Mike Cummens, MD Semantic Interoperability - 15 August, 2006

© 2006 NORTHROP GRUMMAN CORPORATION 2 17 Mar 06 Northrop Grumman Private / Proprietary Level I Agenda  AHLTA Goals  Terminology Interoperability  Future Directions

© 2006 NORTHROP GRUMMAN CORPORATION 3 17 Mar 06 Northrop Grumman Private / Proprietary Level I AHLTA Scope  9.2 Million beneficiaries  129,000 Staff  411 clinics  104 Military Treatment Facilities  70 hospitals  Theater (partial list)  Iraq  Afghanistan

© 2006 NORTHROP GRUMMAN CORPORATION 4 17 Mar 06 Northrop Grumman Private / Proprietary Level I AHLTA Weekly Volume  2.1 million prescriptions  1.8 million outpatient encounters  2,000 births for Uniformed Services members, retirees and their families

© 2006 NORTHROP GRUMMAN CORPORATION 5 17 Mar 06 Northrop Grumman Private / Proprietary Level I What Did the MHS Set Out to Do?  Make patient record available at point of care  Complete  Timely  Accurate  Noise free  Legally acceptable  Capture computable data to support business of healthcare  Achieve Gartner level 5 system  Quality  Granular  Structured  Coded

© 2006 NORTHROP GRUMMAN CORPORATION 6 17 Mar 06 Northrop Grumman Private / Proprietary Level I Functionality First Generation: The Collector Second Generation: The Document Fourth Generation: The Partner Fifth Generation: The Mentor Minimal Full AHLTA Release 1 Requirements Predicted Marketplace Maturity Data Acquired Through Feeder Systems Document Care in Free Text Structured Documentation Spanning Episodes of Care Clinical Workflow Intervention Screening Decision Support Automated Generation Of Pathways and Workflow; Use by Consumers The CPR in US Industry: Gartner Group (1999) Now Third Generation: The Helper CHCS II development accelerated predicted timeline Care Innovation Commercially Available

© 2006 NORTHROP GRUMMAN CORPORATION 7 17 Mar 06 Northrop Grumman Private / Proprietary Level I Systems to be integrated  Outpatient encounter documentation  Medicomp MEDCIN  PKC  Inpatient encounter documentation  CliniComp  Others  Clinical decision support  Medicomp MEDCIN  PKC  Local treatment facilities laboratory systems  Local treatment facilities pharmacy systems  Clinical data repository

© 2006 NORTHROP GRUMMAN CORPORATION 8 17 Mar 06 Northrop Grumman Private / Proprietary Level I MHS Terminologies (partial)  SNOMED CT  Medicomp MEDCIN  PKC  3M HDD NCID  MTF Laboratory IEN  MTF Allergy AIEN  NDC  CliniComp

© 2006 NORTHROP GRUMMAN CORPORATION 9 17 Mar 06 Northrop Grumman Private / Proprietary Level I Healthcare Standards  Consolidated Health Informatics  Office of Management and Budget's (OMB) eGov initiative  Departments of Veterans Affairs and Defense are committed to use of CHI standards for data mediation of terminologies with external agencies  Twenty federal agencies/departments are active in CHI governance

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Healthcare Standards  Consolidated Health Informatics Standards(partial)  Diagnosis, Problem List, Non Laboratory Tests, laboratory Result Contents  SNOMED CT  Medications  Semantic Clinical Drug Name of RXNORM  Drug Product  NDC  Laboratory Test Order  LOINC  Messages  HL7  Text Based Reports  HL7 CDA Release 1.0

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I COTS Application Terminology Challenges  Non Standard  Task oriented  “Ontology lite” at best  Decentralized usage  Context dependent terms  Propositional terms  Proprietary restrictions

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Clinical Data Repository/Health Data Repository (CHDR)  Real Time Interoperability mediation between Departments of Veterans Affairs and Defense  Drug Allergies Text(VISTA)IEN(CHCS)

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Clinical Data Repository/Health Data Repository (CHDR)  Interoperability mediation between Departments of Veterans Affairs and Defense  Drug Allergies Text(VISTA)UMLS CUIIEN(CHCS)

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Clinical Data Repository/Health Data Repository (CHDR)  Interoperability mediation between Departments of Veterans Affairs and Defense  Allergic Reactions Text(VISTA)IEN or Text(CHCS)

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Clinical Data Repository/Health Data Repository (CHDR)  Interoperability mediation between Departments of Veterans Affairs and Defense  Allergic Reactions Text(VISTA)SNOMED CT Concept ID IEN or Text(CHCS)

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Clinical Data Repository/Health Data Repository (CHDR)  Interoperability mediation between Departments of Veterans Affairs and Defense  Medications NDRFT (VISTA) 3M NCID(DoD)

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Clinical Data Repository/Health Data Repository (CHDR)  Interoperability mediation between Departments of Veterans Affairs and Defense  Medications NDRFT (VISTA) UMLS RXNORM 3M NCID(DoD)

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Clinical Data Repository/Health Data Repository (CHDR)  Interoperability mediation between Departments of Veterans Affairs and Defense  Medications NDRFT (VISTA) UMLS RXNORM NDC3M NCID(DoD)

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Clinical Data Repository/Health Data Repository (CHDR)  Translation table of Drug Allergies, Allergic Reactions and Medications in Real Time

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Terminology Services Bureau  Mediation of MHS terminologies  “Core Domain” ontology based SNOMED CT as modified by Language & Computing  Hosted in Language &Computing LinkFactory  Source terminologies retained intact  Source terminologies mapped to “Core Domain”  Content management environment  Run Time environment

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I PKC Codes and Structure AHLTA CDR, MEDCIN, and PKC Interoperability Provider AHLTA CDR PKC MEDCIN 3M Codes and Structure MEDCIN Codes and Structure Stovepipe Systems  Systems isolated  Provider must correlate data  Provider must filter data  No knowledge support across all data  Duplicate data entry MHS Clinical Ontology (From TSB) Integrated Systems  Systems integrated  System correlates data  System filters data  Knowledge support across all data  Eliminate duplicate data entry Separate Clients: AHLTA Client, PKC Client, MEDCIN Client Single Client

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Terminology Services Bureau  Content management environment  Semi-automated term mapping using NLP  Manual mapping and editing by terminology experts  Run Time environment

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Terminology Services Bureau Contents  SNOMED CT  Core Domain for all areas of medical practice  PKC  Wellness, health screening, military readiness  MEDCIN  Granular outpatient encounter documentation  RXNORM  Medications  LOINC  Laboratory results  Document types

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Terminology Services Bureau Advantages  Reusability  LOINC Laboratory Content integrated into TSB for MEDCIN flowsheet implementation  LOINC content is being used for AHLTA Clinical Reminder Notification  LOINC content is being reused for CliniComp Monitoring Device data integration  Ease of maintenance  Central mapping repository versus distributed, redundant hard code and data tables.

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Terminology Services Bureau Challenges  Proprietary content  Source terminology issues  Inconsistent use of terminology  Task specific structure of terminologies.  Context dependency  Rules based mapping  The content of several local fields determine concept to be mapped to core ontology  “Systolic blood pressure in the left arm while seated”  Run time implementation  One to one mapping  Rules assisted information translation

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Use Case: Lab Flow Sheet  Goal:  Given diagnosis from MEDCIN – show all related lab results for the patient.  Issues:  Diagnosis is a MEDCIN ID  Lab data stored in the CDR using 3M NCIDs  CDR does not understand MEDCIN IDs for Lab  MEDCIN contains list of LOINC codes associated with each diagnosis  Solution:  Need to correlate knowledge from MEDCIN and CDR

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Use Case: Lab Flow Sheets - What the Provider Sees Provider 1. Select the patient. 2. Show list of the current problems. 3. Show only lab results which are pertinent to the selected problem.

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Use Case: Lab Flow Sheet - How it is technically done AHLTA CDR NCID LOINC MEDCIN MEDCIN ID LOINC MHS Clinical Ontology (in TSB) TSB Run-time Environment Flow Sheet Knowledge Agent MEDCIN/LOINC Mappings NCID/LOINC Mappings Lab Results via NCID Lab Results from CDR Displays Pertinent Lab Results For Diagnosis Import Export Web Services Data Display

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Planned and Future Uses of TSB  Encourage use of TSB for all integration tasks  Eliminate custom point-to-point mappings  Map once – use many times  Lab flow sheet project in progress  Allow provider to retrieve pertinent lab results for specific problem  Interoperability MEDCIN and AHLTA CDR  Interoperability between PKC, MEDCIN, and CDR  Pre-populate PKC coupler with data already in CDR  Pre-populate MEDCIN note with data already in CDR  Pre-populate MEDCIN note with data entered into the coupler  Use of PKC knowledge engine against CDR and MEDCIN data  Use of MEDCIN Diagnosis Prompt against CDR and PKC coupler data

© 2006 NORTHROP GRUMMAN CORPORATION Mar 06 Northrop Grumman Private / Proprietary Level I Planned and Future Uses of TSB (cont.)  Educate customers to the advantages of reuse of mediating terminologies  Increase number of mediation terminologies and maps.