Overview of ONC HIT Standards Committee Vocabulary Recommendations

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1 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

2 Outline Background & Mission Scope Definitions Recommendations Examples Challenges & Discussion

3 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)

4 Scope Scope: Reporting of clinical-quality measures Facilitate standardized information exchange Out of Scope: Intra-organization information management Reporting to other external entities

5 Desiderata for Standard Vocabularies Circa 1998, JJ Cimino MD, described desiderata for the design of a healthcare vocabulary; Seminal work / Desiderata contributed to WG considerations

6 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

7 Desiderata for Standard Vocabularies Interdisciplinary relevance Minimum necessary Maturity Logical (hierarchical data model vs. flat structure) Technical (eg meaningless identifiers)

8 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

9 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.

10 Vocabulary Summary Recommended SNOMED CT LOINC RxNorm ICF UCUM CVX Transition ICD-9-CM ICD-10-CM ICD-10-PCS Current Procedural Terminology, CPT HCPCS CDC PHIN VADS (HL7) ISO 639 PHDC Payor Typology

11 Vocabulary Summary Recommended SNOMED CT LOINC RxNorm ICF UCUM CVX Transition ICD-9-CM ICD-10-CM ICD-10-PCS Current Procedural Terminology, CPT HCPCS CDC PHIN VADS (HL7) ISO 639 PHDC Payor Typology

12 Definitions: SNOMED CT Systematized Nomenclature of Medicine Clinical Terms A comprehensive clinical terminology developed by the College of American Pathologists (CAP); now owned and maintained by International Health Terminology Standards Development Organization; > 310,000 active concepts > 790,000 active descriptions or names & synonyms > 920,000 relationships -Released semi-annually in Jan & July -Developed & maintained by clinicians

13 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.

14 Definitions: SNOMED CT Incorporated into healthcare applications Manual lookup and coding Transparent to the user

15 Definitions: LOINC Logical Observation Identifiers Names and Codes A universal code system that facilitates exchange, pooling and processing of results; Laboratory LOINC Lab results and observations Clinical LOINC Clinical results and observations Name partitioned into segments to coordinate with messaging standards Developed and maintained by the Regenstrief Institute

16 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 answers 1 1 https://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.

17 Definitions: LOINC What is my patient s hemoglobin level? 718-7:Hemoglobin:MCnc:Pt:Bld:Qn How fast does my patient usually walk? :Walking speed:vel:1w^mean:^patient:qn:ca lculate 2 LAB LOINC Clinical LOINC Answers in SNOMED CT: mean corpuscular hemoglobin concentration (MCHC) - low (finding) walks meters in 1 minute (finding) 2 https://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.

18 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

19 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) ICF PHDC Payor Typology PHIN-VADS ICF-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) Payor Typology is a standard that allows consistent reporting of payor data to public health agencies for health care services and research 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

20 Definitions, ISO, UCUM ISO 639 ISO 639 represents names of languages UCUM The 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.

21 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 1

22 Recommendation Vocabulary Concept QDM Category Allergies Adverse Effect: Allergy SNOMED CT Non-allergic adverse effects, eg intolerance Non-medication Substances eg, latex Adverse Effect: Non-allergy Substance Artifacts of communication, eg, med list; clinical summary Communication*

23 Recommendation Vocabulary Concept QDM Category Disorders, diseases, conditions, problems Condition, Diagnosis, Problem SNOMED CT Symptoms, eg nausea, vomiting, pain (reported by the patient) Any patient provider interaction, eg phone calls, etc; regardless of reimbursement status Instruments, hardware Symptom Encounter Device

24 Recommendation Vocabulary Concept QDM Category Physical Exam SNOMED CT Results and findings for laboratory results, diagnostic studies, physical exam, Procedures surgical, physical manipulation Results and findings for procedures Laboratory Test Diagnostic Study (nonlaboratory) Procedure

25 Recommendation Vocabulary Concept QDM Category Characteristics 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, Experience Preference Risk Evaluation Family History Functional Status

26 Recommendation Vocabulary Concept QDM Category SNOMED CT Available medical equipment settings (eg home, SNF) that a patient is released to or receive from; concepts support care coordination System Resources Transfer

27 Recommendation Vocabulary Concept QDM Category Characteristics Experience LOINC Assessment instruments Assessment questions Preference Risk Evaluation Family History Functional Status

28 Recommendation Vocabulary Concept QDM Category LOINC Laboratory test and Diagnostic study names Laboratory Test Diagnostic Study Staffing Resources eg nursing units System Resources

29 Recommendation Vocabulary Concept QDM Category Medications that cause allergies Adverse Effect: Allergy RxNorm Medications and inert ingredients associated with non-allergic adverse effects eg intolerance Medications administered (excluding vaccines) Adverse Effect: Non-allergy Medication CVX Vaccines administered Medication

30 Recommendation Vocabulary Concept QDM Category ICF* UCUM Categories of function Units of measure Functional Status Diagnostic Study Laboratory Test

31 Recommendation Vocabulary Concept QDM Category Administrative Gender, Race & Ethnicity, DOB (CDC PHIN-VADS) Characteristic HL7 Messaging among systems Health Record Artifact EHR capabilities and function, eg e-prescribing System Resource ISO 639 Payor topology Preferred language Payor Characteristic Characteristic

32 Transition Vocabularies Vocabulary 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 One year after MU-3 is effective *Final Date, relevant for reporting of quality measure results only. Not relevant for other purposes, eg, claims reporting.

33 Transition Vocabularies Vocabulary Concepts Final Date* CPT HCPCS Encounter; Intervention; Procedure Communication, Nonlab diagnostic study, Encounter, Intervention, Procedure) One year after MU-3 is effective One year after MU-3 is effective *Final Date, relevant for reporting of quality measure results only. Not relevant for other purposes, eg, claims reporting..

34 Examples Demonstrate 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

35 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

36 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

37 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 Vocab ICD 9 CM ICD10 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*

38 Measure 2 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 3 rd generation cephalosporin

39 Measure 2 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 3 rd generation cephalosporin

40 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 3 rd generation cephalosporin Concept/Data Element QDM Category Vocabulary Peripheral Vascular Disease Condition/Diagnosis/Problem SNOMED CT (disorder hierarchy) Transition Vocab ICD 9 CM ICD10 Foot Ulcer Condition/Diagnosis/Problem SNOMED CT (disorder hierarchy) Transition Vocab ICD 9 CM ICD10 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*

41 Challenges Gaps in terminology, eg LOINC, SNOMED CT Transition recommendations, adoption, traction rather than gaps

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