1. Special Topics in Vendor-Specific Systems
Unit 6
Vendor strategies for terminology, knowledge management, and data exchange

2. Health IT Workforce Curriculum Version 1.0/Fall 2010
Objective
Evaluate EHR strategies for terminology management, knowledge management and data exchange
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

3. After this completing this unit, you should be able to:
Define interoperability
Describe vendor strategies for terminology and knowledge management, and how these impact interoperability
Describe processes and requirements for exchanging data with personal health records
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

4. Health IT Workforce Curriculum Version 1.0/Fall 2010
Interoperability
If I’m faxed a discharge summary which I can read, is that interoperable, since it’s human interpretable? If I’m sent an electronic note via that notes “Allergy to MS”, is that interoperable? Of course MS could mean Morphine Sulfate, Magnesium Sulfate, or even Minestrone Soup. If I’m sent an electronic message which has an agreed upon format, a standard vocabulary, and a set of business rules which enable me to take action, is that interoperable? i.e. Your patient is allergic to medication NDC Code Administration will cause a SEVERE reaction with HIGH CONFIDENCE. My e-Prescribing software could use this information to display a warning alerting me to the issue and could suggest an effective alternative medication.
John D. Halamka MD, MS, Chair, Health Information Technology Standards Panel (HITSP)
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

5. Three Types of Interoperability:
Technical
Physical conveyance of a ‘payload’
Semantic
Communication of consistent meaning
Process
Integration into actual work setting assuring the systems’ usability and usefulness
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

6. Technical Interoperability
If I’m faxed a discharge summary which I can read, is that interoperable, since it’s human interpretable? If I’m sent an electronic note via that notes “Allergy to MS”, is that interoperable? Of course MS could mean Morphine Sulfate, Magnesium Sulfate, or even Minestrone Soup. If I’m sent an electronic message which has an agreed upon format, a standard vocabulary, and a set of business rules which enable me to take action, is that interoperable? i.e. Your patient is allergic to medication NDC Code Administration will cause a SEVERE reaction with HIGH CONFIDENCE. My e-Prescribing software could use this information to display a warning alerting me to the issue and could suggest an effective alternative medication.
John D. Halamka MD, MS, Chair, Health Information Technology Standards Panel (HITSP)
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

7. Technical Interoperability: Messaging Standards
Health Level Seven (HL7)
All-volunteer, non-profit organization involved in development of international healthcare standards
HL7 and its members provide a framework (and related standards) for the exchange, integration, sharing, and retrieval of electronic health information
MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4| ||ORU^R01|CNTRL-3456|P|2.4<cr> PID||| ||EVERYWOMAN^EVE^E^^^^L|JONES| |F|||153 FERNWOOD DR.^ ^STATESVILLE^OH^35292||(206) |(206) ||||AC ||67-A4335^OH^ <cr>
OBR|1|845439^GHH OE| ^GHH LAB|15545^GLUCOSE||| ||||||||| ^PRIMARY^PATRICIA P^^^^MD^^|||||||||F|||||| ^HIPPOCRATES^HOWARD H^^^^MD<cr>
OBX|1|SN|1554-5^GLUCOSE^POST 12H FST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F<cr>
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

8. Semantic Interoperability
Health Level Seven (HL7)
All-volunteer, non-profit organization involved in development of international healthcare standards
HL7 and its members provide a framework (and related standards) for the exchange, integration, sharing, and retrieval of electronic health information
MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4| ||ORU^R01|CNTRL-3456|P|2.4<cr> PID||| ||EVERYWOMAN^EVE^E^^^^L|JONES| |F|||153 FERNWOOD DR.^ ^STATESVILLE^OH^35292||(206) |(206) ||||AC ||67-A4335^OH^ <cr>
OBR|1|845439^GHH OE| ^GHH LAB|15545^GLUCOSE||| ||||||||| ^PRIMARY^PATRICIA P^^^^MD^^|||||||||F|||||| ^HIPPOCRATES^HOWARD H^^^^MD<cr>
OBX|1|SN|1554-5^GLUCOSE^POST 12H FST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F<cr>
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

9. Semantic Interoperability (cont.)
If I’m faxed a discharge summary which I can read, is that interoperable, since it’s human interpretable? If I’m sent an electronic note via that notes “Allergy to MS”, is that interoperable? Of course MS could mean Morphine Sulfate, Magnesium Sulfate, or even Minestrone Soup. If I’m sent an electronic message which has an agreed upon format, a standard vocabulary, and a set of business rules which enable me to take action, is that interoperable? i.e. Your patient is allergic to medication NDC Code Administration will cause a SEVERE reaction with HIGH CONFIDENCE. My e-Prescribing software could use this information to display a warning alerting me to the issue and could suggest an effective alternative medication.
John D. Halamka MD, MS, Chair, Health Information Technology Standards Panel (HITSP)
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

10. Semantic Interoperability: Terminology Standards
How many ways to say “heart attack”?
Easy for clinicians, hard for computer systems
Communication among & within electronic systems  must speak common “language”
Richness & variety of medical concepts are barriers to formulating standardized clinical terminologies:
ICD-9 (International Classification of Diseases) [WHO]: Diagnoses & billing
CPT-4 (Current Procedural Terminology) [AMA]: Procedures/billing
SNOMED-CT (Systematized Nomenclature of Medicine) [College of American Pathologists]: Medical concepts
LOINC (Logical Observation Identifiers Names and Codes) [Regenstrief Inst.]: Laboratory tests
Acute myocardial infarction, coronary infarction, AMI, coronary infarct, cardiac arrest, coronary thrombosis, angina pectoris
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

11. Health IT Workforce Curriculum Version 1.0/Fall 2010
ICD-9 Codes
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

12. Health IT Workforce Curriculum Version 1.0/Fall 2010
Transition to ICD-10
October 1, 2013:
ICD‑10 CM (International Classifcation of Diseases, Tenth Revision, Clinical Modifcation) and
ICD‑10 PCS (Procedure Coding System)
Will take effect, replacing the 30‑year‑old ICD‑9 system
Will impact every paper-based system and software application, information system, and functional department that currently uses or generates ICD-9 codes
Essentially, ICD‑10 is more fexible and detailed, allowing new codes to be added
easily. ICD‑9 is nearly 30 years old and does not provide enough detail to describe
clinical advances or the procedures and services performed on hospitalized patients.
As a result, limited and sometimes inaccurate information becomes the foundation
for clinical quality improvement, public reporting, and payment.
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

13. Health IT Workforce Curriculum Version 1.0/Fall 2010
LOINC
LOINC browser. LOINC defines laboratory tests. The code contained in the HL7 message shown here identifies a Blood Glucose measurement obtained after a 12 hour fast.
MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4| ||ORU^R01|CNTRL-3456|P|2.4<cr> PID||| ||EVERYWOMAN^EVE^E^^^^L|JONES| |F|||153 FERNWOOD DR.^ ^STATESVILLE^OH^35292||(206) |(206) ||||AC ||67-A4335^OH^ <cr>
OBR|1|845439^GHH OE| ^GHH LAB|15545^GLUCOSE||| ||||||||| ^PRIMARY^PATRICIA P^^^^MD^^|||||||||F|||||| ^HIPPOCRATES^HOWARD H^^^^MD<cr>
OBX|1|SN|1554-5^GLUCOSE^POST 12H FST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F<cr>
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

14. Process Interoperability
If I’m faxed a discharge summary which I can read, is that interoperable, since it’s human interpretable? If I’m sent an electronic note via that notes “Allergy to MS”, is that interoperable? Of course MS could mean Morphine Sulfate, Magnesium Sulfate, or even Minestrone Soup. If I’m sent an electronic message which has an agreed upon format, a standard vocabulary, and a set of business rules which enable me to take action, is that interoperable? i.e. Your patient is allergic to medication NDC Code Administration will cause a SEVERE reaction with HIGH CONFIDENCE. My e-Prescribing software could use this information to display a warning alerting me to the issue and could suggest an effective alternative medication.
John D. Halamka MD, MS, Chair, Health Information Technology Standards Panel (HITSP)
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

15. Process Interoperability (cont.)
The most complex and difficult to achieve, but the most important for patients and clinicians
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

16. Health IT Workforce Curriculum Version 1.0/Fall 2010
Example: Cerner
Nomenclature tool
Permits creation & modification of nomenclature values & includes ability to use & link to standard vocabularies
Rules Editor
Allows creation of expert rules & can import standard based rule formats, e.g. MLMs
Clinical knowledge sources
Advanced clinical automation systems
XML import tool for linking to external evidence based systems to supply expert rules &reminders
Clinical Measurement
Several levels of support, from Discern Expert (rules engine) to HealthFacts (aggregated client data)
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

17. Health IT Workforce Curriculum Version 1.0/Fall 2010
Example: Eclipsys
Uses HL7 2.3 messaging to exchange messages with other systems containing results, documents, observations, & tasks
Vocabulary manager module to map internal concepts to terminologies such as ICD-9, CPT-4, SNOMED
Partnerships with third-party terminology solutions such as Multum (for medications) and Intelligent Medical Objects (for problems)
Supports send/receive of patient summary information encoded using the HL7 Continuity of Care Document (CCD) standard
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

18. Example: eClinicalWorks
Semi-uniform structured data model that permits identification of common data elements across multiple installations
Predefined mappings for internal codes to LOINC, ICD-9, CPT-4, NDC, etc. & manual mapping capability for custom added codes
Uses CCR and CCD standards for clinical document sharing with health information exchanges (HIEs)
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

19. Examples of Third-party Terminology Products
Several vendors provide tools for managing & updating standard & localized medical terminology
Intelligent Medical Objects, Inc.
Health Language, Inc.
Vendor systems specific to medication management
First Databank
Micromedex
MediSpan
Multum
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

20. Personal Health Records
Vendor-specific “patient portals”
Google Health
Microsoft HealthVault
Dossia
Electronic health records are beginning to support data exchange with personal health records
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

21. Accuracy of EHR->PHR Data
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

22. Health IT Workforce Curriculum Version 1.0/Fall 2010
Benefits of PHRs
PHRs may draw their information from a variety of sources sent by hospitals, pharmacies, and laboratories, insurers, etc.
Supplying this information to patients has benefits:
Greater sense of empowerment
More engaged in their care
Higher satisfaction
Increased adherence to their care plans
Better health outcomes
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010

23. Barriers to Linking EHR and PHR Data
Logistics to work out to prevent misinformed patients
Presentation of medical diagnoses, laboratory and radiology results before physician review
Clinicians concerned that they would have to change they way they document
Privacy concerns for patients, institutions
Web-based applications
Component 14/Unit 6
Health IT Workforce Curriculum Version 1.0/Fall 2010