1. Nationwide management of laboratory information with the NPU terminology Ulla Magdal, MI National Board of Health, Denmark

2. What the NPU terminology is  Coding system for identification of medical laboratory results  Developed jointly by IFCC and IUPAC via the  (Sub)Committee on Nomenclature for Properties and Units  IFCC – International Federation of Clinical Chemistry and Laboratory Medicine  IUPAC - International Union of Pure and Applied Chemistry  In nationwide use in Denmark and Sweden

3. Who I am and what I do  Manager of the Danish version of the NPU terminology for the Board of Health  Titular member for IFCC of the international ’NPU committee’  Laboratory technologist – clinical biochemistry  Degree in Health Informatics  Work on  laboratory informatics  concept analysis  translation of SNOMED CT Ulla Magdal Petersen Denmark ump@sst.dk

4. Why a terminology for laboratory results? ensure that examination results are  fully defined in the clinical context  transferable between systems  comparable to others of same kind  reuseable – for decision support, calculations, research, statistics For this you need  (common IDs)  clear and stable definitions of result types

5. Describe the property examined  Use structured definitions - describing  what part of the universe you are observing  what component you observe in that part  what property of that component you estimate (add SI unit and more detail where relevant)  Use standard scientific concepts and terms Patient—Body; mass = ? kilogram Blood—Erythrocytes; volume fraction = ? Blood—Hemoglobin(Fe); substance concentration = ? millimole per litre

6. Translation of structured NPU definitions  Keep the structure as a carrier of meaning  Translate each term of the definition  Assume that the translated definition describes the same concept NPU03431 Urine—Sodium ion; substance concentration = ? millimole per litre Urine—Ion sodium; concentration en matière = ? millimole/litre Urin—Natrium-ion; stofkoncentration = ? millimol per liter System term Component term Kindofproperty term Unit term System term Component term Kindofproperty term Unit term

7. Health care in Denmark  The National Health Service serves all 5,5 mill. citizens  27 hospitals owned by 5 Regions (no major private hospitals)  15 600 hospital beds  3600 general practitioners have 90% of all patient contacts  GPs are largely publicly funded

8. NPU in Denmark  1998 – 2001 Danish Board of Health supports development of the NPU coding system and of its Danish version  2001 NPU coding system recommended for national use in Denmark. Most biochemistry labs implement it  2003 Biochemistry labs with EDI - 95 % NPU coded  2006 20 million NPU coded results from labs to GPs  2007 Web applications for GPs to order and access results from labs nationwide – NPU is main coding system  2009 NPU use slowly spreading into immunology, microbiology and genetics. A few local and proprietary coding systems remain in use

9. The Danish NPU Release Center  2 specialists (with a laboratory and informatics background)  translate the NPU terminology into Danish  manage and publish the Danish NPU version via a national website  publish a Users’ Guide  support and advise users (laboratories and system developers)  manage a (small) non-standard extension for specific Danish use  analyse ’coding needs’ of Danish users for communication to the international NPU committee

10. EHR in Danish health care 2009  About 35% of hospital beds are served by Electronic Health Records (EHR), usually combined with direct access to local lab systems (LIS)  All general practitioners use EHR - about 20 different systems!  All GP’s receive laboratory data messages directly into the EHR

11. MedCom - the Danish Health Data Network  Co-operative venture between authorities, organisations and private firms linked to the Danish healthcare sector  Nationwide transmission of messages between GPs and hospitals and health authorities  discharge reports  referrals  laboratory requests  laboratory reports  drug prescriptions  reimbursement www.medcom.dk

12. Messages to/from GPs (1992 – 2008) Prescriptions 1039105 = 73% Prescriptions 1389023 = 84% Disch. Letters 682923 = 85 % Disch. Letters 1131750 = 94 % Lab.reports 543040 = 82 % Lab.reports 988151 = 99 % Referrals 177525 = 65 % Referrals Reimbursement 21049 = 99 % Lab Requests 349840 = 85 % Source: www.medcom.dk July 2009

13. Web based ordering of laboratory tests  on-line laboratory requesting from GP to laboratory of choice

14. Web based access to laboratory information  GP may search for laboratories that hold recent results for a certain patient  look up the results right away - dependant on proper permissions, secure software and digital signature!

15. It was not that easy – some challenges  Conceptual - a new medical language  using standard terminology and SI units  naming the information produced, not the process  describing properties of the patient, not of the sample  Technical  long names vs. screen sizes and field lengths  primitive information models  Organizational and cultural  distrust of ’codes and numbers’ in parts of the medical environment  it-setback caused by a total makeover of public administration in 2007

16. Tradition for naming results ’by process’ 50 years ago Red cell microscopy was a good name for Blood—Erythrocytes, number concentration – but the process has changed  Definitions by ’patient property estimated’ last longer  And are clinically more relevant  But they make unwieldy names, especially on screens  Local names and and abbreviations are often used  NPU information can be available ’behind the screen’

17. Tradition for naming results ’by process’ 50 years ago Red cell microscopy was a good name for – but the process has changed  Definitions by ’patient property estimated’ last longer  And are clinically more relevant  But they make unwieldy names, especially on screens  Local names and and abbreviations are often used  NPU information can be available ’behind the screen’ NPU01960 Blood—Erythrocytes; number concentration 10 12 /litre

18. Complexity of lab data is underestimated  Clinical, administrative and technical data often needed  Not ’slots’ in systems or messages  There is always a ’test code’ slot  But there are no NPU definitions with ’extra info’   Local ’test codes’ replace NPU codes in order to convey e.g.:  New, more sensitive method  POCT result  Patient is in pregnancy care program  Bill the sports clinic for this  The information models need revision If you only have a hammer, all your problems must be nails

19. Harmonization is a long process The Danish release center  does almost all the initial coding work for ’first time’ laboratories  publishes a national ’User’s Guide’  sends out a monthly NPU newsletter  regularly offers all regions to send in their coding tables for checking and updating  helps create Danish ’shortcut names’ for use in EHR result overviews

20. Visible gains  Reusable information in EHRs  calculation of clinical indexes  graphical representation of results  Security when transmitting lab results nationwide  result values end up in the right row every time  A national reference  laboratories gradually achieve a common language  NPU codes are used in laboratory documentation, e.g. in certification or accreditation processes

21. Useful links  Short description of the terminology - with links http://www.sst.dk/English/NPULaboratoryTerminology.aspx http://www.sst.dk/English/NPULaboratoryTerminology.aspx  Latest version of the NPU terminology for download (abbreviated definitions,.csv files) http://www.labterm.dk/Enterprise%20Portal/NPU_download.aspx http://www.labterm.dk/Enterprise%20Portal/NPU_download.aspx  All the background litterature http://old.iupac.org/divisions/VII/labinfo/English/IFCC_Document s.html http://old.iupac.org/divisions/VII/labinfo/English/IFCC_Document s.html

22. Please ask questions