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Special Topics in Vendor-Specific Systems

Learn about the various strategies employed by commercial EHR vendors for terminology and knowledge management and how they impact interoperability. Discover how these concepts facilitate the use of personal health records.

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Special Topics in Vendor-Specific Systems

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  1. Special Topics in Vendor-Specific Systems Vendor Strategies for Terminology, Knowledge Management, and Data Exchange This material (Comp14_Unit6) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.

  2. Vendor Strategies for Terminology, Knowledge Management, and Data ExchangeLearning Objectives • Define what is meant by interoperability • Describe commercial EHR vendor strategies for terminology and knowledge management, and how these impact interoperability • Describe how these concepts facilitate the use of personal health records Special Topics in Vendor-Specific Systems Vendor Strategies

  3. 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) Special Topics in Vendor-Specific Systems Vendor Strategies

  4. Three Types of Interoperability: • Technical • physical conveyance of a ‘payload’ • Semantic • communication of consistent meaning • Process • integration into an actual work setting assuring the systems’ usability and usefulness Special Topics in Vendor-Specific Systems Vendor Strategies

  5. 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) Special Topics in Vendor-Specific Systems Vendor Strategies

  6. 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. MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4|200202150930||ORU^R01|CNTRL-3456|P|2.4<cr> 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<cr> 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<cr> OBX|1|SN|1554-5^GLUCOSE^POST 12H FST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F<cr> Special Topics in Vendor-Specific Systems Vendor Strategies

  7. 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. MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4|200202150930||ORU^R01|CNTRL-3456|P|2.4<cr> 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<cr> 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<cr> OBX|1|SN|1554-5^GLUCOSE^POST 12H FST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F<cr> HL-7 Table: Sex Table 1.1 Special Topics in Vendor-Specific Systems Vendor Strategies

  8. Semantic 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) Special Topics in Vendor-Specific Systems Vendor Strategies

  9. 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 Special Topics in Vendor-Specific Systems Vendor Strategies

  10. ICD-9 Codes (ICD-9 Data, 2011). Special Topics in Vendor-Specific Systems Vendor Strategies

  11. Transition to ICD-10 • October 1, 2013 is the day ICD‑10 CM (International Classification of Diseases, Tenth Revision, Clinical Modification) and ICD‑10 PCS (Procedure Coding System) will take effect, replacing the 30‑year‑old ICD‑9 system • This change will impact every paper-based system and software application, information system, and functional department that currently uses or generates ICD-9 codes Special Topics in Vendor-Specific Systems Vendor Strategies

  12. LOINC MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4|200202150930||ORU^R01|CNTRL-3456|P|2.4<cr> 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<cr> 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<cr> OBX|1|SN|1554-5^GLUCOSE^POST 12H FST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F<cr> (LOINC, 2011). Special Topics in Vendor-Specific Systems Vendor Strategies

  13. 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) Special Topics in Vendor-Specific Systems Vendor Strategies

  14. Process Interoperability • Process interoperability is the most complex and difficult to achieve, but it is the most important for patients and clinicians Special Topics in Vendor-Specific Systems Vendor Strategies

  15. Example: Cerner • Nomenclature tool - The tool permits the creation and modification of nomenclature values and includes ability to use and link to standard vocabularies • Rules Editor – allows for the creation of expert rules and 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 and reminders • Clinical Measurement – several levels of support, from Discern Expert (rules engine) to HealthFacts (aggregated client data) Special Topics in Vendor-Specific Systems Vendor Strategies

  16. Example: Allscripts • Uses HL7 2.3 messaging to exchange messages with other systems containing results, documents, observations, and tasks • Has a vocabulary manager module to map internal concepts to terminologies such as ICD-9, CPT-4, SNOMED • Has 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 Special Topics in Vendor-Specific Systems Vendor Strategies

  17. Example: eClinicalWorks • Uses a semi-uniform structured data model that permits identification of common data elements across multiple installations • Has predefined mappings for internal codes to LOINC, ICD-9, CPT-4, NDC, etc. and manual mapping capability for custom added codes • Uses Continuity of Care Record (CCR) and CCD standards for clinical document sharing with health information exchanges (HIEs) Special Topics in Vendor-Specific Systems Vendor Strategies

  18. Examples of Third-party Terminology Products • Several vendors provide tools for managing and updating standard and localized medical terminology • Intelligent Medical Objects, Inc. • Health Language, Inc. • Vendor systems specific to medication management • First Databank • Micromedex • MediSpan • Multum Special Topics in Vendor-Specific Systems Vendor Strategies

  19. Personal Health Records • Electronic health records are beginning to support data exchange with personal health records • Vendor-specific “patient portals” • Microsoft HealthVault • Dossia Special Topics in Vendor-Specific Systems Vendor Strategies

  20. Accuracy of EHR->PHR Data (Wagsness, 2009). Special Topics in Vendor-Specific Systems Vendor Strategies

  21. 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 Special Topics in Vendor-Specific Systems Vendor Strategies

  22. 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 Special Topics in Vendor-Specific Systems Vendor Strategies

  23. Vendor Strategies for Terminology, Knowledge Management, and Data ExchangeSummary • Defined Interoperability and Technical Interoperability • Technical Interoperability: Messaging Standards and Semantic Interoperability • ICD 9 codes and transitions to ICD 10 • LOINC-search/ example • Process Interoperability and various vendor examples • EHR data accuracy and PHRs benefits • Finally Barriers to linking EHR and PHR data Special Topics in Vendor-Specific Systems Vendor Strategies

  24. Vendor Strategies for Terminology, Knowledge Management, and Data ExchangeReferences References: Halamka, D.J. (2011). Interoperability. Retrieved from Health Information Technology Standards Panel (HITSP) on September 4th, 2011. http://www.hitsp.org/Halamka.aspx Walker et al. Inviting patients to read their doctors' notes: patients and doctors look ahead: patient and physician surveys. Ann Intern Med. 2011 Dec 20;155(12):811-9. Health Level Seven (2007). Data definition tables: Final Standard. Retrieved on September 5th, 2011 from http://www.hl7.org/special/committees/vocab/V26_Appendix_A.pdf. Charts, Tables, Figures: 1.1 Table: Health Level Seven (2007). Data definition tables: Final Standard. Retrieved on September 5th, 2011 from http://www.hl7.org/special/committees/vocab/V26_Appendix_A.pdf. Images: Slide 10: Retrieved on August 20th, 2011 from http://www.icd9data.com/2012/Volume1/390-459/410-414/410/default.htm Slide 12: Retrieved on August 20th, 2011 from http://search.loinc.org/search.zul?query=glucose Slide 20: Wagsness, L. (2009). Electronic health records raise doubt. Retrieved on August 20th, 2011 from The Boston Globe. http://www.boston.com/news/nation/washington/articles/2009/04/13/electronic_health_records_raise_doubt/. Special Topics in Vendor-Specific Systems Vendor Strategies

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