Nationwide management of laboratory information with the NPU terminology

Ulla Magdal, MINational Board of Health, Denmark

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

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

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

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 = ? kilogramBlood—Erythrocytes; volume fraction = ?

Blood—Hemoglobin(Fe); substance concentration = ? millimole per litre

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

Systemterm

Componentterm

Kind of propertyterm

Unitterm

Systemterm

Componentterm

Kind of propertyterm

Unitterm

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

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

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

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

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

Messages to/from GPs (1992 – 2008)

0

100000

200000

300000

400000

500000

600000

700000

800000

900000

1000000

1100000

1200000

1300000

1400000

1500000

92 93 94 95 96 97 98 99 20 O1 O2 O3 O4 O5 O6 O7 O8

MedCom -The Danish Health Data NetworkMessages/Month Prescriptions

1039105 = 73%Prescriptions1389023 = 84%

Disch. Letters 682923 = 85 %Disch. Letters 1131750 = 94 %

Lab. reports543040 = 82 %Lab. reports988151 = 99 %

ReferralsReferrals177525 = 65 %ReferralsReferrals

Reimbursement

21049 = 99 %

Lab Requests349840 = 85 %

Source: www.medcom.dk July 2009

Web based ordering of laboratory tests

on-line laboratory requesting from GP to laboratory of choice

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!

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

Tradition for naming results ’by process’

50 years ago Red cell microscopywas 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’

Tradition for naming results ’by process’

50 years ago Red cell microscopywas 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

1012/litre

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

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

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

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6,5

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8,5

9

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Serie1

Useful links

Short description of the terminology - with links 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

All the background litteraturehttp://old.iupac.org/divisions/VII/labinfo/English/IFCC_Documents.html

Please ask questions