Veterinary Informatics Standards Development and Harmonization AVMA Stakeholders Meeting July, 2002 Nashville, TN

Where do we need standards? Generally… Communication between computer systems Laboratory-to-clinic data transmission Laboratory-to-government agency, clinic-to-government agency Central data repositories (all kinds) Cancer registries Eye-disease registries Electronic health certificates Portable electronic medical records “You talk - it types” medical record keeping

Where do we need standards? Specifically… When we need to transmit or receive the correct meaning of a concept. “Test for Equine Infectious Anemia” – which one? When we need to transmit the specific “context” of a concept (Von Willebrand’s Disease). This dog has “VWD” This dog’s littermate has “VWD” Dog has family history of “VWD”

SNOMED history / future Reduce storage sizeReduce Storage sizeNo longer relevant Categorize information Multiple code-based hierarchies Poly-hierarchical categorization Pathology content“All Medicine” Veterinary content separate, then integrated Integrated content “Computability” for retrieval. Natural language, artificial intelligence, decision support SNOP SNOMED SNOVET SNOMED III SNOMED RTSNOMED CT

Funding models LOINC – NIH Grant from inception HL7 – Membership (dues) from medical records vendors, hospitals, medical device suppliers, government organizations SNOMED – College of American Pathologists (99%), AVMA (1%) SNOMED hopes to establish a government- funded national license. Not clear if veterinary medicine will share in this support.

What standards are incomplete, underutilized or missing? Vocabulary Laboratory tests Disorders / findings Procedures Anatomy, organisms, substances, etc. Data structure Messaging

Veterinary standards? Reference Lab A Reference Lab B Regulatory Agency A Regulatory Agency B Registry A Registry B Practice System APractice System B Without standards: 13 vocabulary technologies, 13 transmission formats With standards: 2 vocabulary technologies, 1 transmission format

Effects of “global” veterinary standards? Reduce cost to system developers IF amortized across multiple projects Learn, manage, deploy a single technology for each major standards component. Reduce total cost of standards development. Facilitate outcomes assessment, epidemiology, disease surveillance, etc.

Effects of global veterinary standards? Increased cost to system developers Adhering to a global standard Increased costs of cooperation? Perceived loss of control, loss of specificity

Complaints about global standards It’s too… Big Complicated Expensive

Is this work “expensive?” Yes, but… We are currently losing opportunities: Early discovery of new diseases Critical evaluation of outcomes of therapy, surgery Early alerts of disease outbreaks (reportable, foreign) Ability to analyze and forecast trends

Is this work “expensive?” IF the long-range goal is useful… Costs shift from individual organizations that would build “mini” standards to a central organization. There may be cost savings to the profession as a whole. The selected standards are more complex, complete and (we believe) more functional than those likely to be undertaken by individual organizations. The cost of standards development may be somewhat higher to the profession as a whole.

Is this work “expensive?” IF the long-range goal is useful… The selected standards adhere to design specifications that have developed through hard experience in the medical profession. Essential / desirable features have been documented. The selected standards represent extraordinary functionality, produced and maintained at great cost to the medical profession. We can leverage these standards for 10¢ / $1.00

Equine reportable disease system. Equine breeds Equine “occupations” Brief list of reportable diseases Lab tests that support disease list Message structures clinic to regulatory authority Lab to regulatory authority

Equine medical record Equine Breeds Equine lab tests All applicable disorders, findings, procedures Message structures lab to clinic clinic to lab clinic to clinic

SNOMED-CT, HL-7, LOINC Mixed practice Subsets of standards Equine practice Equine disorders Equine Reportable

WNV Rabies FMD SNOMED 1 LOINC 1 HL7 2 Disease reporting system 1 = three independent subsets 2 = one subset of necessary messages

AVMA-adopted standards HL-7 Messaging and medical record infrastructure LOINC Lab test vocabulary SNOMED General medical vocabulary

Questions for audience discussion: Are veterinary-wide information standards worth pursuing? What’s the appropriate time-frame?

What has been accomplished so far? All three standards are (literally) open and committed to veterinary inclusion. All three standards publicly recognize veterinary commitment and expertise.

What has been accomplished so far? LOINC Extensive list of veterinary-specific concepts are present in the nomenclature. HL7 Standard now recognizes animals, animal identification, animal groupings, owners, etc. SNOMED Considerable veterinary content is present. Mechanisms for improving the functionality of veterinary anatomy.

Can standards be implemented now? Yes, but NOTHING about standards is, currently, “off the shelf.” LOINC – yes, veterinary labs can manage their test lists in LOINC (with an investment in mapping). HL7 – yes, although specific veterinary messages definitions must be derived… SNOMED – yes but capturing the medical information currently requires considerable manual labor.

What has to be done to make standards “practical” LOINC – consensus and mapping by labs, distribution to computer system vendors. HL7 – develop a library of messages, maintain work-group to continue development. SNOMED – make anatomy functional, make species functional, develop subsets for all conceivable purposes in a medical record system.

Current funding / costs… SNOMED ½ time veterinarian ½ time full professor Travel to working meetings per year LOINC 1/6 time full professor Travel to 3 meetings per year HL-7 1/6 time full professor Travel to 6 meetings per year

Current funding / costs… SNOMED - $100,000+ per year LOINC – $30,000 per year HL-7 - $30,000 per year AVMA covers 40% UC Davis and Virginia-Tech currently cover almost 60%. VMDB provided start-up funding for standards selection, development. Continues to support veterinary health information managers at veterinary schools.

Current funding… Nominal NOT Optimal

What does AVMA offer? Technical expertise… Infrastructure providing connection to users, vendors, etc. Established relationships with standards organizations… Past and ongoing investment…

What does your group have to offer? A market… Content expertise… Presence Definition Subsetting expertise… Financial support… Willingness to understand… Contacts with foundations, granting agencies, etc. Subject-specific grant writing expertise.

Veterinary Information Standards Development Institute (VISDI) Purpose: provide infrastructure and expertise necessary to develop and deploy veterinary information standards. Approach: membership-based as an initial funding mechanism. Activities: standards liaison, standards development, project consultation, subsetting and mapping services.

Veterinary Information Standards Development Institute (VISDI) Resources: Human Board of Directors (drawn from “membership”) Case & Wilcke Veterinarians Computer systems support personnel Business staff Technical Computer (hardware, database, communications and internet services) Office

Veterinary Information Standards Development Institute (VISDI) Membership ABVS Colleges (ACVO, ACVIM, ACVS, etc.) Professional organizations (AVMA, AAEP, AAHA, AASP, etc.) Data Repositories (VMDB, etc.) Government Organizations Veterinary Schools / Teaching hospitals Medical records vendors Private practices