1. 1 Clinical Documents Standardization Text Integrated Utility (TIU) Veterans Health Administration Office of Information Health Data and Informatics Loren Stevenson, M.D. Adapted from: CPRS National Call, Feb 2006 Jamie Bennett, Analyst Data Standardization

2. 2 Why Standardize Clinical Document Titles? Share meaningful titles across systems Create searchable, retrievable, comparable, and computable data Capture complete health information

3. 3 How Was the Note Title Standard Determined? Researched existing Standard Development Organizations (SDO) for existing clinical document standards (LOINC and HL7) Extracted all TIU document titles from 128 databases (156,000) Analyzed every term within the extracted titles Categorized the title terms to follow LOINC and HL7 standards

4. 4 Local Title Examples (The Need for Standardization) AUDIO/REEVAL/HA CHECK (T)(CI) CH-SARP NOTE CIH/STAR II CONSULT DME CLINIC (T) IC/ID/V SOCIAL WORK BOMH DISPOSITION NOTE (O) (T) UR 67CD (T)(K) BLDG 85 CAFFEINE CLASS BED STY NURSING NOTE BUDGET GROUP, PHASE I (CI) DIVERSIONAL ACTIVITY - K PATIENT HEALTH EDU POINT AND CLICK RAP NOTE (K) STARDOM EVALUATION

5. 5 The LOINC Clinical Document Title Standard Five Axes that Characterize a Title:  Subject Matter Domain – Characterizes the subject matter of a note.  Role - Characterizes the training or professional level of the author of the document, but does not breakdown to specialty or subspecialty.  Setting – Characterizes the general setting of the health care being provided. Setting is not equivalent to location, which typically has more locally defined meanings.  Service - Characterizes the kind of service or activity that was provided to/for the patient as described in the note. Common subclasses of service would be examinations, evaluations, and management.  Document Type - Characterizes the general structure of the document at a macro level.

6. 6 The LOINC Clinical Document Title Standard (cont.) Examples from Each Axis:  Subject Matter Domain -- Primary Care, Cardiology, Surgery  Role -- Physician, Registered Nurse, Attending  Setting -- Inpatient, Outpatient, Home Health  Service -- Counseling, Diagnostic Study, Evaluation and Management  Document Type -- Note, Consult, Report

7. 7 Order of Title Terms Axis terms are combined in the following order:  Subject Matter Domain : Role : Setting : Service : Document Type Not all axes are required to create a valid document title; any may be blank except Document Type For example, if we took "Cardiology" from the SMD axis and "Consult" from the Document Type axis, the following title could be created: Cardiology : No Author/Role : No Setting : No Service : Consult Result: Cardiology Consult

8. 8 More Examples of Standard Titles Report of Contact (Document Type only) Physical Therapy Note (SMD, Document Type) Primary Care Nursing Outpatient Note (SMD, Role, Setting, Document Type) Advance Directive (Document Type) Audiology Inpatient Diagnostic Study Report (SMD, Setting, Service, Document Type)

9. 9 Important Facts No delimited characters in standard titles with the exception of “&”. HL7 specifications use delimited characters for message transmission.  Examples of delimited characters: ; ~ ^ : | (no longer a necessary constraint) Sites will maintain their local titles in the Text Integrated Utility Document Definition file 8925.1 Active local titles must be mapped to a standard title before transmission to the HDR. Local and Standard titles will be transmitted and stored in the HDR.

10. 10 Mapping Local Titles to Standard Titles HEART FAILURE CLINIC FIRST VISIT NOTE Note Cardiology Outpatient Initial evaluation SUBJECT MATTER DOMAIN SETTING SERVICE DOCUMENT TYPE Local note title Standardized Title

11. 11 Vista Implementation Files added to VistA TIU Package:  TIU VHA ENTERPRISE STANDARD TITLE (#8926.1)  TIU LOINC SUBJECT MATTER DOMAIN (#8926.2)  TIU LOINC ROLE (#8926.3)  TIU LOINC SETTING (#8926.4)  TIU LOINC SERVICE (#8926.5)  TIU LOINC DOCUMENT TYPE (#8926.6) These files are locked down to local modification and are updated exclusively by regular NTRT deployments from STS.

12. 12 Vista Implementation (cont.) Standardization patch (TIU*1*211) sent to sites 11/06 Sites given 90 days to complete mapping of local titles to Standard Titles Over 700 new title requests captured by web-based NTRT system between 12/06 and 3/07 Mappings captured from each site in 5/07 for evaluation New Title Request committee meets on weekly basis to consider new requests, fine-tune the standard, and continue validation review of sites’ mapping to standard