Defining Interoperability Standards
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1 DEPARTMENT OF VETERANS AFFAIRS Defining Interoperability Standards Brian P. Burns Office of Information & Technology
2 Agenda Interoperability Overview What Is It and What Drives Us? Terminology Standardization Example Interoperability Evolution Why Pursue Health Data Interoperability? Who Sets the Standards? HHS Office of the National Coordinator for Health IT (ONC) ONC, DoD, and VA Collaborate for Interoperability Management of Health Data Interoperability 2
3 EHR Modernization Guiding Principles Design a patient centric system focusing on quality, safety, and patient outcomes that meet readiness objectives Standardization of clinical and business processes across organizations Flexible and open, enterprise healthcare solution for stationary and mobile environments Clinical business process reengineering, adoption, and implementation over technology Configure not customize Decisions shall be based on doing what is best for clinical care as a whole not a single individual area Decision making and design will be driven by frontline care delivery professionals Drive toward rapid decision making to keep the program on time and on budget Provide timely and complete communication, training, and tools to ensure a successful deployment Build collaborative partnerships to advance national interoperability Enable full patient engagement in their health 3
4 Interoperability Overview Interoperability*: the ability of two or more systems or components to exchange information and to use the information that has been exchanged For interoperability, data needs to conform to standards for three distinct aspects: Terminology Content Structure Exchange Methods NDAA 2014 Sec 713: Electronic Health Records of the DoD and VA The Secretary of DoD and the Secretary of VA shall each ensure that the EHRs of the DoD and VA are interoperable with an integrated display of data, or a single EHR, by complying with the national standards and architectural requirements identified by the IPO of the Departments in collaboration with the Office of the National Coordinator for Health Information Technology of the Department of Health and Human Services *IEEE Standard Computer Dictionary: A Compilation of IEEE Standard Computer Glossaries (New York, NY: 1990). **Center for Information Technology Leadership Reference: 4
5 Interoperability Evolution Semantic Interoperability Syntactic Interoperability Non Electronic Paperbased, mail, or phone calls Technical Interoperability Fax, , scanned documents, PDFs Indexed documents and images; data not standardized and requires translation Structured messages containing standardized and coded data; transfer without translation DoD/VA Examples Paper record carried from DoD to VA AHLTA Chart Print PDF files BHIE Share VLER Health 5
6 Terminology Standardization Example Semantically interoperable data is both exchanged between systems and normalized within a known context, so systems know if data has the same meaning Data Domain DoD Local Name & Code VA Local Name & Code Private Sector System Local Name &Code Vital Signs Pulse (NCID 2051) Heart Rate (VUID ) HR (local text entry) VA Maps Mapped to National Standard Codes Standard Name (LOINC) Heart rate 6
7 Why Pursue Health Data Interoperability? The new transformational power of data in our everyday lives is coming to medicine We receive healthcare from multiple care providers across different health networks and geographic areas Complete and accurate records during evaluations are key for quality and efficiency in healthcare 7
8 Who Sets the Standards? 23 standards organizations 8
9 HHS Office of the National Coordinator for Health IT (ONC) ONC is the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health IT and electronicallyexchanged health information The Federal Health Architecture (FHA) is an E Government Line of Business initiative managed by ONC The Standards & Interoperability Framework is one approach adopted by ONC s Office of Standards & Interoperability to enable harmonized interoperability specifications 9
10 Collaboration for Interoperability Collaboration Private Sector Partners 10
11 Management of Health Data Interoperability Determination Track and shape evolving HDI standards and federal healthcare policy Select health data interoperability standards Adoption Identify and prioritize business use cases Provide HDI technical guidance, i.e. architecture, privacy, and security Define monitoring and measurements associated with HDI objectives Sustainment Perform monitoring and measurement Perform external reporting Perform configuration management Implementation Incorporate selected standards into HDI capabilities Perform end end HDI functional verification Deploy HDI capability 11
12 Who Sets the Standards? Organization Standards Organization Standards American College of Radiology and National Electrical Manufacture Associate DICOM International Health Terminology Standards Development Organization American Medical Association CPT-4 International Organization for Standardization American National Standards Institute Accredited Standards Committee X12 SNOMED CT ISO 3166 Country Codes X12N National Cancer Institute (NCI) NCI Thesaurus American Psychiatric Association DSM National Council for Prescription Drug Programs (NCPDP) American Society for Testing and Materials Centers for Disease Control and Prevention (CDC) Centers for Medicare and Medicaid Services (CMS) CCR CVX, MVX (Vaccine) NPI, HPID/OEID, HCPCS, RARC National Library of Medicine & National Institutes of Health (NIH) National Uniform Billing Committee (NUBC) National Uniform Claim Committee (NUCC) Council of Affordable Quality Healthcare CAQH Core Public Health Data Standards Consortium (PHDSC) U.S. Food and Drug Administration (FDA) NDC, MDR Radiological Society of North America (RSNA) Health Level 7 HL7, CDA, C- CDA, CCD, FHIR Institute of Electrical and Electronics Engineers (IEEE) Regenstreif Institute Script 10.6 RxNORM, NDF- RT, UMLS, SNOMED CT UB-04 Health Care Provider Billing Code Sets PHDSC Source of Payment Typology RadLex ISO / IEEE World Health Organization (WHO) ICD LOINC, UCUM 12
13 Legacy Data and Standardization: Data Domains and Representative Prioritization Data Domain Proposed National Standard Terminology (for primary data element) Allergies (multiple types) -Drug UMLS CUIs (or RxNorm) -Food/Substance- UNII -Drug Classes- NDF RT Medications RxNorm August 6, 2012 Release Immunizations CVX Problem Lists SNOMED CT (US Ext) March 2012 edition Vital Signs LOINC vitals subset Documents (many types) LOINC Document Types Results - Lab Chemistry & Hematology LOINC v2.40 Results - Lab Anatomic Pathology LOINC v2.40 Results - Lab Microbiology LOINC v2.40 Results - Radiology Reports Clinical LOINC Encounter Data Appointments Encounter DXs ICD-10 or SNOMED CT Encounter Data Admissions Encounter DXs ICD-10 or SNOMED CT Procedures CPT4/HCPCS or ICD-10-PCS (either) Demographics Ethnicity & Race OMB/CDC Race codes Preferred Language -ISO alpha-3 codes Social History SNOMED CT (including smoking status subset) Family History SNOMED CT 2012 edition Scanned & Imported Paper Records & Non-Radiology Images Clinical LOINC (for type); PDF-A, Text, JPEG, etc. for file type Plan of Care- Pending Orders -Med Orders (RxNorm) -Lab Orders (LOINC) (multiple types) -Rad Orders (LOINC) -Consult Orders (none) Radiology Images DICOM Other Past Medical History (e.g., travel) Uncertain (possibly SNOMED CT) Payers Insurance Types LOINC Questionnaires (general & standard instruments) None/Uncertain Pre- & Post-Deployment Assessments None Functional Status SNOMED CT Providers Provider Types NUCC Taxonomy Advance Directives (metadata only) SNOMED CT Advanced Directives Type Medical Equipment Uncertain-UMDNS-SNOMED CT Additional C-CDA Clinical Data Elements Will vary by data element SLIDE WIL BE UPDATED 13
14 ICIB Primary Data Element National Standard Terminology DoD/VA IPO Status Data Domain Priority Drug Allergen RxNorm Required UMLS Interim 1 Allergies (multiple types) Drug Class Allergen NDF RT Emerging Food Allergen SNOMED CT Emerging Ingredient UNII Emerging 2 Medications Medication RxNorm Required 3 Immunizations Vaccine Administered CVX Required 4 Problem Lists Problem SNOMED CT Required 5 Vital Signs Vitals Type LOINC (vitals subset) Required 6 Documents (many types) Document Type LOINC (Document Types) Required 7 Results - Lab Chemistry & Hematology Result Type LOINC Required 8 Results - Lab Anatomic Pathology Result Type LOINC Required 9 Results - Lab Microbiology Result Type LOINC Required 10 Results - Radiology Reports Result Type LOINC Required CPT4 Interim Encounter Type CPT4 Required 11 Encounter Data Appointments Encounter Diagnosis (Dx) SNOMED CT Required 12 Encounter Data Admissions Encounter Type CPT4 Required Encounter Diagnosis (Dx) SNOMED CT Required Procedure Type-Outpatient/Clinician CPT4/HCPCS Required 13 Procedures Procedure Type-Hospital ICD-10 PCS Required ICD-9 CM Interim 14 Demographics Ethnicity & Race OMB/CDC Race codes Required Preferred Language ISO alpha-3 codes Required 15 Social History Social History Entry SNOMED CT (including smoking status subset) Required 16 Family History Family History Entry SNOMED CT Required 17 Scanned & Imported Paper Records & Non-Radiology Images Document Type LOINC Required 18 Plan of Care- Pending Orders (multiple types) Legacy Data and Standardization: Data Domains and Representative Prioritization Med Order Item RxNorm (Med Orders) Required Lab Order Item LOINC Required Rad Order Item LOINC Required CPT4 Interim Consult Order Item None No National Standard 19 Radiology Images Image Format DICOM (a format, not a terminology) No National Standard Other Past Medical History (e.g., travel) 20 Payers Insurance Type ASC X12N (Health Insurance Type) Required 21 Functional Status Functional Status entry SNOMED CT Emerging 22 Providers Provider Types NUCC Taxonomy Required 23 Advance Directives (metadata only) Advanced Directives Type SNOMED CT Required 24 Medical Equipment Medical Equipment Type UMDNS-SNOMED CT Emerging 25 Questionnaires (general & standard instruments) Document Unstructured Document with LOINC Document Type Interim 14
15 Current Data Sharing Mechanisms Clinical Data Repository / Health Data Repository (CHDR) Bi Directional Health Information Exchange (BHIE) Virtual Lifetime Electronic Record (VLER) Joint Legacy Viewer (JLV) Since 2003: DoD VA bidirectional exchange of computable outpatient information, including drug interaction and allergies for patients who receive care from both DoD and VA facilities BHIE Since 2004: Realtime, read only viewing of DoD and VA patient clinical data via BHIE Share, BHIE AHLTA, and BHIE DoD Adaptor FHIE Since 2002: Monthly transfer of discharged service members clinical data Since 2009: Allows public and private sector health care providers secure access to a patient s health record. Enhances data sharing to create more interoperability inside and outside of the DoD and VA Since 2013: Provides integrated view of standardized / normalized patient healthcare information, regardless of where data is stored in DoD and VA from DoD to VA 15
16 JLV Viewer A viewer provides the ability for an end user to access and view stored information. The viewer is a graphical user interface and, in conjunction with a server or service, provides access control for authorized individuals using secure transport protocols and protects stored data. Required for NDAA Compliance 15 Domains Functionality duplicated by JLV 2 Domains 5 Domains JLV HAIMS VLER BHIE SHARE BHIE AHLTA Clinical Data Domains Allergies Documents Immunizations Results Lab Chemistry & Hematology Medications Problem Lists Vital Signs Results Lab Anatomic Pathology Results Lab Microbiology Results Radiology Reports Social History Family History Other Past Med History Plan of Care Pending Owners Encounter Data Admissions Encounter Data Appointments Procedures Demographics Payers Providers Scanned and Imported Paper Records Radiology Images 16
17 Summary The goal is a single, integrated view of a patient record, regardless of where care is originated or provided 17
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