Daniel J. Vreeman, PT, DPT, MScAssociate Research Professor, Indiana University School of Medicine

Associate Director for Terminology Services, Regenstrief Institute, Inc

2015 CC-BY-NC

Challenges and successes in managing local healthcare terminologies in a

community-wide HIE

Terminology Services to Reduce Avoidable CT Imaging F2F Meeting | 2015 10 14

Overview

1. We want fluid, comprehensive health data everywhere

2. We love standards

3. We love our local terminology

4. Five lessons weve learned

photo via Vernio77

Informatics Pioneers40 years of EMR work

Indiana Network for Patient Care

Regenstrief is the Data Switzerland

Most comprehensive and longest tenured Health Information Exchange (HIE) in USA

Informatics Pioneers40 years of EMR work

Indiana Network for Patient Care

Regenstrief is the Data Switzerland

Most comprehensive and longest tenured Health Information Exchange (HIE) in USA

Crash Test Dummies

Patients typically move faster and further than their health information

Finnell JT, Overhage JM, Grannis SJ. All Health Care is Not Local: An Evaluation of the Distribution of Emergency Department Care Delivered in Indiana. AMIA Annu Symp Proc. 2011;:409-416.

41% of ED visits are for patients with

data at another institution

Finnell JT, Overhage JM, Grannis SJ. All Health Care is Not Local: An Evaluation of the Distribution of Emergency Department Care Delivered in Indiana. AMIA Annu Symp Proc. 2011;:409-416.

Connectedness among Indiana EDs

Nearly every ED in Indiana shares patients with

every other ED in the state

A Humongous Database200+ source systems

16+ million patients

5.6 billion results

164 million text reports

more than 1 million transactions/day

Fundamental challenges: Local systems have different ways of identifying the same concept.

Things that look alike arent the same.

photo via pagedooley

Standards let us (re)use the data for everything

Clinical care, public health reporting, quality management, clinical and epidemiological research, etc

Data Standards UsGetting the data when and where it is needed

R

Long History

ASTM 1238-88

HL7 (O&O, V3, etc)

LOINC

UCUM

Collaborator with other SDOs HL7, IHTSDO, RSNA, SCO

You might be thinkingLOINC, SNOMED CT, RxNORM, etc are all pretty mature now

Only crazy people would manage their own terminology!

photo via Tatiana Gerus

LOINC has Pretty Good Coverage

Vreeman DJ, McDonald CJ. A comparison of Intelligent Mapper and document similarity scores for mapping local radiology terms to LOINC. AMIA Annu Symp Proc. 2006;809-813. PMID: 17238453.

Vreeman DJ and McDonald CJ. Automated mapping of local radiology terms to LOINC. AMIA Annu Symp Proc. 2005;769-773. PMID: 16779144.

Early studies found 91-92% content type coverage for a typical hospital radiology system.

LOINC has Pretty Good Coverage

Vreeman DJ, McDonald CJ. A comparison of Intelligent Mapper and document similarity scores for mapping local radiology terms to LOINC. AMIA Annu Symp Proc. 2006;809-813. PMID: 17238453.

Vreeman DJ and McDonald CJ. Automated mapping of local radiology terms to LOINC. AMIA Annu Symp Proc. 2005;769-773. PMID: 16779144.

Theres a fair bit of highly localized content in most systems.

Early studies found 91-92% content type coverage for a typical hospital radiology system.

The Regenstrief Dictionary

photo via muffet

Indiana Network for Patient Care

St. Vincent

St. Francis

IU Health

Wishard Health

Community

IUMG

Public Health

Referral Labs, RxHub, etc

Indiana Network for Patient Care

St. Vincent

St. Francis

IU Health

Wishard Health

Community

IUMG

Public Health

Global Patient Index Concept

Dictionary

Referral Labs, RxHub, etc

Global Provider Index

Regenstrief DictionaryCore interface terminology

Progenitor of LOINC

More than 43,000 terms

Questions, answers, and units

HIE services and CPOE at one institution

Term AttributesID 26189

Universal Name Liver CT WO&W Contr

Description CT without and with contrast of the liver.

Units

Type (data type) 7

Code (class) x

Source METHODIST RADIOLOGY

Synonyms Liver CT WWO Contr; Liver CT WOW Contr; CT Liver WWO Contr

MappingsMapped to standard vocabularies (ICD, LOINC, SNOMED CT, etc)

All source codes from local institutions are mapped to Dictionary terms

Pros and ConsWeighing the benefits and costs of maintaining a local master dictionary

photo via neurmadic aesthetic

Pros1. Ultimate control 2. Single code system for

applications across all content domains

Pros1. Ultimate control 2. Single code system for

applications across all content domains

Hugely valuable

Cons1. Expensive

2. Cant easily use tools from others

3. Others cant use our innovation applications as easily

Lessons Learned Along the Way

photo via IMLS DCC

Lesson 1.Life is messy.

HL7 messages can be syntactically correct but semantically bastardized.

Everything is an OBX.

Everything in the NTE.

HL7 messages can be syntactically correct but semantically bastardized.

Everything is an OBX.

Everything in the NTE.

68 different terms for Pathologist Name

Radiology term names are more descriptive than lab tests, but

Local nomenclature is still the wild wild west.

photo via mikemartelli

Variations in kinds of specificity laterality, views, contrast, etc

Many systems invent multiple codes for the same test to distinguish facilities

ZXR1234 STERNOCLAVICULAR JOINTS MIN 3V

CXR1234 STERNOCLAVICULAR JOINTS MIN 3 V

VXR1234 STERNOCLAVICULAR JOINTS MIN 3VWS

XRW1234 STERNOCLAVICULAR JOINTS MIN 3 VIphoto via mikemartelli

Lesson 2.Terminology management is hard.

A short history of modernist painting (part 2) by Mark Tansey

It might not be brain surgery, but it requires both expertise and effort that is easy to underestimate.

Baorto DM, Cimino JJ, Parvin CA, Kahn MG. Combining laboratory data sets from multiple institutions using the logical observation identifier names and codes (LOINC). Int J Med Inform.1998 Jul;51(1):29-37.

photo via brainblogger

A journey, not a destination.

Vreeman DJ, Stark M, Tomashefski GL, Phillips DR, Dexter PR. Embracing change in a health information exchange. AMIA Annu Symp Proc. 2008 Nov 6:768-72.

For radiology terms, in 2 years after go live we saw 71% as many new local terms appear as what we started with.

0100

200

300

400

500

600

700

800

900

0 2 4 6 8 10 12 14 16 18 20 22 24

New

Pos

t-Im

plem

enta

tion

Loc

al T

erm

s (n

)

Months Post Initial System Implementation

Meanwhile, weve always struggled to find adequate funding for this work.

photo via Vincent Anderlucci

Lesson 3.Clear descriptions are king.

photo via JD Hancock

Humans need to choose terms accurately

Clear, concise text descriptions for each term are essential.

Descriptions are King

photo via _fxr

Humans need to choose terms accurately

Clear, concise text descriptions for each term are essential.

Descriptions are King

We didnt always understand this.

photo via _fxr

Distinguishes this concept from others

Describes what the heck it is

Good Descriptions

photo via _fxr

Distinguishes this concept from others

Describes what the heck it is

Good Descriptions

What does it measure? What is it used for? What is the clinical relevance? How is the test performed?

photo via _fxr

Lesson 4.Work smarter, not harder.

photo via consumerist

Not every term has equal value

Pareto Principle

Vreeman DJ, Finnell JT, Overhage JM. A rationale for parsimonious laboratory term mapping by frequency. AMIA Annu Symp Proc. 2007 Oct 11:771-5. PubMed PMID: 18693941.

Not every term has equal value

Pareto Principle

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 500 1000 1500 2000 2500 3000 3500 4000

Cu

mu

lati

ve L

abo

rato

ry O

bse

rvat

ion

Vo

lum

e (%

)

Number of Laboratory Observation Codes (N)

Vreeman DJ, Finnell JT, Overhage JM. A rationale for parsimonious laboratory term mapping by frequency. AMIA Annu Symp Proc. 2007 Oct 11:771-5. PubMed PMID: 18693941.

In INPC, 80 codes made 80% of lab

test volume

Ongoing exploration of how/what can be automated.

Bootstrap mappings for similar names from same institution.

Vreeman DJ. Keeping up with source system changes in a local health information infrastructure: running to stand still. Stud Health Technol Inform. 2007;129:775-779. PMID: 17911822.

Ongoing exploration of how/what can be automated.

Bootstrap mappings for similar names from same institution.

In INPC, 46% of new radiology terms were exact dupes of existing names!

Vreeman DJ. Keeping up with source system changes in a local health information infrastructure: running to stand still. Stud Health Technol Inform. 2007;129:775-779. PMID: 17911822.

Lesson 5.Standards that get used get better.

Sharing is CaringStandards will get better if users help improve them through new term requests.

Most local vocabulary work is done in isolation at each institution and not shared. Even among users of the same vendor.

Fidahussein M, Vreeman DJ. A corpus-based approach for automated LOINC mapping. J Am Med Inform Assoc. 2014 Jan 1;21(1):64-72. PMID: 23676247.

Sharing is CaringStandards will get better if users help improve them through new term requests.

Most local vocabulary work is done in isolation at each institution and not shared. Even among users of the same vendor.

We built this concept into LOINC license & culture from the beginning.

Fidahussein M, Vreeman DJ. A corpus-based approach for automated LOINC mapping. J Am Med Inform Assoc. 2014 Jan 1;21(1):64-72. PMID: 23676247.

Sharing is CaringStandards will get better if users help improve them through new term requests.

Most local vocabulary work is done in isolation at each institution and not shared. Even among users of the same vendor.

We built this concept into LOINC license & culture from the beginning.

On the mapping front, see https://loinc.org/community/mappingsFidahussein M, Vreeman DJ. A corpus-based approach for automated LOINC mapping. J Am Med Inform Assoc. 2014 Jan 1;21(1):64-72. PMID: 23676247.

Were trying to find harmony using local terms and standards together

photo via scarlatti2004_images

We love local terms! We love standards!

photo via milos milosevic

danielvreeman.com/speaking