Query Health Concept-to-Codes (C2C) SWG Meeting #6 January 17, 2012 1.

Query Health Concept-to-Codes (C2C) SWGMeeting #6

January 17, 2012

1

Today’s Agenda

Topic Time Allotted

Quick Review of Updated Timeline and Future Meeting Times 2:30 – 2:35Presentation by Subject Matter Experts

Shaun Shakib – 3M 2:35 - 3:00Zeshan Rajput- RELMA (Regenstrief LOINC Mapping Assistant) 3:00 – 3:30

David Baorto – NY Presbyterian Terminology Services 3:30 - 4:00

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Proposed Timeline

3

TODAY

Coordinate offline activities to summarize approaches and develop draft deliverable from presentations

Meeting 1 – Dec 6

Meeting 2 – Dec 13

Meeting 3 – Dec 20

Meeting 4 – Jan 03



Meeting 7 –Jan 24


Meeting 9 –Feb 7

Meeting 10 – Feb 14

Tasks• Preliminary review of presentation summaries and Draft Deliverable

Presentation•I2b2 (Cont.)•Intermountain Health•DOQS (Data Warehousing / Mapping)

Tasks•Introductions •Scope•Proposed Approach•Identify SME and presentation timeline for next few meetings

Meeting times extended from 2:30-4:00pm

Presentation•hQuery •i2b2

Presentation•DOQS (Data Warehousing / Mapping) Cont.•PopMedNet•NLM

Presentation•Ibeza•CDISC SHARE

Tasks •Review of presented concept mapping frameworks to select a proposed approach

•Begin Consensus Voting process

Presentation•RELMA (LOINC)•3M•NY Presbyterian Hospital Vocab Team

Tasks •AHIMA•LexEVS and CTS2•NQF

Tasks •Consensus Voting Finalized

Announcement – Follow up Questions from 1/3 DOQS presentation by Rick Biehl

Document posted under Presentation / Reference Materials• http://wiki.siframework.org/Clinical+Concept+Mapping+%28Sub-

Work+Group%29

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3M Health Information Systems, Inc.

Concept Mapping Approach3M Healthcare Data Dictionary

Shaun Shakib, MPH

801-265-4432

[email protected] Health Information Systems

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History: HELP System

• Developed by Dr. Homer Warner, first chair of the University of Utah Department of Medical Informatics, with Dr. Allan Pryor and Dr. Reed Gardner, and others

• Origin goes back to 1954 (in the LDS Hospital’s Cardiovascular Laboratory), but the system is first described in 1972

• The vision was not only to acquire and present data, but also to interpret data so as to “help” the physician in patient care

• Integrated database• Data dictionary• Decision support

• Functional applications• Interfaces and data capture• Reports

© 3M 2012. All rights reserved. 3M CONFIDENTIAL ─ DO NOT DISTRIBUTE

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Example: HDD in support of a CDR

Clinical Data Repository

Dat

a S

tora

ge

Ser

vice

s

Ale

rt

Man

agem

ent

Sys

tem

Dat

a A

cces

s S

ervi

ces

Security – Access Filtering

Auditing – Read / Update

ELECTRONIC HEALTH RECORD

Demographics

Residence Gender EthnicityReligion Images, etc.

EncountersScheduling Next of Kin LocationsDiagnosis Procedures ProvidersImages Insurance Information, etc.

Clinical DataLaboratory Radiology PharmacyECG with Images Orders ImagesText, etc.

Healthcare Data Dictionary

Knowledge Base

Medical Information Model

Controlled Medical Vocabularies

Enterprise Master Person Index

Ad

van

ced

M

atc

hin

g L

og

ic

Security – Access Filtering

Auditing – Read / Update

En

cou

nte

rs

Up

dat

e

Ad

d

Loo

kup

Interface Engine

Pres

enta

tion

Laye

r

ClinicalInformation

System (HIS)

Radiology Information

System (RIS)

Feeder Systems

PatientAdministrationSystem (PAS)

LaboratoryInformation

System (LIS)


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• A system that organizes, defines, and encodes concepts• A practical, enterprise solution for implementing and maintaining reference terminology and

knowledge• A critical data governance tool• A metadata repository that defines the logical structure of instance data to make it computable

What is the 3M Healthcare Data Dictionary?

3M Healthcare Data Dictionary

Knowledge Base

Medical Information Model

Controlled Medical Vocabularies

ICD-10-CM

ICD-10-PCS

ICD-9-CM

MS-DRG

CPT

HCPCS

APC

SNOMED CT

LOINC

FDB

RxNorm

HDD

Lab, Rx, Radiology, Dental, Demographics, etc.

2.4 million concepts26 million representations15.9 million relationships


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Manage Complexity in the 3M HDD Content

Encode data – Crosswalk between any code/term

(standard or legacy)

Query, analyze and reason – Sharable

logic

Exchange data – Semantic

interoperability

Customize or extend content – Support local

needs

Standardization, Simplicity and Flexibility for End Users

733

A AM

Ampicillin

387170002

Contexts Representations Concepts

Mapping

Relationships

Penicillin*NCID 3000250527

Has Child

*NCID = 3M HDD’s Numerical Concept Identifier

Cloxacillin*NCID 3000253892

Hospital AInterface Code

Hospital A Name

SNOMED CT ID

SNOMED CTFull Name

RxNORM RxCUI

RxNORM Name

Ampicillin(Substance)

2625

CLOX

…

Antibiotic*NCID 3000250095

Staphylococcus*NCID 154285

Treatment For

Ampicillin*NCID 3000253893

… …

Data Standardization Using the 3M HDD


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Concept Mapping Defined

• Process of building links among concepts to integrate various vocabularies

• Context: the purpose of the map• Are these drugs being mapped for

inventory, allergens, or as clinical drugs?

• Matching technologies/tools/process to avoid duplicate concepts and increase consistency and efficiency

• String comparison mapping and semantic mapping

• Requires subject matter expertise

Herpesvirus 3, Human

C0042338 (UMLS ID)

3M HDD

Herpes-zoster Virus

Display 2

Chickenpox Virus

Display 1

Varicella-zoster Virus11557 (3M HDD ID)

VZV 243 = Ft Hood Lab Interface Context

Healthcare Data Dictionary

Concept Mapping

SMEs, Expert Tools


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Semantic Mapping for Drugs


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HDD Mapping Result – Rosetta Stone

• Manages ongoing updates from standard terminologies as well as local additions and changes from health care facilities

• Translates/transforms an enterprise’s data to standards such as LOINC®, so it can be interpreted by all other systems using standards

• Moves Syntactic Interoperability to the level of Semantic Interoperability and enables Meaningful Use

HDD ID26277

Protime Concept

3M HDD ID26277

LOINC®Code

5902-2

Fort Sill Interface

Code467-73

DoD Long Name

Protime

DoD Short NamePT

Camp LeJeune Interface

Code3650-73


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3M HDD and HL7 Common Terminology Services

• HL7 CTS provides functional specifications to query terminology servers in a standard way

• HL7 CTS frees the application developers from the constraints of the terminology service.

• If the EMR applications are CTS compliant, they can work with any CTS compliant terminology service

• HL7 CTS v1 query only• HL7 CTS2, adds distributed authoring and versioning

capabilities


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HL7 CTS Application Programming Interface

. . .

Modified From HL7 Service-Oriented Architecture SIG, OMG Healthcare Domain Task Force, January 2008

Applications

Interface

Services

Data

CTS


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HL7 CTS Application Programming Interface

Applications

Interface

Service

Data

Find all the children of “Units of Measure”

Modified From HL7 Service-Oriented Architecture SIG, OMG Healthcare Domain Task Force, January 2008

3M HDD

VocabularyBrowser

CTS

3M HDD Terminology

Serverselect * from rsform, rsform_context, concept_relation where concept_relation.CONCEPT_RELATION_NCID=1110 and concept_relation.RELATIONSHIP_NCID=363 andconcept_relation.CONCEPT_NCID=rsform.NCID and rsform.RSFORM_ID=rsform_context.RSFORM_ID and rsform_context.CONTEXT_NCID=2000 and rsform_context.PREFERRED_SCORE=0;


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Exchanging Standard CodesTwo Implementation Strategies - Comparison

Encode with the identifiers of standard

terminologies

Encode with the identifiers of standard

terminologies

*CDR

Patient: John DoeLab Result: 2823-3 2823-3

*CDR=Clinical Data Repository **HDD=Healthcare Data Dictionary

Encode with internal identifiers, “translate” to standard codes for

external exchange

Encode with internal identifiers, “translate” to standard codes for

external exchange

2823-3

**HDD

Internal code: 1234

LOINC®:2823-3

*CDR

Patient: John DoeLab Result: 1234


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The Mapping Challenge

SNOMEDTarget 1

Source

Source

Source

Source

Source

Source

Source

LOINCTarget 2 HDD

Source

Source

Source

Source

Source

Source

Source

LOINC

SNOMED

Mappings = 15Adding 1 source adds 2 mapsAdding 1 target adds 9 maps

Mappings = 9Adding 1 source adds 1 map

VS.


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NDC 00074433501NDC 00074433501

Shift the Meaning of a Standard Code Encoding Data Using Standard Codes

Before July 2002Before July 2002

CDR

Patient: John DoeMedication: 00074433501

Liposyn (Fat Emulsions), 10%, IV Solution, IV, Abbott Hospital, 200ml Bag

After July 2002After July 2002

CDR


Paclitaxel (Paclitaxel, Semi-Synthetic), 6mg/ml, Vial, Injection, Abbott Hospital, 5ml Vial


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Shift the Meaning of a Standard CodeEncode With Internal Identifiers, Map to Standards (HDD Approach)

Before July 2002Before July 2002

CDR


After July 2002After July 2002

CDR


HDD ID 3000493238 HDD ID 3000493238

Active NDC 00074433501 Liposyn (Fat Emulsions), 10%, IV Solution, IV, Abbott Hospital, 200ml Bag

Inactive NDC 00074433501 Liposyn (Fat Emulsions), 10%, IV Solution, IV, Abbott Hospital, 200ml Bag

Concept Permanence


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Removal of a Standard CodeEncoding Data Using Standard Codes

Before December 31, 2003Before December 31, 2003

CDR

Patient: John DoeProcedure: 0002T

After December 31, 2003After December 31, 2003

CDR

Patient: John DoeProcedure: 0002T

CPT 0002TCPT 0002T

Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; aorto-uni-iliac or aorto-unifemoral prosthesis

?


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Removal of a Standard Code Encode With Internal Identifiers, Map to Standards (HDD Approach)

Before December 31, 2003Before December 31, 2003

CDR

Patient: John DoeProcedure: 14780136

After December 31, 2003After December 31, 2003

CDR

Patient: John DoeProcedure: 14780136

HDD ID 14780136HDD ID 14780136

Inactive CPT 0002T Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; aorto-uni-iliac or aorto-unifemoral prosthesis

Active CPT 0002T Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; aorto-uni-iliac or aorto-unifemoral prosthesis

Concept Permanence


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LOINC®LOINC®

April 1995April 1995

Database

6,500 lab results from the master data files of 7 U.S. labs

December 2004December 2004

Database

28,000 lab results + 14,000 clinical observations

Updates2000: Feb, June2001: Jan, Jul2002: Jan, Feb, Aug, Sep2003: May, Oct

Updates2000: Feb, June2001: Jan, Jul2002: Jan, Feb, Aug, Sep2003: May, Oct

Lack of Comprehensive Standard CodesEncoding Data Using Standard Codes


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Frameworks 3M Healthcare Data Dictionary

Overview and Current Status

• How do you define concept mapping within your system (e.g. are you mapping in between standards, or are you mapping from standards to your local data dictionary)?

Mapping to local data dictionary = centralized concept mapping; not point-to-point

• Are there any internal mechanism?Quality Control? – Inter-rator agreement; internal terminology models; db triggers and constraints; business logic in domain specific tools

• Do you use any external tools? We do use external technologies, but all our tooling is in-house

• Are you able to maintain the integrity of the original data in its native form (i.e. data as collected and not modified)?

Yes

Integration and Infrastructure

• How can you integrate with external tools for mapping? JavaScript library? Java? Web Services API?

Web services API = CTS v1.2

• How do you see your framework integrating with the QH Reference Implementation solution? Native integration or through the API

Alignment to Query Health

• Where does the mapping occur? Is it at the Data Source level? Or at the Information Requestor level? Or Both?

Both; Local terminologies (terms and codes) are integrated with standards through concept mapping

• Can it be easily implemented elsewhere? Yes

Maintenance

• Who maintains your concept mapping tool? Domain specific mapping tools maintained by a Development team

• Who maintains the mappings and how often are they released?

A team of nearly 30 SMEs with domain specific clinical expertise and informatics training

• What is the associated cost with maintenance? N/A


C2C Questions for Consideration

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Questions?


Clinical Concept ManagementMapping For Flexibility

David Baorto, MD, PhD

New York PresbyterianTerminology Service

Query Health Working Group MeetingJanuary 17, 2012

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Terminology Management at NYP

• At NYP, terminology management began over 20 years ago with “the MED” (Medical Entities Dictionary) developed by Jim Cimino.

• Still have that tool, but it has developed into a “Terminology Service” that serves the multi-hospital system.

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How do you define concept mapping?

• Tasks:– Local to local codes.– Local to standard codes.– Standard to Standard.

• Types:– Equivalency. (HR = Heart Rate)

– Hierarchical. (“Attending Physician Cardiology Consult Note” is a subclass of “Cardiology Consult Note”)

– Relational. (“What LOINC codes test for this SNOMED code”)

Concept Mapping need not always mean finding equivalency.

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How do you view criteria for concept mapping?

• Goal – oriented.– “I want to plot T3 (triiodothyronine) values from

different labs on a single graph.”– “Please show me all testing for RSV on a patient.”

The supporting concept maps for these 2 use cases have different requirements.

• Flexible.– To support different goals.– To support changes to evolving standards.– To support updated information about local codes.

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K+1 = 4.2

K+3 = 3.3

K+2 = 3.2

K+1 = 3.0

K+4 = 2.6

Retrieving Results Individually

1

2

3

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K+1 = 4.2

K+3 = 3.3

K+2 = 3.2

K+1 = 3.0

K+4 = 2.6

Do you Retain the Integrity of the Original Data? Yes, by Retrieving Results according to Class

K#1

K#2 K#4

K

1

2

3

Original Data is retained at the granularity of the source system. Semantics about the data are maintained in the central terminology system..

K#3

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1. POSITIVE FOR STREPTOCOCCUS GROUP B, NEGATIVE FOR YEAST, LISTERIA, N. GONORR.

2. NYH LAB TERM: STREPTOCOCCUS AGALACTIAE

3. NYH LAB TERM: STREPTOCOCCUS GROUP B (STREPTOCOCCUS AGALACTIAE)

4. NYH LAB TERM: POSITIVE FOR STREPTOCOCCUS GROUP B.

5. MESSAGE: POSITIVE FOR STREPTOCOCCUS GROUP B.

6. MESSAGE: BACTERIAL ANTIGEN POSITIVE FOR STREPTOCOCCUS GROUP B

7. ME TERM: STREPTOCOCCUS AGALACTIAE (GROUP B)

...or retrieving Results by SematicsDecision Support for Infection Control

Lab Results

1

2

3Group B Strep Results

Result 2.

Result 6.

Result 7.

Result 1.

Result 3.

Result 4.

Result 5.

Microorganisms

Group B StrepSNOMED ID: 43492007

Reported By Result

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Architecture?

DataTerminology

EHRs

Data Stores

Reporting

CentralTermino-

logy

The MED connects in real time for production queries to certain systems, and provides batch interval results for other vendor systems.

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How does mapping occur?

32126 - Serum Total T3 Tests (MCNC)LOINC: 3053-6

48946 - Intravascular Total T3 Tests

69198 - Intravascular Thyroid Test 30893 - Triiodothyronine

32099 - Intravascular Chemistry Test

48822 - CPMC Laboratory Test: T3 Total

112971 - Cerner ME DTA: Triiodothyronine, T3 (E)

60037 - CPMC Laboratory Test: Triiodothyronine,T3

50069 - NYH Lab Procedure: Triiodothyronine

108478 - Cerner ME DTA: Triiodothyronine

Entity Measured

30 – Pharmacologic Substance

33 - Hormone

58751 - WebCIS Thyroid Display

Is Display Parameter of

Mapping does not occur at data source level, nor at information requestor level, but at the level of a dedicated terminology server

100000 – Columbia LabTest

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Example of Use Case Outside Scope of Standard

32126 - Serum Total T3 Tests (MCNC)LOINC: 3053-6

48946 - Intravascular Total T3 Tests

69198 - Intravascular Thyroid Test 30893 - Triiodothyronine

32099 - Intravascular Chemistry Test

48822 - CPMC Laboratory Test: T3 Total

112971 - Cerner ME DTA: Triiodothronine, T3 (E)

60037 - CPMC Laboratory Test: Triiodothyronine,T3

50069 - NYH Lab Procedure: Triiodothyronine

108478 - Cerner ME DTA: Triiodothyronine

Entity Measured

30 – Pharmacologic Substance

33 - Hormone

New - Serum Total T3 Tests ng/dlNew - Serum Total T3 Tests ng/ml

Don’t graph here!

Graph at this level!

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Example of how to support Version changes of StandardsDocument Class: Endocrinology Consult Note

LOINC: 34879-7 “Endocrinology Consult note“

103429 - Eclipsys West Campus Document: PEDIATRIC ENDOCRINOLOGY CONSULT

105324 - Eclipsys East Campus Documents: Ped endocrinology Attending Consult Note

NEW – Document Class: Pediatric Endocrinology Consult Note

LOINC: 68897-8 “Pediatric Endocrinology Hospital Consult Note“

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Example of how to support Version changes of Standards

48967 - Intravascular Rubella IgG Antibody TestsLOINC: 25514-1 “Rubella virus IgG Ab [Presence] in Serum“

111479 - Cerner ME DTA: Rubella Antibody IgG

50747 - NYH Lab Procedure: RUBELLA AB, IGG

NEW – Intravascular Rubella IgG Antibody EIA Tests

LOINC: 40667-8 “Rubella virus IgG Ab [Presence] in Serum by Immunoassay“

X

X

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Mapping Tools• Internal tools – task specific

• Lexical, synonymy, hierarchy and semantics.• Terminology team builds some tools (perl)

– Frequently more ‘service’ than ‘tool’.– Sometimes need to be creative, but often tedious.– Sufficient information about source and target codes

critical. (No tool will map without it).• => phone and email.

• External tools• Available crosswalks.

– Standards: ICD – CPT; ICD9 – ICD10– Local: Legacy system maps.

• RELMA for LOINC37

Content Provision Tools

• All homegrown.• Web-based MED browser.• Active memory versions for real time

interaction with clinical information system. (Java web serv and C API)

• Perl scripts for regular pre-determined queries.

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Maintenance• Slow accrual -> easy

– Once a terminology has been incorporated, maintenance consists of regular updates.

• Local sources average 20 weekly changes.

• New terminology -> difficult– Ex., 2 independent laboratories merged into single

laboratory information system.– Importance of terminology issues often unrecognized by

source systems at outset.

• Communication and Information Critical for knowledge management.

• Costs: 3 FTEs and 2 unix servers.39

Zeshan Rajput

RELMA (LOINC)

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Introduction to RELMA

• Objectives– Overview of LOINC and RELMA - Very Brief!– Demonstrate the concept mapping functionality in RELMA

Disclaimer– Contractor to ONC to support S&I Framework (Standards

Development support team Informatics Lead)– Any opinions are my own and not those of ONC, Accenture, etc.

• For More Information– LOINC.org– The Current Lab LOINC Tutorial

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http://loinc.org/

http://loinc.org/slideshows/lab-loinc-tutorial

The Point of this Presentation

• Show how (some) concept mapping is done currently• RELMA is an example of a class of concept mapping tools

– These tools facilitate translation of a local set of concepts into a standard language

• Tools like RELMA can help query composers create queries– But as one off tools, may be better to consume the underlying

data structure and combine for uses like QH

Background

• State of the Art in Concept Mapping?– From codebooks to tools like RELMA to terminology services

• LOINC - Logical Observation Identifiers Names and Codes• Use to code questions in healthcare

– Lab Questions (e.g., "What is my patient's hemoglobin?" -- 718-7)

– Clinical Questions (e.g., "How far can my patient walk in 6 minutes?" -- 64098-7)

• Answers are represented using other standards– Value + UCUM– SNOMED– etc.

RELMA Overview

• Tool distributed with LOINC– Same free use (see license)

• Provides manual and automated mapping functions– User creates file of local term/names and codes– RELMA tools help assign a LOINC term to local test/battery code

• Features– "Common Tests" subset– "Google-Like" search functions

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Four Ways to Present Local Codes

• Direct entry into LMOF from within RELMA (painful)– Local master observation file (in case you were wondering)

• Create an access table that mimics LMOF structure (less painful but tedious)

• Create a delimited ASCII file from your local test catalog (good)• Load directly from HL7 v2.x messages (best)

– Pulls data from OBR and OBX segments– Stores NTE segment data

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Demonstration

• Run LOINC• Load LMOF• One or two manual searches• Help file• Auto mapper and conflict reconciliation

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Tips for Improving Mapping Success

• Expand Abbreviations• Standardize Colloquial Terms ("ABG" for arterial blood gas)• Ignore "Administrative" Terms• Standardize Time References• RELMA has built in tools for these

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Answering the QH C2C Questions

• How does your tool function? – Take any of four sources of local observations and map them to

LOINC using automated or manual (facilitated) approaches• Are you able to maintain the integrity of the original data in native

format?– Since you have to get your information into LMOF format (in one

way or another), the mapping would not affect the original data as long as you don’t delete your original data after conversion to LMOF

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• How can your tool be leveraged? External APIs? How can QH use this tool?– No API or interface (as far as I’m aware)– Representative of tools (another is RxNav) that facilitate

adoption of a single standard• Tools tend to be one off, but critical in their role• For measure/query composers, tools like RELMA can facilitate

making sure you ‘ask the question’ specifically and in a language your targets likely understand

– LOINC also distributed with .mdb• Could be directly imported into another interface and used to

facilitate query composition, interpretation, or response

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• Where does the mapping occur? – Probably at both the query composer and data source– Query composer – makes sure the right question is being asked– Data source – makes sure the question is translated into local

terms• Can the mapping be easily implemented elsewhere?

– The point of RELMA is to facilitate implementation of the LOINC standard

– Constant improvements to its ease of use– Freely available for download

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• Who maintains the tool? – Regenstrief Institute and multiple partners around the world

• Who maintains the mappings?– The mappings are created by each user of RELMA– The tool is updated with LOINC, twice yearly

• Associated cost of maintainence– RELMA makes mapping easier, but still requires concept

dictionary curation and some ‘elbow grease’

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Query Health Concept-to-Codes (C2C) SWG Meeting #6 January 17, 2012 1.

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Transcript of Query Health Concept-to-Codes (C2C) SWG Meeting #6 January 17, 2012 1.