test Mapping Aspartate Aminotransferase AHLTA Display

18. Data Mapping Delta Management Every change to Lab files is captured and sent to Chantilly by an overnight task Files monitored: Lab Test, Lab Method, Antibiotic Susceptibility, Collection Sample, Etiology Field, Topography Field Every change will be evaluated by the Data Standardization Team the next business day, communicating as necessary with 3M and your lab Concept already mapped New concept and/or mapping required Concept invalid Valid changes go into a daily HDD update Updates delivered each Wednesday, tested, and generally applied the weekend following all approvals Ideally, the changes should be evaluated and the HDD update installed before the first result arrives to avoid mapping errors 02/28/200718

19. Typical Delta Events Often more than 2500 changes evaluated per person/day Each involves effort and therefore cost to the Government Invalid or questionable concepts require the most research and time Majority of rejected changes represent invalid concepts Unrealistic specimen for the test Actual examples: Vitamin K assay on tissue, fibrinogen on feces Documented causes “Shotgunning” virtually all specimens onto new methods A collection sample without a default specimen, forcing HCP to choose one Default specimen for a panel not available or appropriate for a constituent test Adding or deleting constituent tests to/from panels Quality control test not identified as such 02/28/200719

20. Mitigation Strategies Make sure all Collection Samples used for Clinical Chemistry tests have a valid default specimen defined For each file change you make, evaluate each test:specimen:method combination for legitimacy Think LOINC—if the combination is in a valid LOINC code, it’s probably good The Team and 3M usually use the units to determine the method For each test, consider every possible site/specimen associated with it The default specimen for each Collection Sample Each site/specimen defined in every Method, including default methods as well as any Work Element specific methods Avoid creating and using “blanket” methods—those containing almost every conceivable site/specimen Make sure all the organisms and antibiotics you may receive from a reference lab are already configured in your files 02/28/200720

21. 02/28/200721 How CHCS Works with AHLTA Nightly data collection Table synchronization Delta data capture Mapping through the Health Data Dictionary (HDD) Order entry 02/28/200721

35. 02/28/200735 How CHCS Works with AHLTA Nightly data collection Table synchronization Delta data capture Mapping through the Health Data Dictionary (HDD) Order entry Result retrieval 02/28/200735

42. 02/28/2007 42 HDDHDD Lab-to-AHLTA Notional Design CDR Clinical Data Repository AHLTA Workstation DBSS DEERSCHCS CoPath CDM Clinical Data Mart Orders Results Failover

43. 02/28/200743 Differences from CHCS Nomenclature Formatting Supported patients Responses to CHCS F/T maintenance System interactions Lookup logic Enterprise-wide effects of the CDR/CDM 02/28/200743

44. 02/28/200744 Nomenclature Different field length constraints 3M/DoD standards and conventions Mapping (again, think LOINC) Vernacular (e.g., “test” vs. “result,” “alert” meaning of “Lab Section,” etc.)

48. 02/28/200748 Formatting GUI opportunities and liabilities Fonts Size Mono-spaced vs. proportional Color, underline, or other attributes may convey added meaning Screen/window size 2D scrolling Mouse usage Select or hide fields Sort on demand Cut and paste

50. 02/28/200750 Formatting (cont’d) Possibly invalid assumptions (e.g., “:” connotes label, space follows “=“, reformatting won’t affect meaning) Column widths and enforcement

52. 02/28/200752 Formatting (cont’d) Possibly invalid assumptions (e.g., “:” connotes label, space follows “=“, reformatting won’t affect meaning) Columnar results window Selective autociting to encounter/SF600 02/28/200752

55. 02/28/200755 Formatting (cont’d) Possibly invalid assumptions (e.g., “:” connotes label, space follows “=“, reformatting won’t affect meaning) Columnar results window Selective autociting to encounter/SF600 Microbiology presentation issues Comments and interpretations in a separate window 02/28/200755

57. 02/28/200757 Formatting (cont’d) Possibly invalid assumptions (e.g., “:” connotes label, space follows “=“, reformatting won’t affect meaning) Columnar results window Selective autociting to encounter/SF600 Microbiology presentation issues Comments and interpretations in a separate window No analogous reports (e.g., Doctor’s Cumulative) 02/28/200757

58. 02/28/200758 Supported Patients AHLTA is currently an outpatient system Inpatient lab results, however, are in the CDR along with the patient’s outpatient results Order entry on an inpatient will likely be treated as an outpatient in some respects Only “real” patients in the CDR; others still maintained only in the associated CHCS QC Non-human specimens (e.g., veterinary patients, environmental specimens, blood units) Officially, CDR is not to contain “test patients”

59. 02/28/200759 Response to CHCS F/T Parameters Nightly—not immediate—table synchronization Historical changes to the CDR or CDM require “repulling” the patient(s) Some CHCS controls not supported Print/display order Print name

60. 02/28/200760 System Interactions RNR and audit trail differences Lag time introduced by transactions Screen refreshes Partially-resulted panels (under development) Remaining tests not seen Displayed results appear complete Amendments and Intermediate results

61. 02/28/200761 System Interactions (cont’d) Extra information screens Anatomic Pathology Order required data Blood Bank subscript still being developed No direct access to CHCS help screens (e.g., ??, ?, OLUM, LTI)

64. 02/28/200764 System Interactions (cont’d) Extra information screens Anatomic Pathology Order required data Blood Bank subscript still being developed No direct access to CHCS help screens (e.g., ??, ?, OLUM, LTI) Most urgent messaging still handled only by CHCS (e.g., ward/clinic auto-printing) Associating orders with encounter becomes more important 02/28/200764

65. 02/28/200765 Lookup Logic “Contains” vs. “Begins with” Prefixing with “x” or punctuation won’t “hide” tests Case (in)sensitivity Contents and order of picklists Synonyms used but not displayed Screening/filtering of some characters Support for wildcards No FileMan-unique cross-references `IEN Soundex FileMan associations

70. 02/28/200770 Enterprise-wide CDR/CDM Local naming or business conventions Designations of sensitive results Panel constituents Use/non-use of standardized tests Inquiries and reports may encompass multiple labs’ work Specimen/method-sensitive Potentially multiple reference ranges Referral specimens (e.g., certification at both labs when Lab Interoperability not used) Multiple time zones

71. 02/28/200771 Lab COTS Issues Details for integration of Cerner Millennium and AHLTA still under development

72. 02/28/200772 Open Discussion Questions Lab experiences related to AHLTA Physicians’ comments Order entry issues Result correlation findings CAP/JCAHO/AABB/FDA inspectors’ comments Physician/facility/patient perceptions Rumors Ideas