Mike Cummens, MD Semantic Interoperability - 15 August, 2006

Mike Cummens, MD

Semantic Interoperability - 15 August, 2006

17 Mar 06 Northrop Grumman Private / Proprietary Level I

© 2006 NORTHROP GRUMMAN CORPORATION

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Agenda AHLTA Goals Terminology Interoperability Future Directions



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AHLTA Scope 9.2 Million beneficiaries 129,000 Staff 411 clinics 104 Military Treatment Facilities

70 hospitals

Theater (partial list) Iraq Afghanistan



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AHLTA Weekly Volume 2.1 million prescriptions 1.8 million outpatient encounters 2,000 births for Uniformed Services members, retirees and their

families

mcummens

Need granular coded documenation from dave parker.



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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



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Fun

ctio

nali

ty

First Generation:The Collector

1993 1998 2003 2008 2012+

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 DocumentationSpanning Episodes of Care

Clinical WorkflowIntervention ScreeningDecision Support

Automated GenerationOf Pathways and Workflow; Use by Consumers

The CPR in US Industry: Gartner Group (1999)

Now

Third Generation: The Helper

CHCS II developmentaccelerated predicted timeline

Care Innovation

CommerciallyAvailable



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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



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MHS Terminologies (partial) SNOMED CT Medicomp MEDCIN PKC 3M HDD NCID MTF Laboratory IEN MTF Allergy AIEN NDC CliniComp



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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



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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



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COTS Application Terminology Challenges

Non Standard Task oriented “Ontology lite” at best Decentralized usage Context dependent terms Propositional terms Proprietary restrictions



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Clinical Data Repository/Health Data Repository (CHDR)

Real Time Interoperability mediation between Departments of Veterans Affairs and Defense

Drug Allergies

Text(VISTA) IEN(CHCS)



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Interoperability mediation between Departments of Veterans Affairs and Defense

Drug Allergies

Text(VISTA) UMLS CUI IEN(CHCS)



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Allergic Reactions

Text(VISTA) IEN or Text(CHCS)



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Allergic Reactions

Text(VISTA) SNOMED CT Concept ID

IEN or Text(CHCS)



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Medications

NDRFT(VISTA)

3M NCID(DoD)



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Medications

NDRFT(VISTA)

UMLS RXNORM

3M NCID(DoD)



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Medications

NDRFT(VISTA)

UMLS RXNORM

NDC 3M NCID(DoD)



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Translation table of Drug Allergies, Allergic Reactions and Medications in Real Time



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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



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PKC Codes and Structure

AHLTA CDR, MEDCIN, and PKC Interoperability

Provider

AHLTA CDR

PKC

MEDCIN

3M Codes and Structure

MEDCIN Codes and Structure

StovepipeSystems

Systems isolated Provider must correlate dataProvider must filter dataNo knowledge support across all dataDuplicate data entry

MHS Clinical Ontology (From TSB)

IntegratedSystems

Systems integrated System correlates dataSystem filters dataKnowledge support across all dataEliminate duplicate data entry

Separate Clients: AHLTA Client, PKC Client, MEDCIN Client

Single

Client



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Terminology Services Bureau

Content management environment Semi-automated term mapping using NLP Manual mapping and editing by terminology experts

Run Time environment



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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



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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.



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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



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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



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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.



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Use Case: Lab Flow Sheet - How it is technically done

AHLTA CDR

NCIDLOINC

MEDCIN

MEDCIN IDLOINC

MHS ClinicalOntology (in TSB)

TSB Run-timeEnvironment

Flow SheetKnowledge Agent

MEDCIN/LOINC Mappings



NCID/LOINC Mappings

Lab Results via NCID

Lab Results from CDR

Displays Pertinent Lab Results For

Diagnosis

Imp

or t

Export

Web

S

ervi

ces

Web Services

Data

Displa

y



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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



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Planned and Future Uses of TSB (cont.) Educate customers to the advantages of reuse of mediating

terminologies Increase number of mediation terminologies and maps.

Documents

Mike Cummens, MD Semantic Interoperability - 15 August, 2006