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Query Health Concept-to-Codes (C2C) SWG Meeting #6

Query Health Concept-to-Codes (C2C) SWG Meeting #6. January 17, 2012. Today’s Agenda . Proposed Timeline . Meeting times extended from 2:30-4:00pm. TODAY. Presentation RELMA (LOINC) 3M NY Presbyterian Hospital Vocab Team. Tasks AHIMA LexEVS and CTS2 NQF. Tasks Introductions

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Query Health Concept-to-Codes (C2C) SWG Meeting #6

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

  2. Today’s Agenda

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

  4. Announcement – Follow up Questions from 1/3 DOQS presentation by Rick Biehl • Document posted under Presentation / Reference Materials • http://wiki.siframework.org/Clinical+Concept+Mapping+%28Sub-Work+Group%29

  5. Concept Mapping Approach3M Healthcare Data Dictionary Shaun Shakib, MPH 801-265-4432 scshakib@mmm.com 3M Health Information Systems

  6. History: HELP System • 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 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

  7. Example: HDD in support of a CDR Interface Engine Presentation Layer

  8. What is the 3M Healthcare Data Dictionary? Lab, Rx, Radiology, Dental, Demographics, etc. 2.4 million concepts26 million representations 15.9 million relationships HDD 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

  9. Data Standardization Using the 3M HDD Standardization, Simplicity and Flexibility for End Users Encode data – Crosswalk between any code/term (standard or legacy) Exchange data – Semantic interoperability Query, analyze and reason – Sharable logic Customize or extend content – Support local needs Manage Complexity in the 3M HDD Content Contexts Representations Concepts Relationships 387170002 SNOMED CT ID Ampicillin *NCID 3000253893 Antibiotic *NCID 3000250095 Ampicillin (Substance) SNOMED CT Full Name Has Child Cloxacillin *NCID 3000253892 RxNORMRxCUI 733 Penicillin *NCID 3000250527 Ampicillin RxNORM Name Treatment For A AM Hospital A Interface Code Mapping … Staphylococcus *NCID 154285 2625 Hospital A Name CLOX *NCID = 3M HDD’s Numerical Concept Identifier … …

  10. Concept Mapping Defined Concept Mapping SMEs, Expert Tools • 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 Chickenpox Virus Display 1 Herpesvirus 3, Human C0042338 (UMLS ID) 3M HDD Varicella-zoster Virus11557 (3M HDD ID) Healthcare Data Dictionary Herpes-zoster Virus Display 2 VZV 243 = Ft Hood Lab Interface Context

  11. Semantic Mapping for Drugs

  12. 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 26277

  13. 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

  14. HL7 CTS Application Programming Interface . . . Applications Interface Services Data CTS Modified From HL7 Service-Oriented Architecture SIG, OMG Healthcare Domain Task Force, January 2008

  15. HL7 CTS Application Programming Interface Vocabulary Browser Applications Interface Service Data Find all the children of “Units of Measure” 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 HDD Modified From HL7 Service-Oriented Architecture SIG, OMG Healthcare Domain Task Force, January 2008

  16. Encode with internal identifiers, “translate” to standard codes for external exchange **HDD *CDR *CDR Internal code:1234 LOINC®:2823-3 Patient: John Doe Lab Result:2823-3 Patient: John Doe Lab Result:1234 2823-3 2823-3 Exchanging Standard CodesTwo Implementation Strategies - Comparison Encode with the identifiers of standard terminologies *CDR=Clinical Data Repository **HDD=Healthcare Data Dictionary

  17. The Mapping Challenge SNOMED Target 1 LOINC Source Source SNOMED LOINC Target 2 Source HDD Source Source Source Source Source VS. Source Source Source Source Source Source Mappings = 9 Adding 1 source adds 1 map Mappings = 15 Adding 1 source adds 2 maps Adding 1 target adds 9 maps

  18. CDR Patient: John Doe Medication:00074433501 Shift the Meaning of a Standard Code Encoding Data Using Standard Codes NDC 00074433501 Before July 2002 After July 2002 CDR Liposyn (Fat Emulsions), 10%, IV Solution, IV, Abbott Hospital, 200ml Bag Paclitaxel (Paclitaxel, Semi-Synthetic), 6mg/ml, Vial, Injection, Abbott Hospital, 5ml Vial Patient: John Doe Medication:00074433501

  19. CDR Patient: John Doe Medication:3000493238 Shift the Meaning of a Standard CodeEncode With Internal Identifiers, Map to Standards (HDD Approach) HDD ID 3000493238 Before July 2002 After July 2002 CDR Active NDC 00074433501 Liposyn (Fat Emulsions), 10%, IV Solution, IV, Abbott Hospital, 200ml Bag Inactive NDC 00074433501 Liposyn (Fat Emulsions), 10%, IV Solution, IV, Abbott Hospital, 200ml Bag Patient: John Doe Medication:3000493238 Concept Permanence

  20. CDR Patient: John Doe Procedure:0002T Removal of a Standard CodeEncoding Data Using Standard Codes CPT 0002T Before December 31, 2003 After December 31, 2003 CDR Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; aorto-uni-iliac or aorto-unifemoral prosthesis ? Patient: John Doe Procedure:0002T

  21. CDR Patient: John Doe Procedure:14780136 Removal of a Standard CodeEncode With Internal Identifiers, Map to Standards (HDD Approach) HDD ID 14780136 Before December 31, 2003 After December 31, 2003 CDR Active CPT0002T Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; aorto-uni-iliac or aorto-unifemoral prosthesis Inactive CPT0002T Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; aorto-uni-iliac or aorto-unifemoral prosthesis Patient: John Doe Procedure:14780136 Concept Permanence

  22. April 1995 December 2004 Database Database 6,500 lab results from the master data files of 7 U.S. labs 28,000 lab results + 14,000 clinical observations Lack of Comprehensive Standard CodesEncoding Data Using Standard Codes LOINC® Updates 2000: Feb, June 2001: Jan, Jul 2002: Jan, Feb, Aug, Sep 2003: May, Oct

  23. C2C Questions for Consideration

  24. Questions?

  25. Clinical Concept ManagementMapping For Flexibility David Baorto, MD, PhD New York Presbyterian Terminology Service Query Health Working Group Meeting January 17, 2012 25

  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 1 2 3 29

  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 1 2 3 K K#3 K#1 K#4 Original Data is retained at the granularity of the source system. Semantics about the data are maintained in the central terminology system. . K#2 30

  31. POSITIVE FOR STREPTOCOCCUS GROUP B, NEGATIVE FOR YEAST, LISTERIA, N. GONORR. NYH LAB TERM: STREPTOCOCCUS AGALACTIAE NYH LAB TERM: STREPTOCOCCUS GROUP B (STREPTOCOCCUS AGALACTIAE) NYH LAB TERM: POSITIVE FOR STREPTOCOCCUS GROUP B. MESSAGE: POSITIVE FOR STREPTOCOCCUS GROUP B. MESSAGE: BACTERIAL ANTIGEN POSITIVE FOR STREPTOCOCCUS GROUP B ME TERM: STREPTOCOCCUS AGALACTIAE (GROUP B) ...or retrieving Results by SematicsDecision Support for Infection Control 1 2 Lab Results Microorganisms 3 Group B Strep Results Reported By Result Group B Strep SNOMED ID: 43492007 Result 1. Result 2. Result 4. Result 6. Result 3. Result 5. Result 7. 31

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

  33. How does mapping occur? 33 - Hormone 30 – Pharmacologic Substance 32099 - IntravascularChemistry Test Entity Measured 30893 - Triiodothyronine 69198 - Intravascular Thyroid Test Is Display Parameter of 48946 - Intravascular Total T3 Tests 58751 - WebCIS Thyroid Display 32126 - Serum Total T3 Tests (MCNC) LOINC: 3053-6 Mapping does not occur at data source level, nor at information requestor level, but at the level of a dedicated terminology server 100000 – Columbia LabTest 48822 - CPMC Laboratory Test: T3 Total 50069 - NYH LabProcedure: Triiodothyronine 60037 - CPMC Laboratory Test: Triiodothyronine,T3 108478 - Cerner ME DTA: Triiodothyronine 112971 - Cerner ME DTA: Triiodothyronine, T3 (E) 33

  34. 30893 - Triiodothyronine 69198 - Intravascular Thyroid Test 48946 - Intravascular Total T3 Tests Example of Use Case Outside Scope of Standard 33 - Hormone 30 – Pharmacologic Substance 32099 - IntravascularChemistry Test Entity Measured 32126 - Serum Total T3 Tests (MCNC) LOINC: 3053-6 Don’t graph here! Graph at this level! New - Serum Total T3 Tests ng/ml New - Serum Total T3 Tests ng/dl 48822 - CPMC Laboratory Test: T3 Total 50069 - NYH LabProcedure: Triiodothyronine 112971 - Cerner ME DTA: Triiodothronine, T3 (E) 108478 - Cerner ME DTA: Triiodothyronine 60037 - CPMC Laboratory Test: Triiodothyronine,T3 34

  35. Example of how to support Version changes of Standards Document Class: EndocrinologyConsult Note LOINC: 34879-7“EndocrinologyConsult note“ NEW – Document Class: PediatricEndocrinologyConsult Note LOINC: 68897-8 “Pediatric Endocrinology Hospital Consult Note“ 105324 - Eclipsys East Campus Documents: Ped endocrinology Attending Consult Note 103429 - Eclipsys West Campus Document: PEDIATRIC ENDOCRINOLOGY CONSULT 35

  36. Example of how to support Version changes of Standards 48967 - IntravascularRubellaIgGAntibody Tests LOINC: 25514-1“Rubella virus IgG Ab [Presence] in Serum“ X X NEW – IntravascularRubellaIgGAntibody EIA Tests LOINC: 40667-8 “Rubella virus IgGAb [Presence] in Serum by Immunoassay“ 50747 - NYH Lab Procedure: RUBELLA AB, IGG 111479 - Cerner ME DTA: Rubella Antibody IgG 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 email. • 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)

  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.org • The Current Lab LOINC Tutorial

  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?" -- 718-7) • Clinical Questions (e.g., "How far can my patient walk in 6 minutes?" -- 64098-7) • 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

  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

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

  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

  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

  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

  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

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