HIMA 4160HIMA 4160Concepts in Health Concepts in Health

Information TechnologiesInformation TechnologiesData and Data Standards

Fall 2009

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OutlinesOutlines

• Data

• Data, Information and Knowledge

• Source of health care data

• Properties of health data

• Healthcare Standards

• Concepts

• Important Health care standards

• The desiderata of controlled terminology

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http://www.youtube.com/watch?v=YKF3Eo5m1P4

Clinical DataClinical Data

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Elements of Data Elements of Data

•The patient in question

•The parameter being observed or measured

•The value of the parameter in question

•The time of observation

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Type of DataType of Data

• Narrative

• Abbreviation

• Phrases

• Numeric

• Continuous signal

• Multimedia

• ...

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Who collects the data?Who collects the data?

•Clinicians

• physicians

• nurses

• pharmacists

• allied health

•Office and administration staff.

•Medical devices7

Use of Medical DataUse of Medical Data

•Create the basis for the historical record

•Support communication among providers

•Anticipate future health problems

•Record standard preventive measures

• Identify deviations from expected trends

•Provide a legal record

•Support clinical research

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Structure of Medical DataStructure of Medical Data

•Conventional clinical data are semi-structured.

•Medicine vs. Computer

•Computer needs more structured data.

•Coding, terminology, vocabulary systems

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Data, Information and Data, Information and KnowledgeKnowledge

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DataData InformatioInformationn

KnowledgKnowledgee

Data StandardsData Standards

•What is standard?

•Why do we need standard in health care?

•What are some of the major types of standard in health care?

•What are some of the standards and standard development organizations?

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Why do we need standard?Why do we need standard?

•To facilitate communication.

•To benchmark product or processes.

•To increase efficiency.

•To increase accessibility – ATM

•To decrease cost

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What are some examples of the What are some examples of the Standards?Standards?

•Languages

•Transportation

• Internet protocols

•Operating systems

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Categories of standard based on Categories of standard based on the development processthe development process

•Government mandates – HIPAA

•Market oriented

• De facto – Microsoft Windows, VCR, Blue-Ray?

• De Jure

• Ad hoc -- DICOM

• Consensus – Many SDOs

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Standard Development Standard Development OrganizationsOrganizations

• SDOs are organizations that develop and maintain the

models, data dictionaries, structure, syntax, and

implementation materials for electronic transaction

standards between and within providers. All designated

SDOs maintain policies that meet the requirements of the

American National Standards Institute (ANSI), which

accredits standards committees and provides an open

forum for participants to identify, plan and agree on

standards and assurance of due process.

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ANSI SDO ProcessANSI SDO Process

• Consensus on a proposed standard

• Broad based public review and comment on draft standards

• Consideration of and response to comments submitted by voting members

of the relevant consensus body and by public review commenter.

• Incorporation of approved changes into a draft standard

• Right to appeal by any participant that believe that due process principles

were not sufficiently respected during the standards development in

accordance with the ANSI-accredited procedures of the standards developer

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ISO, ANSI, and SDOsISO, ANSI, and SDOs

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ISOISO

ANSIANSI

ASTMASTM HL7HL7 ASCASC … … … …

… … … …

Why Do We Need Standards in Why Do We Need Standards in Health CareHealth Care

Facilitate Information SharingImprove EfficiencyAvoid Waste and RedundancyImprove Quality

Health Care StandardsHealth Care Standards

•Classifications, Nomenclature, Vocabulary and Terminology

•Data Interchange

•Health Record Content and Structure

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Analogy -- LanguageAnalogy -- Language

•Classifications, Nomenclature, Vocabulary and Terminology – Words and Semantics

•Data Interchange – Conversation

•Health Record Content and Structure – Composition

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Classification -- DefinitionClassification -- Definition

• Classification: A clinical vocabulary, terminology, or

nomenclature that lists words or phrases with tier meanings,

provides for the proper use of clinical words as names or

symbols, and facilitate mapping standardized terms to broader

classifications for administrative, regulatory, oversight, and

fiscal requirements.

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NomenclatureNomenclature

•A recognized system of terms used in a science or art that follows pre-established naming conventions; a disease nomenclature is a listing of the proper name for each disease entity with its specific code number.

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Terminology -- DefinitionTerminology -- Definition

•A set of terms representing the system of concepts of a particular subject field; a clinical terminology provides the proper use of the clinical words as names or symbols

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Vocabulary – DefinitionVocabulary – Definition

• list or collection of clinical words or phrases and their meanings.

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Classification SystemsClassification Systems

• ICD

• ICF

•CPT

•DRG

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TerminologyTerminology

•SNOMED

•LOINC

•RxNorm

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Systematic Nomenclature of Systematic Nomenclature of Medicine – Clinical TermMedicine – Clinical Term

•SNOMED-CT

•Clinical terminology/nomenclature

•College of American Pathologies + National Health Service (NHS).

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SNOMED -- CTSNOMED -- CT

•Concepts (344,000)• Findings (swelling of arm)

• Diseases (pneumonia)

• Procedures (biopsy)

• Observable entities (tumor stage)

• Body structure (structure of thyroid)

• Organism (DNA virus)

• Substance (Gastric acid)

• Pharmaceutical/biologic product (tamoxifen)

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SNOME – CT Concepts (cont.)SNOME – CT Concepts (cont.)

• Specimen (urine specimen)

• Physical object (suture needle)

• Physical force (friction)

• Events (flash flood)

• Environments/geographical location (intensive care unit)

• Social context (organ donor)

• Context – dependent categories (no nausea)

• Staging and Scales (Nottingham ten-point ADL index assessment scale)

• Attribute (controlled temperature)

• Qualifier value (bilateral)

• Duplicate concept (inactive concept)

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SNOMED -- CTSNOMED -- CT

•913,000 Description/Synonym -- to express the clinical concepts

•~1.3 million semantic relationship to enable reliability and consistency of data retrieval

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SNOMED -- CTSNOMED -- CT

• SNOMED CT Concepts are modelled using• Hierarchies

• Each “child” must be a subtype of its “parent”

• concept may have multiple parents

• Defining relationships

• Using attributes, concepts may be linked to each other

• Only relationships that are necessarily true are included

• Appendicitis : site = appendix OK

• All appendicitis has location in the appendix.

• SLE : manifestation = anemia O no

• Only some people with SLE have anemia.

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The Principles behind SNOMED CT The Principles behind SNOMED CT structurestructure

•SNOMED is concept based• Each concept represents a unit of meaning

• Each concept has one or more human language terms that can be used to describe the concept

• Every concept has inter-relationships with other concepts that provide logical computer readable definitions. These include hierarchical relationships and clinical attributes.

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The Principe Behind SNOMED CTThe Principe Behind SNOMED CT

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Relationship allow multiple Relationship allow multiple hierarchy hierarchy

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Multiple HierarchyMultiple Hierarchy

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Semantic RelationshipSemantic Relationship

•SNOMED CT contains relationships that link concepts to form logical computer readable definitions.

•Logical definitions allow data to be recorded in a flexible way, whilst retaining the ability to analyze it in a consistent fashion.

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UseUse

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• SNOMED CT is one of a suite of designated data standards for use in U.S. Federal Government systems for the electronic exchange of clinical health information.

• The National Library of Medicine (NLM), on behalf of the U.S. Department of Health and Human Services, entered into an agreement with College of American Pathologists for a perpetual license for the core SNOMED CT (in Spanish and English) and ongoing updates.

• The contract provides to NLM a perpetual license to distribute SNOMED within the NLM’s Unified Medical Language System UMLS Metathesaurus for no cost use within the U.S. by both U.S. government (federal, state, local, and territorial) and private organizations.

• The contract also covers updates to SNOMED CT issued by the College of American Pathologists between June 30, 2003 and June 29, 2008.

LOINCLOINC

•Logical Observation Identifier Names and Codes

•Facilitate lab results transmission

•Developed and maintained by Regenstreif Institute at IU.

•About 32,000 observation terms

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LOINC codes are created LOINC codes are created systematically using a six axis modelsystematically using a six axis model

•<component>:<property>:<timing>:<system>:<scale>:<method>

•8331-1 Body temperature: TEMP: PT: MOUTH: QN

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Six Primary AxesSix Primary Axes• Component

• Ejection fraction, heart beats, cardiac output, circumference

• Kind of property

• Angle, area, length, mass, pressure, temperature

• Timing

• Point in time, study minimum, maximum in 8 hours

• System

• Head of fetus, tricuspid valve, ventilator setting

• Scale

• Quantitative, ordinal, nominal, narrative

• Method

• Stated, measured, estimated

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RxNormRxNorm

•Standardized nomenclature for the clinical drug

•Maintained by the National Library of Medicine

•The name of a clinical drug combines its ingredients, strengths, and form

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RxNormRxNorm

•Acetaminophen 500 MG Oral Tablet for a generic drug name

•Acetaminophen 500 MG Oral Tablet [Tylenol] for a branded drug name

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RxNormRxNorm

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UMLSUMLS

•A project at NLM to integrate many nomenclature systems

•Three basic components

• UMLS Metathesaurus

• SPECIALIST Lexicon

• UMLS Semantic Network

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Data Interchange StandardsData Interchange Standards

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System A System B

HL7 Messaging StandardHL7 Messaging Standard

•OSI Model level 7 – application

•Define

• The data to be exchanged

• The timing of the exchange

• The communication of errors between application

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HL7 MessageHL7 Message

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DICOMDICOM

• Digital Imaging and Communications in Medicine.

• For Medical Imaging Data Storage and Transmission

• Developed by American College of Radiology and National Electrical Manufacturer Association

• Foundations for PACS (Pictures Archiving and Communication System)

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NCPDP standardsNCPDP standards

•National Council on Prescription Drug Programs

• To create and promote data interchange standards for the pharmacy services sector of the health care industry

• To provide information and resources that educate the industry and support the diverse needs of the members.

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NCPDP standardsNCPDP standards• Batch transaction

standard.

• Billing unit standard

• Compound transaction standard

• Data dictionary

• Diskette standard

• External code list

• Formulary and benefit standard

Manufacturer Rebates, utilization, plan, formulary, market basket and reconciliation flat file standard.

Member enrolment standard

Pharmacy ID cardPrior authorizationProfessional pharmacyScript standardTelecommunication

standard

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ASC X12N StandardsASC X12N Standards

•Electronic exchange of business information

•X12N deals with insurance industry.

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Health Record Content StandardsHealth Record Content Standards

•HL7 EHR Functional Model

•ASTM Continuity of Care Record Standard

•OpenEHR

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HL7 EHR HL7 EHR FUNCTIONAL MODEL FUNCTIONAL MODEL

•Need identified for a standardized functional specification for electronic health record systems

•Public-private partnership approached HL7 to develop consensus standard

• Department of Health & Human Services

• Veterans Health Administration

• Health Information Management Systems Society

• Robert Wood Johnson Foundation

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HL7 EHR-S HL7 EHR-S FUNCTIONAL MODEL FUNCTIONAL MODEL

•What is it?

•A reference list of functions that may be present in an EHR System • Described from user perspective

• Enables consistent expression of system functionality

• Focuses on systems that operate on the EHR vs. the EHR as a singular entity

• Presents a superset of functions from which a user specific subset can be generated

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HL7 EHR HL7 EHR FUNCTIONAL MODEL FUNCTIONAL MODEL

•Consists of:• Functional Outline divided into functions for:

Direct Care

Supportive

Information Infrastructure

• Functional Profiles overlaying the Functional Outline

• Assigned priorities for the functions in the profiles

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HL7 EHR-S HL7 EHR-S FUNCTIONAL MODEL FUNCTIONAL MODEL

•The EHR Functional model does not:

• Address or endorse technology used

• Include data content of the EHR

• Address or endorse the EHR-S as a single system vs. system-of-systems

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HL7 EHRHL7 EHR FUNCTIONAL MODEL FUNCTIONAL MODEL

•Uses of the HL7 EHR Functional Model?

•Facilitate describing end-user benefits in terms of standard EHR-S functions

•Promote common understanding of EHR functions

•Provide framework to drive requirements and applications of next level standards (i.e. EHR content, coding, information models)

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HL7 EHR FUNCTIONAL MODELHL7 EHR FUNCTIONAL MODEL

•Overview•Three sections in EHR-S Functional

Model• Direct Care

• Supportive

• Information Infrastructure

•Over 130 functions 63

CCRCCR

•ASTM

•Prepared by the provider at the end of a health care encounter in order to provide a summary of the patient’s health status

•Figure 1. Conceptual model.

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OpenEHROpenEHR

UK + Australia

• promote and publish the formal specification of requirements for representing and communicating electronic health record information, based on implementation experience, and evolving over time as health care and medical knowledge develop;

• promote and publish EHR information architectures, models and data dictionaries, tested in implementations, which meet these requirements;

• manage the sequential validation of the EHR architectures through comprehensive implementation and clinical evaluation;

• maintain open source "reference" implementations, available under license, to enhance the pool of available tools to support clinical systems; and

• collaborate with other groups working towards high quality, requirements-based and interoperable health information systems, in related fields of health informatics.

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Why is making standards in health Why is making standards in health care so difficult?care so difficult?

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ResourcesResources

•http://www.snomed.org/

•http://www.regenstrief.org/loinc/

•http://umlsks.nlm.nih.gov/

•http://www.hl7.org

•http://www.astm.org/cgi-bin/SoftCart.exe/COMMIT/COMMITTEE/E31.htm?L+mystore+cnfn0409

•http://www.nahit.org.

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SummarySummary

•Three types of standards

•The importance of standards

•The challenge of standardization in health care

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