Efficient Remediation of Terms Inactivated by Dictionary Updates AMIA Symposium – November 8, 2017 Benjamin J. Gross, MD, MMSc,1 David H. Dubois, MBA, PMP,2 Mark H. Twelves MSW, LICSW,2 Roberto A. Rocha, MD, PhD2,3,4 1InterSystems Corporation 2Clinical Informatics, Partners eCare, Partners Healthcare System 3Brigham and Women’s Hospital 4Harvard Medical School, Boston, MA

Abstract Ongoing maintenance of a diagnosis dictionary in an electronic health record includes replacing inactivated terms with clinically equivalent terms in configuration and data records Partners Healthcare has developed an efficient process that relies on Detailed reports to suggest active replacement terms Clinical review by subject matter experts Replacements which are made manually or with the help of system tools Learning Objectives: Recognize dependencies of terms inactivated by dictionary updates Formulate an approach towards remediation

Background Partners Healthcare System (PHS) 800,000+ clinical terms Commercial EHR Third party diagnosis dictionary 800,000+ clinical terms Mapped to ICD-10-CM codes, SNOMED CT concepts Hundreds of terms inactivated with each periodic update + PHS customization

Implications of inactivating terms Providers can usually find desired terms despite inactivations thanks to significant redundancy After >2 years, 7% of terms accounted for 99% of usage However, certain inactivated terms must be replaced with active terms: Terms with “configuration dependencies” – linked to other system elements Terms with “process dependencies” – appear in patients’ records and can be used downstream

Diagnosis terms with dependencies Configuration dependencies Examples: questions on a form, triggers for decision support Inactive terms cause runtime errors and functionality gaps Terms must be replaced in advance Process dependencies Examples: patient’s problems, future orders Inactive terms hinder workflows, especially billing Providers may make replacements themselves EHR system offers alternative terms when available Replacing terms in advance reduces workflow interruptions and saves providers time

Finding appropriate replacement terms Mapping requires clinical expertise and each replacement requires approval To improve efficiency, PHS developed reports to suggest multiple options for each inactivated term Number of suggested terms for each inactive term (recent update) Suggestions ranked by likelihood of semantic equivalence Terminology engineers select a single optimal replacement term Clinical subject matter experts review proposed replacements Report type Median Mean Configuration dependencies 17 36 Process dependencies 20 41

Suggestion reports Criteria for suggesting alternative terms Rank 1 Previously approved mapping 2 Suggested by the dictionary vendor 3 Textual match + SNOMED CT concepts + ICD-10-CM codes 4 Textual match + SNOMED CT concepts only 5 Textual match + ICD-10-CM codes only 6 Textual match only (similarity function) 7 Textual match only 8 Matching SNOMED CT concepts + ICD-10-CM codes only 9 Matching SNOMED CT concepts only 10 Matching ICD-10-CM codes only

Configuration dependency – Protocol Chemical conjunctivitis ICD-10-CM: Configuration dependency – Protocol Chemical conjunctivitis ICD-10-CM: H10.219 Acute toxic conjunctivitis, unspecified eye SNOMED CT: 415733008 Toxic conjunctivitis (disorder) Term name ICD-10-CM SNOMED CT Matching criteria ACUTE CHEMICAL CONJUNCTIVITIS H10.219 415733008 SNO + ICD ACUTE CHEMICAL CONJUNCTIVITIS, UNSPECIFIED LATERALITY CHEMICAL CONJUNCTIVITIS, BILATERAL H10.213 SNO CHEMICAL CONJUNCTIVITIS, RIGHT H10.211 CHEMICAL CONJUNCTIVITIS, LEFT H10.212 TOXIC CONJUNCTIVITIS, LEFT TOXIC CONJUNCTIVITIS, RIGHT TOXIC CONJUNCTIVITIS, BILATERAL DRUG-INDUCED TOXIC CONJUNCTIVITIS 415734002 ICD DRUG-INDUCED TOXIC CONJUNCTIVITIS, UNSPECIFIED LATERALITY

Configuration dependency – Preference list High myopia, bilateral ICD-10-CM: H52.13 Myopia, bilateral SNOMED CT: 34187009 Severe myopia (disorder) Term name ICD-10-CM SNOMED CT Matching criteria SEVERE MYOPIA OF BOTH EYES H52.13 s34187009 Suggested by vendor SEVERE MYOPIA, UNSPECIFIED LATERALITY H52.10 SNO HIGH MYOPIA SEVERE MYOPIA … [2 more] … MYOPIA OF BOTH EYES s57190000 ICD CONGENITAL AXIAL MYOPIA OF BOTH EYES s232134006 SIMPLE MYOPIA s232133000 MYOPIC RETINOPATHY OF BOTH EYES s29555009

Process dependency – Future order Dry eye syndrome, bilateral ICD-10-CM: H04.123 Dry eye syndrome of bilateral lacrimal glands SNOMED CT: 346221000119103 Tear film insufficiency of bilateral eyes (disorder) 46152009 Tear film insufficiency (disorder) Term name ICD-10-CM SNOMED CT Matching criteria INSUFFICIENCY OF TEAR FILM OF BOTH EYES H04.123 346221000119103 46152009 Suggested by vendor BILATERAL DRY EYES 162290004 Textual match + ICD DRY EYES ICD DRY EYE SYNDROME OF BILATERAL LACRIMAL GLANDS INSUFFICIENCY OF BOTH LACRIMAL SACS 231840003 CHRONIC DRYNESS OF BOTH EYES 302896008 DRYNESS OF BOTH EYES DUE TO DECREASED TEAR PRODUCTION 302896008 46152009

Textual match + SNO + ICD Process dependency – Future order Hepatic cirrhosis, unspecified hepatic cirrhosis type ICD-10-CM: K74.60 Unspecified cirrhosis of liver SNOMED CT: 19943007 Cirrhosis of liver (disorder) Term name ICD-10-CM SNOMED CT Matching criteria HEPATIC CIRRHOSIS K74.60 s19943007 Suggested by vendor CIRRHOSIS OF LIVER Textual match + SNO + ICD OTHER CIRRHOSIS OF LIVER K74.69 Textual match + SNO CIRRHOSIS SNO + ICD CIRRHOSIS OF LIVER WITHOUT ASCITES … [2 more] … CONGENITAL CIRRHOSIS P78.81 SNO NON-ALCOHOLIC CIRRHOSIS s266468003 ICD … [5 more]

Results of recent updates Jun 2017 Oct 2017 Inactive terms queued for replacement 847 778 Replacement terms identified 743 (88%) 658 (85%) Elements impacted by replacements: When replacements were not made Configuration dependencies 402 662 Configuration dependencies were otherwise changed or removed Process dependencies Future orders 163,279 107,903 Terms associated with < 50 orders were left to providers Problem lists 23,749 41,940 Terms associated with < 50 problems were left to providers Active treatment protocols 682 339 All inactive terms were replaced Total elements impacted 188,112 150,844

Effort required Initial report design and development 1 x Clinical Informatician (report design) 1 x Software Engineer (report development) Single dictionary update (x4/year): Approximately 75 hours 12-13 people with complementary roles and expertise 1 x Terminology Team Lead (project management) 1 x Clinical Informatician (project management) 1 x Software Engineer (report delivery) 2-3 x Terminology Engineers (selection of optimal replacement terms) 6 x Clinical Subject Matter Experts (review of proposed replacements) 1 x Application Coordinator (implementation)

Summary This is the PHS approach for replacing terms inactivated by periodic updates of the diagnosis dictionary Terms with “configuration dependencies” – to avoid runtime errors and functionality gaps Terms with “process dependencies” – to reduce workflow interruptions and save providers time

Conclusions Just one example of overall effort to maintain system configuration and data integrity Costs and expertise required may be the “Achilles heel” of complex EHR systems EHR vendor offers few tools for knowledge management Data integrity is only one consideration of content vendors. Others include term availability, term “friendliness”, matching multiple terminologies simultaneously Responsibilities split between EHR vendor (search) and content vendor (content), and available solutions are limited to single domains (diagnoses, meds, procedures) PHS has large quantities of configured content and patient data to consider PHS has dedicated resources for knowledge management and necessary expertise. Not available at every institution

Thank you Ben Gross, MD, MMSc grossdoc@gmail.com