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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
2
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 5 – Jan 10
Meeting 6 – Jan 17
Meeting 7 –Jan 24
Meeting 8 – Jan 31
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
5
3M Health Information Systems, Inc.
Concept Mapping Approach3M Healthcare Data Dictionary
Shaun Shakib, MPH
801-265-4432
[email protected] Health Information Systems
6
3M Health Information Systems, Inc.
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
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7
3M Health Information Systems, Inc.
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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3M Health Information Systems, Inc.
• 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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3M Health Information Systems, Inc.
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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10
3M Health Information Systems, Inc.
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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3M Health Information Systems, Inc.
Semantic Mapping for Drugs
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12
3M Health Information Systems, Inc.
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 Health Information Systems, Inc.
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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14
3M Health Information Systems, Inc.
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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3M Health Information Systems, Inc.
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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16
3M Health Information Systems, Inc.
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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3M Health Information Systems, Inc.
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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3M Health Information Systems, Inc.
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
Patient: John DoeMedication: 00074433501
Paclitaxel (Paclitaxel, Semi-Synthetic), 6mg/ml, Vial, Injection, Abbott Hospital, 5ml Vial
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3M Health Information Systems, Inc.
Shift the Meaning of a Standard CodeEncode With Internal Identifiers, Map to Standards (HDD Approach)
Before July 2002Before July 2002
CDR
Patient: John DoeMedication: 3000493238
After July 2002After July 2002
CDR
Patient: John DoeMedication: 3000493238
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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3M Health Information Systems, Inc.
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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21
3M Health Information Systems, Inc.
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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3M Health Information Systems, Inc.
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
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C2C Questions for Consideration
24
3M Health Information Systems, Inc.
Questions?
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Clinical Concept ManagementMapping For Flexibility
David Baorto, MD, PhD
New York PresbyterianTerminology Service
Query Health Working Group MeetingJanuary 17, 2012
25
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.
26
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.
27
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.
28
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
29
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
30
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
31
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.
32
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
33
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!
34
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“
35
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
36
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.
38
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)
40
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
41
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
44
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
45
Demonstration
• Run LOINC• Load LMOF• One or two manual searches• Help file• Auto mapper and conflict reconciliation
46
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
47
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
48
Answering the QH C2C Questions
• 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
49
Answering the QH C2C Questions
• 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
50
Answering the QH C2C Questions
• 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’
51