healthcare standards? what a concept!

Healthcare  Standards?  What  a  Concept!  

Tomasz  Adamusiak  MD  PhD    

@7omasz  

Tomasz  Adamusiak  MD  PhD  

•  Chair  AMIA  Knowledge  RepresentaEon  and  SemanEcs  WG  

•  Past:  postdoc  at  NLM,  bioinformaEcian  at  EBI  

Conflict  of  interest  disclosure  

•  Pre-­‐sales  and  post-­‐sales  support  for  Thomson  Reuters  Data  Fusion  

Learning  ObjecEves  

•  Describe  the  Meaningful  Use  requirements  and  its  data  standards  

•  Recognize  the  value  of  structured  clinical  informaEon  

•  IdenEfy  challenges  in  interoperability  of  clinical  informaEon  systems  

$30  880  000  000  

Total  payments  for  Medicare  and  Medicaid  Electronic  Health  Record  (EHR)  IncenEve  Programs  (2011  -­‐  July  2015)  

h_p://big.assets.huffingtonpost.com/2013_09_HealthCareCosts11.png  

US.  health  care  system  is  the  most  expensive  and  underperforms  on  most  dimensions  of  performance  

AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US

OVERALL RANKING (2013) 4 10 9 5 5 7 7 3 2 1 11

Quality Care 2 9 8 7 5 4 11 10 3 1 5

Effective Care 4 7 9 6 5 2 11 10 8 1 3

Safe Care 3 10 2 6 7 9 11 5 4 1 7

Coordinated Care 4 8 9 10 5 2 7 11 3 1 6

Patient-Centered Care

5 8 10 7 3 6 11 9 2 1 4

Access 8 9 11 2 4 7 6 4 2 1 9

Cost-Related Problem 9 5 10 4 8 6 3 1 7 1 11

Timeliness of Care 6 11 10 4 2 7 8 9 1 3 5

Efficiency 4 10 8 9 7 3 4 2 6 1 11

Equity 5 9 7 4 8 10 6 1 2 2 11

Healthy Lives

4 8 1 7 5 9 6 2 3 10 11

Health Expenditures/Capita, 2011** $3,800 $4,522 $4,118 $4,495 $5,099 $3,182 $5,669 $3,925 $5,643 $3,405 $8,508

COUNTRY RANKINGS

Top 2*

Middle

Bottom 2*

EXHIBIT ES-1. OVERALL RANKING

Notes: * Includes ties. ** Expenditures shown in $US PPP (purchasing power parity); Australian $ data are from 2010.Source: Calculated by The Commonwealth Fund based on 2011 International Health Policy Survey of Sicker Adults; 2012 International Health Policy Survey of Primary Care Physicians; 2013 International Health Policy Survey; Commonwealth Fund National Scorecard 2011; World Health Organization; and Organization for Economic Cooperation and Development, OECD Health Data, 2013 (Paris: OECD, Nov. 2013).

2004  à  2009  HITECH/ARRA  à  2010  PPACA  

$30  880  000  000  

Total  payments  for  Medicare  and  Medicaid  Electronic  Health  Record  (EHR)  IncenEve  Programs  (2011  -­‐  July  2015)  

Meaningful  Use:  it  paid  to  start  early  

h_p://www.cms.gov/RegulaEons-­‐and-­‐Guidance/LegislaEon/EHRIncenEvePrograms/Downloads/Beginners_Guide.pdf  

Each  stage  has  its  own  set  of  requirements  

Final  rule,  September  4,  2012  

Achieving  Meaningful  Use  CerEficaEon  is  not  straighiorward  

InformaEon  exchange  is  at  the  heart  of  Meaningful  Use  

h_ps://www.cms.gov/RegulaEons-­‐and-­‐Guidance/LegislaEon/EHRIncenEvePrograms/Downloads/EHR_Medicaid_Guide_Remediated_2012.pdf  

Stage  2  

Core  Measures:    12.  Provide  paEents  with  an  electronic  copy  of  their  health  informaEon,  upon  request  13.  Provide  clinical  summaries  for  paEents  for  each  office  visit  14.  Capability  to  exchange  key  clinical  informa>on  

Menu  Measure:    8.  The  EP  (…)  should  provide  summary  care  record  for  each  transiEon  of  care  or  referral  

“unstructured  document”  is  explicitly  prohibited  in  transiEon  of  care  

Electronic  Access  

Clinical  Summaries  

InformaEon  exchange  in  MU  Stage  2  

PaEents   Referring  provider  

Receiving  provider  

Receiving  provider  

Blue  Bu_on  Get  It  •  Find  out  what  kinds  of  health  informaEon  are  available  via  

Blue  Bu_on  and  which  providers  offer  it  .    Check  It  •  Get  advice  about  what  to  look  for  in  your  health  record,  

and  your  right  to  correct  it.    Use  It  •  Discover  what  you  can  do  with  your  health  informaEon  and  

ways  to  safeguard  and  protect  your  health  informaEon  

Structured  Summary  of  Care  

Problem  lists  •  SNOMED  CT  

MedicaEons  •  RxNorm  

Laboratory  tests  •  LOINC  

Procedures  •  SNOMED  CT  •  HCPCS  +  CPT-­‐4  •  CDT  •  ICD–10–PCS  

Consolidated  CDA  provides  templates  for  care  summaries

Medication Information ManufacturedProduct

Medication Activity SubstanceAdministration

Medication Supply Order  ManufacturedProduct

Immunization   SubstanceAdministration  

By إإببنن االلببييططاارر own work - [Public domain], via Wikimedia Commons

Only  structured  informaEon  allowed  in  MU  TransiEon  of  Care  

 <manufacturedProduct  classCode="MANU">      <templateId  root="2.16.840.1.113883.10.20.22.4.23"/>      <manufacturedMaterial>        <code  code="310965"          codeSystem="2.16.840.1.113883.6.88"          codeSystemName="RxNorm"          displayName="Ibuprofen  200  MG  Oral  Tablet">        </code>      </manufacturedMaterial>    </manufacturedProduct>

Only  structured  informaEon  allowed  in  MU  TransiEon  of  Care  

 <manufacturedProduct  classCode="MANU">      <templateId  root="2.16.840.1.113883.10.20.22.4.23"/>      <manufacturedMaterial>        <code  code="310965"          codeSystem="2.16.840.1.113883.6.88"          codeSystemName="RxNorm"          displayName="Ibuprofen  200  MG  Oral  Tablet">        </code>      </manufacturedMaterial>    </manufacturedProduct>

MedicaEon  InformaEon  Template  

RXCUI  

Normalized    Drug  Name  

 Fast  Healthcare  Interoperability  Resources  

•  Aims  to  simplify  implementaEon  without  sacrificing  informaEon  integrity  

•  Derived  from  HL7  RIM  and  other  important  content  models  

•  Intended  to  address  the  most  common  (80%)  interoperability  needs  of  implementers  

•  Because  v3  is  hard  

Medical  expert  systems  date  back  to  the  1970s  

Knowledge  acquisiEon  bo_leneck  

Computer-­‐Assisted  Diagnosis  à    Clinical  Decision  Support  

CDS  is  difficult  because  computers  do  not  understand  text  very  well  

 HISTORY  OF  PRESENT  INQUIRY:      Mr.  Smith  is  a  34-­‐year  old  gentleman  who  presents  at  our  branch  to  obtain  a  car  loan  secondary  to  growing  maintenance  costs  of  his  current  vehicle.  He  otherwise  reports  doing  well.  His  past  financial  history  is  insignificant.  

{vitamin  supplements,  loEon,  hand  saniEzers}  à  

{baby-­‐related  products}  

Target  isn't  just  predicEng  pregnancies:  expect  more  savvy  data-­‐mining  tricks    (Hill,  K.  2012,  February  24)    

Mining  associaEons  in  Electronic  Health  Records  

Diabetes  mellitus  

Yes   No  

Glucohemoglobin  measurement  

Yes   1509   5442  

No   881   99  

PosiEve  associaEon  

Background  reference  

EHR-­‐based  phenome  wide  associaEon  study  in  pancreaEc  cancer.  Adamusiak  T,  Shimoyama  M,  AMIA  Jt  Summits  Transl  Sci  Proc.  2014  Apr  7;2014:9-­‐15  

Expansion  +  associaEon  

31  

CPT-­‐4  83036  

ICD10  E08-­‐E13  

What  is  in  a  paEent  EHR?  

32  

0%   10%   20%   30%   40%   50%   60%   70%  

Other  

Labs  

MedicaEons  

Procedures  

Problems  

Concepts  (7k)  ObservaEons  (2M)  

Hierarchical  expansion:    all  DVT  terms  in  ICD-­‐10-­‐CM  

33  

Child  Concepts  

Caveat:  flat  hierarchy  results  in  disconnected  clinical  contexts  

Find  paEents  with  tuberculosis?    •  010-­‐018.99  TUBERCULOSIS  •  137  Late  effects  of  tuberculosis  •  647.3  Tuberculosis  complicaEng  pregnancy  childbirth  or  the  puerperium  

34  

More  difficult  in  SNOMED  CT  

35  

MulEple  inheritance  

Child  Concepts  

Gap  between  clinical  and  billing  terminology  standards  

In pursuit of a single language

Pieter Brueghel the Elder (1526/1530–1569) [Public domain], via Wikimedia Commons

IntegraEng  terminologies  with  Unified  Medical  Language  System  

Donald A.B. Lindberg, M.D

Clinical Terminologies

UMLS

UMLS  

Exanthema C0015230

SNOMED  CT  

ICD-­‐10-­‐CM  

UMLS  establishes  equivalence  mappings  across  biomedical  terminologies  

SNOMED  CT  

rash NOSICD-10:R21

Cutaneous eruptionSCT:112625008

EruptionSCT:1806006

UMLS  

Exanthema C0015230

SNOMED  CT  

ICD-­‐10-­‐CM  

UMLS  establishes  equivalence  mappings  across  biomedical  terminologies  

SNOMED  CT  

Cutaneous eruptionSCT:112625008

rash NOSICD-10:R21Eruption

SCT:1806006

Expansion  in  UMLS  across  MU  sources  

41  

Diabetes  mellitus  without  menEon  of  complicaEon,  type  II  or  unspecified  type,  not  stated  as  uncontrolled  

ICD-­‐9  

ICD-­‐10  

SNOMED  CT  

NDF-­‐RT  

SituaEon  with  explicit  context  

Metabolic  diseases  

roots:  

Ontological  six  degrees  of  Kevin  Bacon  

Acute  myocardial  infarcEon  

Myocardial  ischemia  

 Vascular  Diseases  

Disorder  of  so�  Essue  

Collagen  Diseases  

ConnecEve  Tissue  Diseases  

Epidermal  and  dermal  condiEons  

Skin  and  subcutaneous  Essue  disorders  

Dermatologic  disorders  

Open  issue:  reconciling  lab  orders  with  results  

Clinical  Laboratory  

Hemoglobin  A1c/�Hemoglobin  

.total  in  Blood  by  HPLC  LOINC:17856-­‐6  

Hemoglobin;  glycosylated  (A1C)  

CPT-­‐4:83036  

43  

ExtracEng  geneEc  informaEon  out  of  EHR  is  a  major  challenge  

44  

•  PLEASE  INFORM  **NAME[ZZZ]  OF  MTHFR  MUTATION.  

•  WE  WILL  NEED  ADDITIONAL  TESTING:  FOR  NOW,  FOLATE,  SAME,  MTHFR.  

•  MARGINAL  PLACENTA  PREVIA        MTHFR  MUTATION,  HETERO  X  2  C677T  AND  A1298C          

•  UTI  COMPLICATING  PREGNANCY        HOMOZYGOUS  FOR  C677T  POLYMORPHISM  OF  MTHFR        1  COPY  OF  MTHFR  MUTATION  A1298C  DETECTED  

LOINC  is  complex  

45  

1  result  

LOINC  is  an  ideal  candidate  for  DL  because  of  its  composiEonal  structure  

46  

Part  Type     Part  Name    Component   Crea>nine    Property   MCnc  Time   Pt    System   Ser/Plas  Scale   Qn    

2160-­‐0     CreaEnine  [Mass/�volume]  in  Serum  or  Plasma  

(has_component  some  Crea>nine)  and  (has_property  some  MCnc)  and  (has_5me_aspect  some  Pt  )  and  (has_system  some  Ser/Plas)  and  (has_scale  some  Qn)  

Code:  

Parts:  

DL  defini>on:  

Used  SNOMED  CT  to  enrich  LOINC  hierarchy  

47  

Urine  

78014005  

Body  fluid  32457005  

Body  Fluids  C0005889  

Urine  C0042036  

owl:EquivalentTo  

owl:EquivalentTo  

ISA  

Body  fluid  LP30504-­‐2  

Urine  LP7681-­‐2  

MulEaxial   Inferred  

OBS  Glucose  

OBS  Glucose|  Urine  

Separated  codes  and  parts  and  defined  corresponding  observaEons  

48  

Protein  &  Glucose  panel  in  Urine  by  

Test  strip  

Glucose  

Glucose  |  Urine   Urine  

≡

≡

Glucose  in  10  hour  Urine  

Glucose  in  Urine  by  Test  

strip  

≡

≡

≡

1.  Created  logical  definiEons  2.  Classified  the  ontology  with  a  reasoner  

49  

OBS  Glucose  |  Urine  

≡

Glucose  in  10  hour  Urine  

≡ has_component  some  Glucose  and  has_property  some  Arbitrary  Concentra5on  and  has_Eme_aspect  some  Point  in  5me  (spot)  and  has_system  some  Urine  and  has_scale  some  Ord  and  has_method  some  Test  strip  

has_component  some  Glucose  and  has_system  some  Urine  DL  definiEon  

DL  definiEon  

Inferred  

Query  expansion  with  subsumpEon  reasoning  

50  

DL:  189  results  

Sugars  /sugar  

metabolism  

Carbohydrates  

Carbohydrates  |  Urine  

16550-­‐6  

Glucose  

Glucose  |  Urine  

2350-­‐7  

Carbohydrates  

Carbohydrates  |  Urine  

Glucose  |  Urine  

2350-­‐7  

Fructose  |  Urine   16550-­‐6  

1  result  

9  006  conc

epts  

693  256  co

nnecEons

Quality  assurance  in  LOINC  using  descripEon  logic    PMID:23304386  

SNOMED CT as possible universal language of healthcare

•  Updated  Technology  Preview  of  the  LOINC-­‐SNOMED  CT  CooperaEve  Project  –  September  2015  15k  LOINC  –  SNOMED  CT  expressions  h_p://www.nlm.nih.gov/research/umls/licensedcontent/snomedciiles.html  

•  Integration with ICD-11 h_p://www.ncbi.nlm.nih.gov/pubmed/23920573  

COST?  

$1.3  trillion  

Thank  You