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

$1.3 trillion

Thank You