Applications of Terminology Standards for Performance Measurement, Clinical Decision Support, and Analysis

Daniella Meeker, PhD

Reference terminologies, interface terminologies- roles and how they complement each other

Overview

• Terminology in the Learning Health System • Uses of Standard Terminologies

– Billing and Payment – Analysis and Discovery – Performance Measurement – Decision Support

Problem centered care delivery. June Bronnert, RHIA, CCS, CCS-P; Chip Masarie, MD; Frank Naeymi-Rad, PhD, MBA; Eric Rose, MD, FAAFP; and Greg Aldin

Terminology in the “Learning Health System”

Ability to combine data from knowlegebases and databases to improve quality of care and knowledge discovery and dissemination - Clinical Trials and “Pragmatic” Trials - Health Services Research - Comparative Effectiveness Research - Safety Surveillance - Implementation Science

Reference Data Model

Extracted Data Set

(“Flat File”)

Data Set Extraction Program

Analysis Program

Estimated Predictive

Model

Terminology mapping for “computable phenotype” or

“inclusion criteria” or “measure denominator”

research

Patient Record

Predictive Model Computation

Standardized Extracted Record

Patient Centered Prediction

Publish

care

Publish

Record Processing Program

CCD

Billing

Payers reimburse for procedures that are justified by diagnosis codes

– Procedure codes tend to be well-specified in a single terminology if they are captured

– Diagnosis codes are tuned with billing standards in mind • Data Capture Interface – Physician-friendly codes or

free text – Most of the discrete code system vendors include

mappings to reference and billing terminologies • Billing Submission – ICD-10-CM

– Laboratory codes and values are not tuned, but poorly standardized

– Orders tend to be well-coded, particularly drug orders

Interpreting Coded Data

Transactional clinical data cannot be interpreted without substantial information about context. The same codes captured in different contexts correspond to different concepts. The absence of codes is also dependent on context. - e.g. 250.01 inpatient vs. outpatient - versioning metadata

- versions of code systems - versions of maps between systems (esp. interface

and billing systems) - autocoded vs. manually coded - HMO vs. FFS changes coding practices

Analysis & Discovery

• Algorithms used to define inclusion criteria for clinical trials enable streamlined screening and recruiting

• Algorithms used to define variables in data sets enable observational analysis of large data sets

• Algorithms that assign clinical concepts based on sequence of billing transactions – Billing transactions ≠ clinical history

The “Computable Phenotype”

Performance Measurement

• Chart Abstraction • Billing Data • Electronic Clinical Quality Measures • Encoding Rules

Example: Annual breast cancer screening for women over 55 that have not had bilateral mastectomy

Human Readable Logic

Value Set Authority Center

• National Library of Medicine maintains and provides interfaces for groups of codes that correspond to clinical concepts.

• Maintenance, mapping, change management processes

Decision Support Alerts

Guideline: Annual breast cancer screening for women over 55 that have not had bilateral mastectomy Implementation: Point of care decision support alerts…

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IMPROVES CARE QUALITY

REDUCES CARE QUALITY Adapted from Bright, 2012

Informatics-based QI interventions have mixed results

ONC Clinical Quality Framework

Conclusions

• Standardized terminology has enabled substantial generation of evidence

• Products that leverage standards need extensive maintenance

• Application and implementation of products that leverage standards also requires attention

Courtesy: MF Walji

Harmonization Reference Set(s)