query health concept-to-codes (c2c) swg meeting #9

Query Health Concept-to-Codes (C2C) SWGMeeting #9

February 7, 2012

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Today’s Agenda

Topic Time Allotted

• Review of Timeline 2:30 – 2:35 pm

• Presentation by Floyd Eisenberg on Value Sets (NQF) 2:35 - 3:15 pm

• Review of Scope – Current Focus and Next Steps• Revisiting Concept Mapping Overview (from initial Kick-Off)• Reviewing Summaries and Extracting Key Themes

3:15 – 3:55 pm

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Proposed Timeline TODAY

Coordinate offline activities to summarize approaches and develop draft deliverable from presentations

Meeting 2 – Dec 13

Meeting 3 – Dec 20

Meeting 4 – Jan 03



Meeting 7 –Jan 24


Meeting 9 –Feb 7

Meeting 10 – Feb 14

Presentation •NQF –Value Set presentation

•Begin Overview of Next steps

•Overview of Constrains and Criteria

Presentation•I2b2 (Cont.)•Intermountain Health•DOQS (Data Warehousing / Mapping)

Meeting times extended from 2:30-4:00pm

Presentation•hQuery •i2b2

Presentation•DOQS (Data Warehousing / Mapping) Cont.•PopMedNet•NLM

Presentation•Ibeza•CDISC SHARE

Tasks •Discussion of presentation summaries and extraction of key themes

Presentation•RELMA (LOINC)•3M•NY Presbyterian Hospital Vocab Team

Presentation•AHIMA•LexEVS and CTS2•Jacob Reider - ONC

Presentation•S&I Repository

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Overview of ONC HIT Standards Committee Vocabulary Recommendations

Marjorie Rallins, DPM, Director, Specifications, Standards & Informatics, AMA, Physician Consortium for Performance Improvement

Floyd Eisenberg, MD Senior Vice President, Health IT, National Quality Forum

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Outline Background & Mission Scope Definitions Recommendations Examples Challenges & Discussion

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Background & Mission Plethora of vocabulary standards HITSC focused on parsimony Clinical Quality and Vocabulary WG

Mission – Evaluate and recommend a minimum set of vocabulary standards that apply to the fundamental concepts in Quality Data Model v.3 (QDM)

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Scope Scope:

Reporting of clinical-quality measures Facilitate standardized information exchange

Out of Scope: Intra-organization information management Reporting to other external entities

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Desiderata for Standard Vocabularies Circa 1998, JJ Cimino MD, described

desiderata for the design of a healthcare vocabulary;

Seminal work http://www.ncbi.nlm.nih.gov/

pubmed/9865037 Desiderata contributed to WG

considerations

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Desiderata Content (comprehensive strategy to address gaps) Unique identifier Polyhierarchy Formal definitions (semantic network) Reject NEC, NOS Evolve gracefully

Concept orientation Concept permanence (no deletions; provide history) Multiple levels of granularity/detail Consistency in meaning along the heirarchy

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Desiderata for Standard Vocabularies Interdisciplinary relevance Minimum necessary Maturity

Logical (hierarchical data model vs. flat structure)

Technical (eg meaningless identifiers)

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Desiderata for Standard Vocabularies Maximum expected useful Life Expectancy

Quality of current and ongoing duration Maximum ability to accommodate Innovation Serves the maximum number of needs, eg:

Intra-organizational clinical and administrative needs

Quality reporting Reporting to public health agencies Safety reporting

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Transition Vocabularies -Rationale

Requiring the immediate, exclusive use of some standard vocabularies might be so burdensome as to compromise clinical-quality measure (CQM) reporting.

Identify acceptable transition vocabularies for specific data categories of the Quality Data Model (QDM)—to support CQM reporting.

Scope: Recommendations for transition vocabularies do not apply beyond the domain of CQM reporting.

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Vocabulary SummaryRecommended SNOMED CT LOINC RxNorm ICF UCUM CVX

CDC PHIN VADS (HL7)ISO 639PHDC Payor Typology

Transition ICD-9-CM ICD-10-CM ICD-10-PCS Current Procedural Terminology, CPT®

HCPCS

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Vocabulary SummaryRecommended SNOMED CT LOINC RxNorm ICF UCUM CVX

CDC PHIN VADS (HL7)ISO 639PHDC Payor Typology

Transition ICD-9-CM ICD-10-CM ICD-10-PCS Current Procedural Terminology, CPT®

HCPCS

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Definitions: SNOMED CTSystematized Nomenclature of MedicineClinical Terms®

> 310,000 active concepts> 790,000 active descriptions or names & synonyms> 920,000 relationships-Released semi-annually in Jan & July-Developed & maintained by clinicians

A comprehensive clinical terminology developed by the College of American Pathologists (CAP); now owned and maintained by International Health Terminology Standards Development Organization;

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Definitions: SNOMED CT Concepts Hierarchies/Trees Parent/child relationships Relationships between

concepts

Clinical finding (disorders and findings) Procedure Body structure Substance Organism Qualifier value Situation with explicit context Physical object (devices) Observable entity Staging and scales Several others….

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Definitions: SNOMED CT Incorporated into healthcare

applications

Manual lookup and coding Transparent to the user

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Definitions: LOINCLogical Observation Identifiers Names and Codes®

A universal code system that facilitates exchange, pooling and processing of results;

Laboratory LOINC – Lab results and observationsClinical LOINC – Clinical results and observations

Name partitioned into segments to coordinate with messaging standards

Developed and maintained by the Regenstrief Institute

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Definitions: LOINC

If an observation is a question and the observation value is an answer…

LOINC provides codes for questions

Other terminologies provide codes for answers1

1https://loinc.org/slideshows/lab-loinc-tutorial/files/loinc-overview-and-introduction-current.pdf/index_

html?portal_status_message=Welcome%21+You+are+now+logged+in.19

https://loinc.org/slideshows/lab-loinc-tutorial/files/loinc-overview-and-introduction-current.pdf/index_

Definitions: LOINC

2https://loinc.org/slideshows/lab-loinc-tutorial/files/loinc-overview-and-introduction-current.pdf/index_

html?portal_status_message=Welcome%21+You+are+now+logged+in.

What is my patient’shemoglobin level?718-7:Hemoglobin:MCnc:Pt:Bld:Qn

How fast does mypatient usually walk?41959-8:Walking speed:Vel:1W^mean:^Patient:Qn:Calculate2

LAB LOINC

Clinical LOINC

Answers in SNOMED CT:165447008 mean corpuscular hemoglobin concentration (MCHC) - low (finding)16526500 walks 30-59 meters in 1 minute (finding)

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https://loinc.org/slideshows/lab-loinc-tutorial/files/loinc-overview-and-introduction-current.pdf/index_

Definitions: RxNorm

RxNorm:A standardized nomenclature that provides names and identifiers for clinical drugs

Scope: Clinical drugs: administered to patients for therapeutic or diagnostic intent; eg Injectable solution vs Powder for dilution Purpose: Allow various systems using different drug nomenclatures to share data efficiently at the appropriate level of abstraction

Produced by the National Library of Medicine (NLM).

Semantic Clinical Drug (SCD CUI) for reporting performance measures

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Definitions: CVX, ICF, PHDC, PHIN VADS

CVX

CVX/V- The CVX code is a numeric string, which identifies the type of vaccine product used. Included in the CDC’s national Center for Immunization and Respiratory Diseases (NCIRD)

ICFICF-International Classification of Functioning, Disability, and Health is a classification of the health components of functioning and disability. (Under consideration for revision by IHTSDO/NLM)

PHDC Payor Typology

Payor Typology is a standard that allows consistent reporting of payor data to public health agencies for health care services and research

PHIN-VADS CDC Public Health Information Network (PHIN) Vocabulary Access and Distribution System (VADS) that supports the standards based vocabularies of the PHIN to promote semantic operability and exchange of consistent information. 22

Definitions, ISO, UCUM

ISO 639 ISO 639 represents names of languages

UCUMThe Unified Code for Units of Measure include all units of measures used in international science, engineering, and business. The purpose is to facilitate unambiguous electronic communication of quantities together with their units.

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Definition: Quality Data Model The Quality Data Model (QDM) is an “information

model” that clearly defines concepts used in quality measures and clinical care and is intended to enable automation of electronic health record (EHR) use. It provides a way to describe clinical concepts in a standardized format so individuals (i.e., providers, researchers, measure developers) monitoring clinical performance and outcomes can clearly and concisely communicate necessary information.

The QDM describes information so that EHR and other clinical electronic system vendors can consistently interpret and easily locate the data required 1

1http://www.qualityforum.org/Projects/h/QDS_Model/Quality_Data_Model.aspx24

RecommendationVocabulary Concept QDM Category

SNOMED CT

Allergies Adverse Effect: Allergy

Non-allergic adverse effects, eg intolerance Adverse Effect: Non-allergy

Non-medication Substances eg, latex Substance

Artifacts of communication, eg, med list; clinical summary

Communication*

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SNOMED CT

Disorders, diseases, conditions, problems Condition, Diagnosis,

Problem

Symptoms, eg nausea, vomiting, pain (reported by the patient)

Symptom

Any patient provider interaction, eg phone calls, etc; regardless of reimbursement status

Encounter

Instruments, hardware Device

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SNOMED CT

Results and findings for laboratory results, diagnostic studies, physical exam,

Physical Exam

Laboratory Test

Diagnostic Study (non-laboratory)

Procedures – surgical, physical manipulation

Results and findings for procedures

Procedure

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SNOMED CT

Excepted answers to patient characteristics, experience, preference, risk evaluation, family history, functional status eg answers to assessment instruments, eg patient has a caregiver,

Characteristics

Experience

Preference

Risk Evaluation

Family History

Functional Status

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SNOMED CTAvailable medical equipment System Resources

settings (eg home, SNF) that a patient is released to or receive from; concepts support care coordination

Transfer

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LOINC Assessment instrumentsAssessment questions

Characteristics

Experience

Preference

Risk Evaluation

Family History

Functional Status

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LOINCLaboratory test and Diagnostic study names

Laboratory Test

Diagnostic Study

Staffing Resources eg nursing units System Resources

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RxNorm

Medications that cause allergies Adverse Effect: Allergy

Medications and inert ingredients associated with non-allergic adverse effects eg intolerance Adverse Effect: Non-allergy

Medications administered (excluding vaccines) Medication

CVX Vaccines administered Medication

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ICF* Categories of function Functional Status

UCUM Units of measureDiagnostic Study

Laboratory Test

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HL7

Administrative Gender, Race & Ethnicity, DOB (CDC PHIN-VADS)

Characteristic

Messaging among systemsHealth Record Artifact

EHR capabilities and function, eg e-prescribing System Resource

ISO 639 Preferred languageCharacteristic

Payor topology Payor Characteristic

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Transition VocabulariesVocabulary Concepts Final Date*

ICD-9 CM Diagnoses condition, diagnosis, problem, family history--

Not usable for services provided after 10/1/2013.

ICD-9 CM Procedures Inpatient Encounter; Intervention; Procedure

Not usable for services provided after 10/1/2013.

ICD-10 CM condition, diagnosis, problem, family history;

One year after MU-3 is effective

ICD-10 PCS Inpatient Encounter; Intervention; Procedure


*Final Date, relevant for reporting of quality measure results only. Not relevant for other purposes, eg, claims reporting. 35

Transition VocabulariesVocabulary Concepts Final Date*

CPT Encounter; Intervention; Procedure


HCPCS Communication, Non-lab diagnostic study, Encounter, Intervention, Procedure)


*Final Date, relevant for reporting of quality measure results only. Not relevant for other purposes, eg, claims reporting.. 36

ExamplesDemonstrate with examples-

”Fictitious/mock” measures - used for demonstration purposes only

no association with guidelines, standards of care, measure steward

Demonstrate use of vocabularies rather than comprehensive QDM modeling and logic

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Measure 1 Percentage of patients age 18 years

and older with a diagnosis of peripheral vascular disease, with symptoms of neuropathy, who received an assessment of foot sensation using a standardized assessment tool with findings communicated to primary care physician

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and older with a diagnosis of peripheral vascular disease, with symptoms of neuropathy who received an assessment of foot sensation using a standardized assessment tool with findings communicated to primary care physician

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Percentage of patients age 18 years and older with a diagnosis of peripheral vascular disease, with symptoms of neuropathy who received an assessment of foot sensation using a standardized assessment tool with findings communicated to primary care

Concept/Data Element

QDM Category Vocabulary

Peripheral Vascular Disease Condition/Diagnosis/Problem SNOMED CT (disorder hierarchy)Transition VocabICD 9 CMICD10

Neuropathy Symptoms Symptom SNOMED CT (findings hierarchy)

Assessment of Foot Sensation

Risk Evaluation LOINC(Clinical LOINC)No transition vocabularies*

Foot Sensation Assessment Findings

Physical Exam SNOMED CT (findings hierarchy)No transition vocabularies*

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and older with a diagnosis of peripheral vascular disease who have a foot ulcer and received a culture and sensitivity and were prescribed a 3rd generation cephalosporin

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and older with a diagnosis of peripheral vascular disease who have a foot ulcer and received a culture and sensitivity and were prescribed a 3rd generation cephalosporin

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Percentage of patients age 18 years and older with a diagnosis of peripheral vascular disease who have a foot ulcer and received a culture and sensitivity and were prescribed a 3rd generation cephalosporin

Concept/Data Element

QDM Category Vocabulary

Peripheral Vascular Disease Condition/Diagnosis/Problem SNOMED CT (disorder hierarchy)

Transition VocabICD 9 CMICD10

Foot Ulcer Condition/Diagnosis/Problem SNOMED CT (disorder hierarchy)

Transition VocabICD 9 CMICD10

Culture Laboratory Test LOINC(Lab LOINC)No transition vocabularies*

Sensitivity Laboratory Test LOINC(Lab LOINC)No transition vocabularies*

Third Generation Cephalosporin

Medication RxNorm(cui for the SCD) No transition vocabularies*

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Challenges Gaps in terminology, eg LOINC,

SNOMED CT Transition recommendations,

adoption, traction rather than gaps

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Current SWG Tasksand

Next Steps

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Next Steps*

Current Focus and Next StepsCurrent SWG Focus

Standards

Tools

Distributed Query Networks

C2C Output Summary of Various Approaches taken by Organizations Identification of Key Themes and Industry Best Practices

List of Constraints to analyze Best Practices for QH within the Technical framework

Identify and assign Value Sets for a core set of data elements within the Harmonized QH CEDD as part of the Cross Walk

Align Proposed Technical Expression with Existing Value Set(s) and Vocabulary Task Force Recommendations

Identify standardized approach to store and access Value Set(s)

Dec

2011

– Fe

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ry 2

012

Feb

2012

- TB

D

Conduct Environmental Scan

Develop Technical Expression of C2C Technical Expression of C2C Approach as it Aligns with the Reference Implementation

Identified Value Set Representations for core set of Data Element in the CEDD

Selection of Existing Value Set in Alignment with the QH CEDD

Reference implementation Guidance for QH

Harmonized CEDD and Selected Value Set

Technical Expression of C2C Approach

Value Set Representation

C2C Output / Recommendation

Suggested Inputs Suggested Outputs

Clinical CEDD

Technical

Technical

C2C / Technical

Task Team

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Value Sets

* Steps are not in sequential order

Criteria and Constraints

1. The approach must be easily implemented as part of the Technical Framework. – The Reference Implementation has to easily be able to use the mappings and the

Value Sets .2. Utilize NQF as starter Value Sets per Jacob Reider’s recommendation

– Additional Value Sets can be identified and included as needed3. Value set representation should utilize NQF and the IHE SVS

– Integrating the Healthcare Enterprise -Sharing Value Sets (IHE SVS) Profile can be thought of as a Value Set Repository that houses Value Sets

– IHE SVS provides a standardized, easy to use, RESTful interface to the value set4. Potential mechanisms to import Value Sets as part of the Reference Implementation

should be identified (ex. - Excel or another format?)5. Each participating organization within the query network should consider operational

best practices for ongoing updates and maintenance of Value Set6. Value Set Owners are expected to perform ongoing maintenance of Value Sets

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query health concept-to-codes (c2c) swg meeting #9

Documents

quality data model

presentation timeline

parsimonyclinical quality

reporting of clinical

vocabulary wg mission

steps overview

standard vocabulariesmaximum

standard vocabulariescirca