AHLTA: How Physicians See Our Lab(s!) Now Society of Armed Forces Medical Laboratory Scientists (SAFMLS)Boston, 28 February 2007

Michael P. Fitch, Lt Col, USAF (ret), BSCmike_fitch@chcsii.com

Purpose

Full disclosure First AHLTA presentation to lab

professionals Presented from a laboratory (i.e., CHCS,

CoPath, DBSS, and eventually PathNet®) perspective

Share knowledge Gather feedback

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Objectives

Learn the concepts behind AHLTA Understand the basic interactions between CHCS

Lab and AHLTA Order entry Result reporting

Become aware of its most significant differences relative to CHCS Lab

Discuss strategies to take advantage of AHLTA to enhance our lab business model and improve communication

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AHLTA Concepts

AHLTA in its present form is a longitudinal electronic medical record (EMR) a clinical documentation tool

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AHLTA Concepts

AHLTA in its present form is a longitudinal electronic medical record (EMR) a clinical documentation tool a single database for clinical events (CDR) a CHCS front-end for direct-care providers a whole enterprise, not just a single product NOT a replacement for laboratory or other

ancillary functionality

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How CHCS Works with AHLTA

Nightly data collectionTable synchronizationDelta data capture

Data mapping through the Health Data Dictionary (HDD)

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Overview of Lab/CHCS-AHLTA Architecture

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CHCS

CoPath

CDR

Clinics(AHLTA

Workstations)

Labs

CoPath

CHCSDBSS

DBSS

Facility 2

Facility 1 Montgomery, AL

Purpose of the Health Data Dictionary (HDD)

NCID20947395

DISA MegacenterHDD

•Purpose: To provide a Common MedicalVocabulary of standardized medicalterminology, where applicable, for linkingmultiple like concepts to a single concept•AHLTA uses the 3M Health InformationSystems Healthcare Data Dictionary® as the Common Medical Vocabulary

Fort Bragg SGOT

Portsmouth AST

Minot AFBAspartate

Aminotransferase

AspartateAminotransferase

CHCS ILab test

Mapping

Mapping

Mapping

Mapping

AspartateAminotransferase

AHLTADisplay

Data Mapping Delta Management

Every change to Lab files is captured and sent to Chantilly by an overnight task Files monitored: Lab Test, Lab Method, Antibiotic Susceptibility,

Collection Sample, Etiology Field, Topography Field Every change will be evaluated by the Data Standardization

Team the next business day, communicating as necessary with 3M and your lab Concept already mapped New concept and/or mapping required Concept invalid

Valid changes go into a daily HDD update Updates delivered each Wednesday, tested, and generally applied

the weekend following all approvals Ideally, the changes should be evaluated and the HDD update

installed before the first result arrives to avoid mapping errors

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Typical Delta Events

Often more than 2500 changes evaluated per person/day Each involves effort and therefore cost to the Government Invalid or questionable concepts require the most research and time

Majority of rejected changes represent invalid concepts Unrealistic specimen for the test

Actual examples: Vitamin K assay on tissue, fibrinogen on feces Documented causes

“Shotgunning” virtually all specimens onto new methods A collection sample without a default specimen, forcing HCP to

choose one Default specimen for a panel not available or appropriate for a

constituent test Adding or deleting constituent tests to/from panels Quality control test not identified as such

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Mitigation Strategies

Make sure all Collection Samples used for Clinical Chemistry tests have a valid default specimen defined

For each file change you make, evaluate each test:specimen:method combination for legitimacy Think LOINC—if the combination is in a valid LOINC code, it’s

probably good The Team and 3M usually use the units to determine the method For each test, consider every possible site/specimen associated

with it The default specimen for each Collection Sample Each site/specimen defined in every Method, including default methods as well as any Work

Element specific methods Avoid creating and using “blanket” methods—those containing

almost every conceivable site/specimen Make sure all the organisms and antibiotics you may

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How CHCS Works with AHLTA

Nightly data collectionTable synchronizationDelta data capture

Mapping through the Health Data Dictionary (HDD)

Order entry

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How CHCS Works with AHLTA

Nightly data collectionTable synchronizationDelta data capture

Mapping through the Health Data Dictionary (HDD)

Order entry Result retrieval02/28/2007 35

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HDD

Lab-to-AHLTA Notional Design

CDRClinical Data Repository

AHLTA Workstation

DBSS

DEERSCHCS

CoPath

CDMClinical Data Mart

Orders

Results

Failover

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Differences from CHCS

Nomenclature Formatting Supported patients Responses to CHCS F/T maintenance System interactions Lookup logic Enterprise-wide effects of the

CDR/CDM

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Nomenclature

Different field length constraints 3M/DoD standards and conventions Mapping (again, think LOINC) Vernacular (e.g., “test” vs. “result,” “alert”

meaning of “Lab Section,” etc.)

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Formatting

GUI opportunities and liabilities Fonts

Size Mono-spaced vs. proportional Color, underline, or other attributes may convey added meaning

Screen/window size 2D scrolling Mouse usage Select or hide fields Sort on demand Cut and paste

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Formatting (cont’d)

Possibly invalid assumptions (e.g., “:” connotes label, space follows “=“, reformatting won’t affect meaning)

Column widths and enforcement

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Formatting (cont’d)

Possibly invalid assumptions (e.g., “:” connotes label, space follows “=“, reformatting won’t affect meaning)

Columnar results window Selective autociting to encounter/SF600

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Formatting (cont’d)

Possibly invalid assumptions (e.g., “:” connotes label, space follows “=“, reformatting won’t affect meaning)

Columnar results window Selective autociting to encounter/SF600 Microbiology presentation issues Comments and interpretations in a separate

window

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Formatting (cont’d)

Possibly invalid assumptions (e.g., “:” connotes label, space follows “=“, reformatting won’t affect meaning)

Columnar results window Selective autociting to encounter/SF600 Microbiology presentation issues Comments and interpretations in a separate

window No analogous reports (e.g., Doctor’s Cumulative)

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Supported Patients

AHLTA is currently an outpatient system Inpatient lab results, however, are in the CDR along with

the patient’s outpatient results Order entry on an inpatient will likely be treated as an

outpatient in some respects

Only “real” patients in the CDR; others still maintained only in the associated CHCS QC Non-human specimens (e.g., veterinary patients,

environmental specimens, blood units) Officially, CDR is not to contain “test patients”

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Response to CHCS F/T Parameters

Nightly—not immediate—table synchronization

Historical changes to the CDR or CDM require “repulling” the patient(s)

Some CHCS controls not supported Print/display order Print name

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System Interactions

RNR and audit trail differences Lag time introduced by transactions Screen refreshes Partially-resulted panels (under

development) Remaining tests not seen Displayed results appear complete

Amendments and Intermediate results

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System Interactions (cont’d)

Extra information screens Anatomic Pathology Order required data Blood Bank subscript still being developed

No direct access to CHCS help screens (e.g., ??, ?<test>, OLUM, LTI)

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System Interactions (cont’d)

Extra information screens Anatomic Pathology Order required data Blood Bank subscript still being developed

No direct access to CHCS help screens (e.g., ??, ?<test>, OLUM, LTI)

Most urgent messaging still handled only by CHCS (e.g., ward/clinic auto-printing)

Associating orders with encounter becomes more important02/28/2007 64

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Lookup Logic

“Contains” vs. “Begins with” Prefixing with “x” or punctuation won’t “hide” tests Case (in)sensitivity

Contents and order of picklists Synonyms used but not displayed

Screening/filtering of some characters Support for wildcards No FileMan-unique cross-references

`IEN Soundex FileMan associations

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Enterprise-wide CDR/CDM

Local naming or business conventions Designations of sensitive results Panel constituents Use/non-use of standardized tests Inquiries and reports may encompass multiple

labs’ work Specimen/method-sensitive Potentially multiple reference ranges

Referral specimens (e.g., certification at both labs when Lab Interoperability not used)

Multiple time zones

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Lab COTS Issues

Details for integration of Cerner Millennium and AHLTA still under development

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Open Discussion

Questions Lab experiences related to AHLTA

Physicians’ comments Order entry issues Result correlation findings CAP/JCAHO/AABB/FDA inspectors’ comments

Physician/facility/patient perceptions Rumors Ideas