Data Element Definitions Pediatric SIG ASN.1 and the CDR 1/17/2019 Data Element Definitions Pediatric SIG Stanley M. Huff, MD http://www.ihc.com Stan.Huff@ihc.com © 2000, Intermountain Health Care

Detailed Clinical Models A new collaboration Intermountain Healthcare, Mayo Clinic, VA, NHS Connecting for Health, CEN, openEHR, NCI/NIH caCORE, HL7, NLM, Siemens, GE, (Partners?) First face-to-face meeting Sept 8-9 in Boca Raton 17 people representing the above groups Long term goal Change the healthcare IT market place Short term goal Create an open, shared library (database) of detailed clinical models 1/17/2019 © 2003, Intermountain Health Care

A Detailed Clinical Model 1/17/2019 © 2003, Intermountain Health Care

What if there is no model? Site #1 70 70 kg Dry Weight: Site #2 70 Dry Weight: 70 kg Wet Ideal 1/17/2019 © 2003, Intermountain Health Care

Too many ways to say the same thing A single name/code and value Dry Weight is 70 kg Combination of two names/codes and values Weight is 70 kg Weight type is dry 1/17/2019 © 2003, Intermountain Health Care

© 2003, Intermountain Health Care Model fragment in XML Pre-coordinated representation <observation> <cd>Dry weight (LOINC 8340-2) </cd> <value>70 kg</value> </observation> Post-coordinated (compositional) representation <cd>Weight (LOINC 3141-9) </cd> <qualifier> <cd> Weight type (LOINC 8337-8) </cd> <value> Dry (SNOMED CT 13880007) </value> 1/17/2019 © 2003, Intermountain Health Care

Relational database implications Patient Identifier Date and Time Observation Type Observation Value Units 123456789 7/4/2005 Dry Weight 70 kg 7/19/2005 Current Weight 73 Patient Identifier Date and Time Observation Type Weight type Observation Value Units 123456789 7/4/2005 Weight Dry 70 kg 7/19/2005 Current 73 How would you calculate the desired weight loss during the hospital stay? 1/17/2019 © 2003, Intermountain Health Care

© 2003, Intermountain Health Care Another example If you use LOINC, and SNOMED You still have many ways to express the same information A single name/code and value Left patellar deep tendon reflex intensity is 2+ Combination of two names/codes and values Patellar deep tendon reflex intensity is 2+ Laterality is left Combination of three names/codes and values Deep tendon reflex intensity is 2+ Body part is patella 1/17/2019 © 2003, Intermountain Health Care

Data from lab interfaces ASN.1 and the CDR 1/17/2019 Interface from system 1: OBX|1|CE|ABO^ABO GROUP||O^Type O| Interface from system 2: OBX|1|CE|BLDTYP^ABO GROUP||TYPEO^Type O| Interface from system 3: OBX|1|CE|ABOTYPE^ABO GROUP||OPOS^Type O| © 2000, Intermountain Health Care

I have presented the most simple examples. More complicated items: Signs, symptoms Diagnoses Problem list Family History Use of negation – “No Family Hx of Cancer” Description of a heart murmur Description of breath sounds “Rales in right and left upper lobes” “Rales, rhonchi, and egophony in right lower lobe” 1/17/2019 © 2003, Intermountain Health Care

The essentials of the proposition The motivation for creating detailed clinical models is to support the capabilities we want the system to have Longitudinal conception to grave EHR Real-time patient specific decision support Sharing of data within and outside of the enterprise Clinical and administrative research and analysis Sharing of decision support logic and protocols Standard, open, modular, application development environment The only feasible way to meet these goals is to support detailed clinical models for clinical data that reference standard coded terminology 1/17/2019 © 2003, Intermountain Health Care

Longitudinal conception to grave EHR Comprehensive of all categories of clinical data History, physical, pharmacy, laboratory, … All types of data Text, numeric, coded, images, sounds, … Retained for 100+ years The legal record for all or part of the patient’s data The data will outlive any particular application, service, programming language, database, or message format 1/17/2019 © 2003, Intermountain Health Care

Real time, patient specific, decision support Alerts Potassium and digoxin Coagulation clinic Reminders Mammography Immunizations Protocols Ventilator weaning ARDS protocol Prophylactic use of antibiotics in surgery Advising Antibiotic assistant Critiquing Blood ordering Interpretation Blood gas interpretation Management – purpose specific aggregation and presentation of data DVT management Diabetic report 1/17/2019 © 2003, Intermountain Health Care

© 2003, Intermountain Health Care Sharing of data Sharing within the enterprise Between ADT/Registration, LIS, RIS, Labor and Delivery Sharing outside the enterprise Adverse event reporting (drugs and devices) Morbidity and mortality reporting Patient safety reporting Quality of care reports - HEDIS measures Regional Health Information Networks Bio-surveillance, infectious disease reports Cancer registries and disease specific repositories 1/17/2019 © 2003, Intermountain Health Care

Clinical and administrative research and analysis Clinical research at Intermountain Effects of inducing labor prior to 39 weeks Length of stay with TURPs Whole blood use Human genomic/proteonomic correlations Health population statistics Clinical trials Post-marketing information on drugs and devices Enrollment 1/17/2019 © 2003, Intermountain Health Care

National and international sharing of decision support modules There are more rules and knowledge to represent than a single entity can create Initiatives to allow sharing Arden syntax HL7 Decision Support Technical Committee SAGE – Shared Active Guideline Environment $18 million dollar NIST contract to IDX 1/17/2019 © 2003, Intermountain Health Care

Creating a new kind of Healthcare IT market place Separate application development (front end) from data persistence (back end) Common detailed models and terminology are shared public infrastructure, not market advantage or product discriminator Competition is based on making the best application and/or providing the best back end 1/17/2019 © 2003, Intermountain Health Care

Order Entry API (adapted from Harold Solbrig) IHC Order Entry Application Update Medication Order VA Order Services COS Interface Service Update PharmacyOrder WHERE orderNumber = “4674” … Data MUMPS Database

Update Medication Order Order Entry API – Different Client, Same Service (adapted from Harold Solbrig) Dept of Defense Application Update Medication Order VA Order Services COS Interface Service Update PharmacyOrder WHERE orderNumber = “4674” … MUMPS Database Data

Update Medication Order Order Entry API – Different Server, Same Client (adapted from Harold Solbrig) Dept of Defense Application Update Medication Order COS Interface GE Services Service Update PharmacyOrder WHERE orderNumber = “4674” … GE Repository Non-Stop Tables Data

Order Entry API (adapted from Harold Solbrig) . . . Application COS Interface Service Data

What needs to be in place? Standard set of detailed clinical data models coupled with… Standard coded terminology Standard API’s (Application Programmer Interfaces) for healthcare related services Open sharing of models, coded terms, and API’s 1/17/2019 © 2003, Intermountain Health Care

Aren’t solutions already available? Terminology alone is insufficient Current terminologies are not complete SNOMED CT, LOINC Detailed models are not available HL7 RIM is a very abstract model Archetypes, templates just getting started 1/17/2019 © 2003, Intermountain Health Care

Why hasn’t this already been done? In the past, little sharing of data or decision logic Mapping of local codes to standard codes is hard People see terminology as a market advantage Organizations trying to make big profits on codes Divergent opinions by expert modelers Different models across different types of care providers and across medical specialties 1/17/2019 © 2003, Intermountain Health Care

National and International activities (1) Health Level Seven (HL7) Version 3 modeling Version 3 Vocabulary HL7 templates TermInfo (HL7 – SNOMED CT collaboration) Common Terminology Services (CTS) Medical Services SIG (Data service APIs) 1/17/2019 © 2003, Intermountain Health Care

National and International activities (2) Archetypes (CEN and OpenEHR) Archetype definition language (ADL) VA VHIM Partners – Boston Mayo Clinic – LexGrid (terminology tools) American College of Cardiology – Data elements National Library of Medicine UMLS Project National Cancer Institute caCORE, caBIG, DSR, VTS Department of Defense – Terminology Service Bureau 1/17/2019 © 2003, Intermountain Health Care

National and International activities (3) Standard coded medical vocabularies SNOMED CT LOINC RxNorm (clinical drugs) FDA identifiers (ingredients, products) NCI Metathesaurus NLM Metathesaurus GALEN 1/17/2019 © 2003, Intermountain Health Care

National and International activities (4) Institutional terminologies Vanderbilt Columbia Presbyterian Hospital (MED) Intermountain Healthcare Veterans administration Kaiser Permanente Department of Defense (TSB) 1/17/2019 © 2003, Intermountain Health Care

National and International activities (5) Medical terminology businesses Apelon Health Language Others 1/17/2019 © 2003, Intermountain Health Care

Questions?