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Agenda AHLTA Goals Terminology Interoperability Future Directions
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AHLTA Scope 9.2 Million beneficiaries 129,000 Staff 411 clinics 104 Military Treatment Facilities
70 hospitals
Theater (partial list) Iraq Afghanistan
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AHLTA Weekly Volume 2.1 million prescriptions 1.8 million outpatient encounters 2,000 births for Uniformed Services members, retirees and their
families
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What Did the MHS Set Out to Do? Make patient record available at point of care
Complete Timely Accurate Noise free Legally acceptable
Capture computable data to support business of healthcare Achieve Gartner level 5 system
Quality Granular Structured Coded
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Fun
ctio
nali
ty
First Generation:The Collector
1993 1998 2003 2008 2012+
Second Generation: The Document
Fourth Generation: The Partner
Fifth Generation: The Mentor
Minimal
Full
AHLTA Release 1 Requirements
Predicted Marketplace Maturity
Data Acquired Through Feeder Systems
Document Care in Free Text
Structured DocumentationSpanning Episodes of Care
Clinical WorkflowIntervention ScreeningDecision Support
Automated GenerationOf Pathways and Workflow; Use by Consumers
The CPR in US Industry: Gartner Group (1999)
Now
Third Generation: The Helper
CHCS II developmentaccelerated predicted timeline
Care Innovation
CommerciallyAvailable
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Systems to be integrated Outpatient encounter documentation
Medicomp MEDCIN PKC
Inpatient encounter documentation CliniComp Others
Clinical decision support Medicomp MEDCIN PKC
Local treatment facilities laboratory systems Local treatment facilities pharmacy systems Clinical data repository
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MHS Terminologies (partial) SNOMED CT Medicomp MEDCIN PKC 3M HDD NCID MTF Laboratory IEN MTF Allergy AIEN NDC CliniComp
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Healthcare Standards Consolidated Health Informatics
Office of Management and Budget's (OMB) eGov initiative Departments of Veterans Affairs and Defense are committed to use of
CHI standards for data mediation of terminologies with external agencies
Twenty federal agencies/departments are active in CHI governance
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Healthcare Standards Consolidated Health Informatics Standards(partial)
Diagnosis, Problem List, Non Laboratory Tests, laboratory Result Contents SNOMED CT
Medications Semantic Clinical Drug Name of RXNORM
Drug Product NDC
Laboratory Test Order LOINC
Messages HL7
Text Based Reports HL7 CDA Release 1.0
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COTS Application Terminology Challenges
Non Standard Task oriented “Ontology lite” at best Decentralized usage Context dependent terms Propositional terms Proprietary restrictions
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Clinical Data Repository/Health Data Repository (CHDR)
Real Time Interoperability mediation between Departments of Veterans Affairs and Defense
Drug Allergies
Text(VISTA) IEN(CHCS)
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Clinical Data Repository/Health Data Repository (CHDR)
Interoperability mediation between Departments of Veterans Affairs and Defense
Drug Allergies
Text(VISTA) UMLS CUI IEN(CHCS)
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Clinical Data Repository/Health Data Repository (CHDR)
Interoperability mediation between Departments of Veterans Affairs and Defense
Allergic Reactions
Text(VISTA) IEN or Text(CHCS)
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Clinical Data Repository/Health Data Repository (CHDR)
Interoperability mediation between Departments of Veterans Affairs and Defense
Allergic Reactions
Text(VISTA) SNOMED CT Concept ID
IEN or Text(CHCS)
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Clinical Data Repository/Health Data Repository (CHDR)
Interoperability mediation between Departments of Veterans Affairs and Defense
Medications
NDRFT(VISTA)
3M NCID(DoD)
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Clinical Data Repository/Health Data Repository (CHDR)
Interoperability mediation between Departments of Veterans Affairs and Defense
Medications
NDRFT(VISTA)
UMLS RXNORM
3M NCID(DoD)
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Clinical Data Repository/Health Data Repository (CHDR)
Interoperability mediation between Departments of Veterans Affairs and Defense
Medications
NDRFT(VISTA)
UMLS RXNORM
NDC 3M NCID(DoD)
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Clinical Data Repository/Health Data Repository (CHDR)
Translation table of Drug Allergies, Allergic Reactions and Medications in Real Time
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Terminology Services Bureau
Mediation of MHS terminologies “Core Domain” ontology based SNOMED CT as modified by
Language & Computing Hosted in Language &Computing LinkFactory Source terminologies retained intact Source terminologies mapped to “Core Domain” Content management environment Run Time environment
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PKC Codes and Structure
AHLTA CDR, MEDCIN, and PKC Interoperability
Provider
AHLTA CDR
PKC
MEDCIN
3M Codes and Structure
MEDCIN Codes and Structure
StovepipeSystems
Systems isolated Provider must correlate dataProvider must filter dataNo knowledge support across all dataDuplicate data entry
MHS Clinical Ontology (From TSB)
IntegratedSystems
Systems integrated System correlates dataSystem filters dataKnowledge support across all dataEliminate duplicate data entry
Separate Clients: AHLTA Client, PKC Client, MEDCIN Client
Single
Client
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Terminology Services Bureau
Content management environment Semi-automated term mapping using NLP Manual mapping and editing by terminology experts
Run Time environment
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Terminology Services Bureau Contents
SNOMED CT Core Domain for all areas of medical practice
PKC Wellness, health screening, military readiness
MEDCIN Granular outpatient encounter documentation
RXNORM Medications
LOINC Laboratory results Document types
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Terminology Services Bureau Advantages
Reusability LOINC Laboratory Content integrated into TSB for MEDCIN flowsheet
implementation LOINC content is being used for AHLTA Clinical Reminder Notification LOINC content is being reused for CliniComp Monitoring Device data
integration
Ease of maintenance Central mapping repository versus distributed, redundant hard code and
data tables.
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Terminology Services Bureau Challenges
Proprietary content Source terminology issues
Inconsistent use of terminology Task specific structure of terminologies. Context dependency
Rules based mapping The content of several local fields determine concept to be mapped to
core ontology “Systolic blood pressure in the left arm while seated”
Run time implementation One to one mapping Rules assisted information translation
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Use Case: Lab Flow Sheet Goal:
Given diagnosis from MEDCIN – show all related lab results for the patient.
Issues: Diagnosis is a MEDCIN ID Lab data stored in the CDR using 3M NCIDs CDR does not understand MEDCIN IDs for Lab MEDCIN contains list of LOINC codes associated with each diagnosis
Solution: Need to correlate knowledge from MEDCIN and CDR
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Use Case: Lab Flow Sheets - What the Provider Sees
Provider
1. Select the patient.
2. Show list of the current problems.
3. Show only lab results which are pertinent to the
selected problem.
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Use Case: Lab Flow Sheet - How it is technically done
AHLTA CDR
NCIDLOINC
MEDCIN
MEDCIN IDLOINC
MHS ClinicalOntology (in TSB)
TSB Run-timeEnvironment
Flow SheetKnowledge Agent
MEDCIN/LOINC Mappings
MEDCIN/LOINC Mappings
MEDCIN/LOINC Mappings
NCID/LOINC Mappings
Lab Results via NCID
Lab Results from CDR
Displays Pertinent Lab Results For
Diagnosis
Imp
or t
Export
Web
S
ervi
ces
Web Services
Data
Displa
y
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Planned and Future Uses of TSB Encourage use of TSB for all integration tasks
Eliminate custom point-to-point mappings Map once – use many times
Lab flow sheet project in progress Allow provider to retrieve pertinent lab results for specific problem Interoperability MEDCIN and AHLTA CDR
Interoperability between PKC, MEDCIN, and CDR Pre-populate PKC coupler with data already in CDR Pre-populate MEDCIN note with data already in CDR Pre-populate MEDCIN note with data entered into the coupler Use of PKC knowledge engine against CDR and MEDCIN data Use of MEDCIN Diagnosis Prompt against CDR and PKC coupler data