Query Health Concept-to-Codes (C2C) SWG Meeting #9 February 7,

Today’s Agenda TopicTime Allotted Review of Timeline2:30 – 2:35 pm Presentation by Floyd Eisenberg on Value Sets (NQF)2:35 - 3:15 pm Review of Scope – Current Focus and Next Steps Revisiting Concept Mapping Overview (from initial Kick-Off) Reviewing Summaries and Extracting Key Themes 3:15 – 3:55 pm 2

Proposed Timeline TODAY Coordinate offline activities to summarize approaches and develop draft deliverable from presentations Presentation NQF –Value Set presentation Begin Overview of Next steps Overview of Constrains and Criteria Presentation I2b2 (Cont.) Intermountai n Health DOQS (Data Warehousing / Mapping) Tasks Introductions Scope Proposed Approach Identify SME and presentation timeline for next few meetings Meeting times extended from 2:30-4:00pm Presentation hQuery i2b2 Presentation DOQS (Data Warehousing / Mapping) Cont. PopMedNet NLM Presentation Ibeza CDISC SHARE Tasks Discussion of presentation summaries and extraction of key themes Presentation RELMA (LOINC) 3M NY Presbyterian Hospital Vocab Team Presentation AHIMA LexEVS and CTS2 Jacob Reider - ONC Presentation S&I Repository 3

Overview of ONC HIT Standards Committee Vocabulary Recommendations Marjorie Rallins, DPM, Director, Specifications, Standards & Informatics, AMA, Physician Consortium for Performance Improvement Floyd Eisenberg, MD Senior Vice President, Health IT, National Quality Forum 4

Outline  Background & Mission  Scope  Definitions  Recommendations  Examples  Challenges & Discussion 5

Background & Mission  Plethora of vocabulary standards  HITSC focused on parsimony  Clinical Quality and Vocabulary WG Mission – Evaluate and recommend a minimum set of vocabulary standards that apply to the fundamental concepts in Quality Data Model v.3 (QDM) 6

Scope  Scope: Reporting of clinical-quality measures Facilitate standardized information exchange  Out of Scope: Intra-organization information management Reporting to other external entities 7

Desiderata for Standard Vocabularies  Circa 1998, JJ Cimino MD, described desiderata for the design of a healthcare vocabulary;  Seminal work  /  Desiderata contributed to WG considerations 8

Desiderata  Content (comprehensive strategy to address gaps)  Unique identifier  Polyhierarchy  Formal definitions (semantic network)  Reject NEC, NOS  Evolve gracefully  Concept orientation  Concept permanence (no deletions; provide history)  Multiple levels of granularity/detail  Consistency in meaning along the heirarchy 9

Desiderata for Standard Vocabularies  Interdisciplinary relevance  Minimum necessary Maturity Logical (hierarchical data model vs. flat structure) Technical (eg meaningless identifiers) 10

Desiderata for Standard Vocabularies  Maximum expected useful Life Expectancy Quality of current and ongoing duration  Maximum ability to accommodate Innovation  Serves the maximum number of needs, eg: Intra-organizational clinical and administrative needs Quality reporting Reporting to public health agencies Safety reporting 11

Transition Vocabularies - Rationale  Requiring the immediate, exclusive use of some standard vocabularies might be so burdensome as to compromise clinical-quality measure (CQM) reporting.  Identify acceptable transition vocabularies for specific data categories of the Quality Data Model (QDM)—to support CQM reporting.  Scope: Recommendations for transition vocabularies do not apply beyond the domain of CQM reporting. 12

Vocabulary Summary Recommended  SNOMED CT  LOINC  RxNorm  ICF  UCUM  CVX CDC PHIN VADS (HL7) ISO 639 PHDC Payor Typology Transition  ICD-9-CM  ICD-10-CM  ICD-10-PCS  Current Procedural Terminology, CPT ®  HCPCS 13

Vocabulary Summary Recommended SSNOMED CT LLOINC RRxNorm IICF UUCUM CCVX CDC PHIN VADS (HL7) ISO 639 PHDC Payor Typology Transition  ICD-9-CM  ICD-10-CM  ICD-10-PCS  Current Procedural Terminology, CPT ®  HCPCS 14

Definitions: SNOMED CT Systematized Nomenclature of Medicine Clinical Terms ® > 310,000 active concepts > 790,000 active descriptions or names & synonyms > 920,000 relationships -Released semi-annually in Jan & July -Developed & maintained by clinicians A comprehensive clinical terminology developed by the College of American Pathologists (CAP); now owned and maintained by International Health Terminology Standards Development Organization; 15

Definitions: SNOMED CT  Concepts  Hierarchies/Trees  Parent/child relationships  Relationships between concepts  Clinical finding (disorders and findings)  Procedure  Body structure  Substance  Organism  Qualifier value  Situation with explicit context  Physical object (devices)  Observable entity  Staging and scales  Several others…. 16

Definitions: SNOMED CT  Incorporated into healthcare applications  Manual lookup and coding  Transparent to the user 17

Definitions: LOINC Logical Observation Identifiers Names and Codes ® A universal code system that facilitates exchange, pooling and processing of results; Laboratory LOINC – Lab results and observations Clinical LOINC – Clinical results and observations Name partitioned into segments to coordinate with messaging standards Developed and maintained by the Regenstrief Institute 18

Definitions: LOINC If an observation is a question and the observation value is an answer… LOINC provides codes for questions Other terminologies provide codes for answers html?portal_status_message=Welcome%21+You+are+now+logged+in. 19

Definitions: LOINC html?portal_status_message=Welcome%21+You+are+now+logged+in. What is my patient’s hemoglobin level? 718-7:Hemoglobin:MCnc:Pt:Bld:Qn How fast does my patient usually walk? :Walking speed:Vel:1W^mean:^Patient:Qn:Ca lculate 2 LAB LOINC Clinical LOINC Answers in SNOMED CT: mean corpuscular hemoglobin concentration (MCHC) - low (finding) walks meters in 1 minute (finding) 20

Definitions: RxNorm RxNorm: A standardized nomenclature that provides names and identifiers for clinical drugs Scope: Clinical drugs: administered to patients for therapeutic or diagnostic intent; eg Injectable solution vs Powder for dilution Purpose: Allow various systems using different drug nomenclatures to share data efficiently at the appropriate level of abstraction Produced by the National Library of Medicine (NLM). Semantic Clinical Drug (SCD CUI) for reporting performance measures 21

Definitions: CVX, ICF, PHDC, PHIN VADS CVX CVX/V- The CVX code is a numeric string, which identifies the type of vaccine product used. Included in the CDC’s national Center for Immunization and Respiratory Diseases (NCIRD) ICF ICF-International Classification of Functioning, Disability, and Health is a classification of the health components of functioning and disability. (Under consideration for revision by IHTSDO/NLM) PHDC Payor Typology Payor Typology is a standard that allows consistent reporting of payor data to public health agencies for health care services and research PHIN-VADS CDC Public Health Information Network (PHIN) Vocabulary Access and Distribution System (VADS) that supports the standards based vocabularies of the PHIN to promote semantic operability and exchange of consistent information. 22

Definitions, ISO, UCUM ISO 639 ISO 639 represents names of languages UCUM The Unified Code for Units of Measure include all units of measures used in international science, engineering, and business. The purpose is to facilitate unambiguous electronic communication of quantities together with their units. 23

Definition: Quality Data Model  The Quality Data Model (QDM) is an “information model” that clearly defines concepts used in quality measures and clinical care and is intended to enable automation of electronic health record (EHR) use. It provides a way to describe clinical concepts in a standardized format so individuals (i.e., providers, researchers, measure developers) monitoring clinical performance and outcomes can clearly and concisely communicate necessary information.  The QDM describes information so that EHR and other clinical electronic system vendors can consistently interpret and easily locate the data required

Recommendation VocabularyConceptQDM Category SNOMED CT AllergiesAdverse Effect: Allergy Non-allergic adverse effects, eg intolerance Adverse Effect: Non-allergy Non-medication Substances eg, latex Substance Artifacts of communication, eg, med list; clinical summary Communication* 25

Recommendation VocabularyConceptQDM Category SNOMED CT Disorders, diseases, conditions, problems Condition, Diagnosis, Problem Symptoms, eg nausea, vomiting, pain (reported by the patient) Symptom Any patient provider interaction, eg phone calls, etc; regardless of reimbursement status Encounter Instruments, hardwareDevice 26

Recommendation VocabularyConceptQDM Category SNOMED CT Results and findings for laboratory results, diagnostic studies, physical exam, Physical Exam Laboratory Test Diagnostic Study (non- laboratory) Procedures – surgical, physical manipulation Results and findings for procedures Procedure 27

Recommendation VocabularyConceptQDM Category SNOMED CT Excepted answers to patient characteristics, experience, preference, risk evaluation, family history, functional status eg answers to assessment instruments, eg patient has a caregiver, Characteristics Experience Preference Risk Evaluation Family History Functional Status 28

Recommendation VocabularyConceptQDM Category SNOMED CT Available medical equipment System Resources settings (eg home, SNF) that a patient is released to or receive from; concepts support care coordination Transfer 29

Recommendation VocabularyConceptQDM Category LOINC Assessment instruments Assessment questions Characteristics Experience Preference Risk Evaluation Family History Functional Status 30

Recommendation VocabularyConceptQDM Category LOINC Laboratory test and Diagnostic study names Laboratory Test Diagnostic Study Staffing Resources eg nursing units System Resources 31

Recommendation VocabularyConceptQDM Category RxNorm Medications that cause allergies Adverse Effect: Allergy Medications and inert ingredients associated with non-allergic adverse effects eg intolerance Adverse Effect: Non-allergy Medications administered (excluding vaccines) Medication CVX Vaccines administeredMedication 32

Recommendation VocabularyConceptQDM Category ICF* Categories of functionFunctional Status UCUM Units of measure Diagnostic Study Laboratory Test 33

Recommendation VocabularyConceptQDM Category HL7 Administrative Gender, Race & Ethnicity, DOB (CDC PHIN-VADS) Characteristic Messaging among systems Health Record Artifact EHR capabilities and function, eg e-prescribing System Resource ISO 639 Preferred language Characteristic Payor topology PayorCharacteristic 34

Transition Vocabularies VocabularyConceptsFinal Date* ICD-9 CM Diagnoses condition, diagnosis, problem, family history- - Not usable for services provided after 10/1/2013. ICD-9 CM Procedures Inpatient Encounter; Intervention; Procedure Not usable for services provided after 10/1/2013. ICD-10 CM condition, diagnosis, problem, family history; One year after MU-3 is effective ICD-10 PCS Inpatient Encounter; Intervention; Procedure One year after MU-3 is effective *Final Date, relevant for reporting of quality measure results only. Not relevant for other purposes, eg, claims reporting. 35

Transition Vocabularies VocabularyConceptsFinal Date* CPT Encounter; Intervention; Procedure One year after MU-3 is effective HCPCS Communication, Non- lab diagnostic study, Encounter, Intervention, Procedure) One year after MU-3 is effective *Final Date, relevant for reporting of quality measure results only. Not relevant for other purposes, eg, claims reporting.. 36

Examples Demonstrate with examples- ”Fictitious/mock” measures - used for demonstration purposes only no association with guidelines, standards of care, measure steward Demonstrate use of vocabularies rather than comprehensive QDM modeling and logic 37

Measure 1  Percentage of patients age 18 years and older with a diagnosis of peripheral vascular disease, with symptoms of neuropathy, who received an assessment of foot sensation using a standardized assessment tool with findings communicated to primary care physician 38

Measure 1  Percentage of patients age 18 years and older with a diagnosis of peripheral vascular disease, with symptoms of neuropathy who received an assessment of foot sensation using a standardized assessment tool with findings communicated to primary care physician 39

Percentage of patients age 18 years and older with a diagnosis of peripheral vascular disease, with symptoms of neuropathy who received an assessment of foot sensation using a standardized assessment tool with findings communicated to primary care Concept/Data Element QDM CategoryVocabulary Peripheral Vascular DiseaseCondition/Diagnosis/ProblemSNOMED CT (disorder hierarchy) Transition Vocab ICD 9 CM ICD10 Neuropathy SymptomsSymptomSNOMED CT (findings hierarchy) Assessment of Foot Sensation Risk EvaluationLOINC (Clinical LOINC) No transition vocabularies* Foot Sensation Assessment Findings Physical ExamSNOMED CT (findings hierarchy) No transition vocabularies* 40

Measure 2  Percentage of patients age 18 years and older with a diagnosis of peripheral vascular disease who have a foot ulcer and received a culture and sensitivity and were prescribed a 3 rd generation cephalosporin 41

Measure 2  Percentage of patients age 18 years and older with a diagnosis of peripheral vascular disease who have a foot ulcer and received a culture and sensitivity and were prescribed a 3 rd generation cephalosporin 42

Percentage of patients age 18 years and older with a diagnosis of peripheral vascular disease who have a foot ulcer and received a culture and sensitivity and were prescribed a 3 rd generation cephalosporin Concept/Data Element QDM CategoryVocabulary Peripheral Vascular DiseaseCondition/Diagnosis/ProblemSNOMED CT (disorder hierarchy) Transition Vocab ICD 9 CM ICD10 Foot UlcerCondition/Diagnosis/ProblemSNOMED CT (disorder hierarchy) Transition Vocab ICD 9 CM ICD10 Culture Laboratory TestLOINC (Lab LOINC) No transition vocabularies* Sensitivity Laboratory TestLOINC (Lab LOINC) No transition vocabularies* Third Generation Cephalosporin MedicationRxNorm (cui for the SCD ) No transition vocabularies* 43

Challenges  Gaps in terminology, eg LOINC, SNOMED CT  Transition recommendations, adoption, traction rather than gaps 44

Current SWG Tasks and Next Steps 45

Next Steps* Current Focus and Next Steps Current SWG Focus Standards Tools Distributed Query Networks C2C Output Summary of Various Approaches taken by Organizations Identification of Key Themes and Industry Best Practices C2C Output Summary of Various Approaches taken by Organizations Identification of Key Themes and Industry Best Practices List of Constraints to analyze Best Practices for QH within the Technical framework List of Constraints to analyze Best Practices for QH within the Technical framework Identify and assign Value Sets for a core set of data elements within the Harmonized QH CEDD as part of the Cross Walk Align Proposed Technical Expression with Existing Value Set(s) and Vocabulary Task Force Recommendations Identify standardized approach to store and access Value Set(s) Dec 2011– February 2012 Feb TBD Conduct Environmental Scan Develop Technical Expression of C2C Technical Expression of C2C Approach as it Aligns with the Reference Implementation Identified Value Set Representations for core set of Data Element in the CEDD Selection of Existing Value Set in Alignment with the QH CEDD Reference implementation Guidance for QH Harmonized CEDD and Selected Value Set Technical Expression of C2C Approach Value Set Representation C2C Output / Recommendation Suggested Inputs Suggested Outputs Clinical CEDD Technical C2C / Technical Task Team 46 Value Sets * Steps are not in sequential order

Criteria and Constraints 1.The approach must be easily implemented as part of the Technical Framework. –The Reference Implementation has to easily be able to use the mappings and the Value Sets. 2.Utilize NQF as starter Value Sets per Jacob Reider’s recommendation –Additional Value Sets can be identified and included as needed 3.Value set representation should utilize NQF and the IHE SVS –Integrating the Healthcare Enterprise -Sharing Value Sets (IHE SVS) Profile can be thought of as a Value Set Repository that houses Value Sets –IHE SVS provides a standardized, easy to use, RESTful interface to the value set 4.Potential mechanisms to import Value Sets as part of the Reference Implementation should be identified (ex. - Excel or another format?) 5.Each participating organization within the query network should consider operational best practices for ongoing updates and maintenance of Value Set 6.Value Set Owners are expected to perform ongoing maintenance of Value Sets 47