Beth Ann Fiedler, Brian Goldiez, Teresita Sotomayor, Joshua Estes, Donald A. Washburn
U.S. Army Research, Development and Engineering Command
Developing Data Exchange Protocol Standards for
Healthcare Simulators
Presentation Date: May 11, 2011
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Outline
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Introduction
Purpose
IEEE1278 Standard
Facilitating Interoperability and Standards for Simulators in
Healthcare
Key Elements of Patient Information and Medical Systems
The Role of the Injury Severity Score
Missing Parameters and Source for Medical Simulator
Information
– Medical Coding Systems
– Data Set Coding Structures
– DICOM
Conclusion
References
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Introduction
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MedBiquitous, a nonprofit organization founded by Johns Hopkins Medicine, has
developed a Virtual Patient (VP), ANSI VP.10.1-2010
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The US Army is interested in prototyping a structure to exchange physiological
information between simulators
– Leveraging existing standards and programs
– Consistent and growth with existing simulators
– Useful by non-DoD entities
– This structure is currently being considered by the SISO for IEEE balloting
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Creation of system architecture for translation of clinical conditions to Virtual Patient
– IEEE1278 Protocol Data Units
– DICOM Hierarchical Client-Server System Architecture
– Current medical coding system (e.g., ICD-9, ICD-10, SNOMED-CT, DRG, and
CPT)
• Medical history
• Integrated and human readable virtual patient chart
• In situ simulation → point of injury data access
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Purpose
• Goal: Create an interoperability standard amongst
computer based medical simulators and between medical &
other simulated entities
• Benefit: Potential to increase the functionality, utility,
training effectiveness, and realism needed to properly train
and maintain proficiency among medical professionals in
both the private and government sectors
• Opportunity: Create standard interchange protocols.
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IEEE 1278 Distributed
Interoperable Simulation (DIS)
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IEEE 1278 Distributed Interactive Simulation (DIS)
– Interchange between virtual simulators communities since 1995
• Utilizes Protocol Data Units (PDUs)
• Multiple connection strategies, real time, no central clock, uses a heart beat, dead
reckoning, etc.
• Built from DARPA SIMNET Program
– Contains Entity State PDU (which includes life forms)
• Opportunity for Enhanced Medical Relevance
• DICOM PDUs
• Medical Code PDUs
– Simulation Interoperability Standards Organization (SISO) manages and
ballots changes for the IEEE
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Compatible with Army’s Program Executive Officer – Simulation, Training and
Instrumentation (PEO-STRI)
– Leverages Synthetic Environment Core (SE CORE)
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Facilitating Interoperability and
Standards for Simulators in Healthcare
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Protocol Data Units (PDUs)
– Data messages passed between network simulation applications
– IEEE Standard 1278.1, Draft 15 contains 60 PDU instances
– Proposed Virtual Patient information and data
• Leverages Medbiquitous Virtual Patient
• Entity State PDU: low fidelity data about VP using Variable Parameter
• Attribute PDU: higher fidelity info about VP via its Attribute Records
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Entity State PDU
– Defines all entities in the simulated environment (e.g., Life Form PDU)
– Basic Patient Data
– Physiological Data
Current design use cases
– Transfer ownership
– Supply consumables
– Partial control of parameters
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Facilitating Interoperability and
Standards for Simulators in Healthcare
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Variable Parameter
– Used by Entity State PDU to store basic information
– 128 bits in length, holds pertinent virtual patient information
– Lower-fidelity information
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Attribute Record
– Similar to Variable Parameter records with exceptions
• Attribute Records are not part of an Entity State PDU
• Attribute Records have no bit limitations (infinite storage capacity)
• Attribute Records are useful for high fidelity patient data
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Facilitating Interoperability and
Standards for Simulators in Healthcare
Figure 3: The Extended Lifeform Basic Attributes Variable Parameter record. This data
structure is used to hold lower-fidelity virtual patient data inside of an Entity State PDU.
Figure 1: The 11
physiological systems
as represented by
Attribute Records (IEEE
1278). These records
hold higher-fidelity
virtual patient data.
Figure 2: A closer look at the Cardiovascular
System Attribute Record. Note that the
parameters are separated into 64-bit blocks.
Figure 4: A diagram outlining one possible method for “sharing ownership”
of a virtual patient. The main steps include: 1)Creating and copying a
patient (so that one exists in each application) and 2) Querying and setting
patient information so that both patients’ statuses are the same.
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Our Focus: Conveying Additional
Relevant Information
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Significant gap in translating clinical conditions to the Virtual Patient (VP)
Existing healthcare medical coding systems may provide the basis to
demonstrate dynamic patient episodes of care through the expression of
physiological conditions supporting the current state of the VP
– Clinical conditions and other patient data from actual/simulated from medical
service encounters incorporated into medical simulation training
• Triage
• Physician office visits
• Hospital emergency
• Surgical procedures
Current Proposition
– Medical codes can be reverse engineered to create a virtual chart
• Specific patient
• A class of patients
– Access to images can augment codes
– Data can be packaged into PDUs.
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Medical Coding Systems
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International Classification of Diseases, Clinical Modification,9th Revision (ICD-9-CM)
– US payer system developed by AHA, AHIMA, NCHS
– Three to five digit field length with variations
• External Cause of Injury (E)
• Reason for Encounter (V)
• Morphology (M)
– 13,000 codes in ICD-9-CM Diagnosis Volumes 1 and 2
– 3,000 codes in ICD-9-CM Procedure Coding System Volume 3
– Classification expansion prohibited due to data structure
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Medical Coding Systems
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International Classification of Diseases, Clinical Modifications, 10th Revision
(ICD-10-CM/PCS)
– Consists of Clinical Modification (CM) and Procedures Coding System (PCS)
– Dominant payer system outside US, expandable
– Three to seven alphanumeric digits
• External Cause of Injury (ICD-9 E Codes) embedded in new structure
• Reason for Encounter (Z) from ICD-9 V Codes
• Morphologies (C, D)
– CMS projected change October 2013 developed in US by AHA, AHIMA,
CDC, CMS
– 68,000 codes ICD-10-CM consolidates ICD-9 V1 and V2
– 72,000 codes ICD-10-PCS replaces ICD-9 V3
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Medical Coding Systems
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Systemized Nomenclature of Medicine, Clinical Terms (SNOMED-CT)
– Provider system developed by CAP to capture primary diagnosis
– Four to nine digit numeric codes, first character alphanumeric
– 366,170 Terminologies
– One million English language descriptions
– 1.46 million semantic relationships
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Current Procedural Terminology (CPT)
– Payer system for non-hospital physician services developed by AMA
– Five digit standard, first character alphanumeric
– Symbol and numeric modifiers to reduce payment time
– 7800 codes
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Diagnostic Related Groups (DRG)
– Internal facility system determines resource utilization developed by CMS
– 500 Medical/Surgical Groups, 1,200 Subclasses
– Medicaid Severity MS DRG common three to five digit codes*
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Data Set Coding Structures
Medical Code System
General Coding Alphanumeric Options
ICD-9-CM
-Diagnosis
-Procedure
-Sub classifications
Character 1 (E, M, U, or V) or null;
Characters 2-4 (numeric); Character 5
(numeric or alpha-x); Character 6 (numeric);
Character 7 (forward slash /); and Character 8
(numeric).
ICD-10-CM/PCS
-Diagnosis
-Procedure
Character 1-7 (alphanumeric).
SNOMED-CT
Character 1 (alphanumeric), Characters 2-9
(numeric).
CPT
Character 1 (alphanumeric); Characters 2-5
(numeric); Character 6 (symbol); Characters
7-8 (numeric)
MS DRG, All Patient AP
DRG.
All Patient Refined
APR DRG
Characters 1-5 (numeric).
Characters 1-3 (numeric), Character 4(alpha);
Characters 5-6 (numeric).
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Enhanced Medical PDU
Designed to support conveyance of data between disparate systems
Not the manipulation at either end point
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Data Set Coding Structures
Figure 1: Medical Codes Attribute PDU
Proposed MEDICAL
CODING SET PDU (Partial)
Group
Field
Range
Number of Bits
Precision
Record
Type
N/A
32-bit enumeration
N/A
Record
Length
N/A
16-bit unsigned integer
N/A
Padding
N/A
8-bit unused
N/A
Number
of ICD
Codes (N)
0-255
8-bit unsigned integer
1 Code
ICD Code
Record
Type
Not specified, Primary
ICD-9-CM, ICD-9-E, ICD9-M, ICD-9-PCS, ICD-9-U,
ICD-9-V, Primary ICD-10CM, ICD-10-PCS, ICD-10C, ICD-10-D, or ICD-10-Z
8-bit enumeration
N/A
International
Classification of
Diseases (ICD)-9 & 10
Record
ICD Code Record (N
Records)
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Digital Images and Communication in
Medicine (DICOM)
• ISO-OSI model of communication
• Established by ACR and NEMA in 1982
– Initial use: transfer of radiology data, data storage
– Current use: Network Protocol Digital Archive and Communication System
• Non radiology expansion
• 20 Working Groups (e.g., nuclear medicine, cardiology)
• International Acceptance
• Opportunity to optimize DICOM protocols
– Establish workflow
– Create unique VP data exchange identifiers
• Permit computer-based mannequins or simulator communication
• Permit communication between clinical equipment modalities and VP
– Magnetic Resonance Imaging (MRI)
– Computed Topography (CT)
– Ultrasounds (US)
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Digital Images and Communication in
Medicine (DICOM)
Proposed DICOM
PDU
Figure
1: DICOM Image Record for Attribute PDU
Group
Field
Range
Number of Bits
Precision
Record
Type
N/A
32-bit enumeration
N/A
Record
Length
N/A
16-bit unsigned integer
N/A
Padding
N/A
16-bit unused
N/A
DICOM Image Record
(1664 bits)
Note: The DIS Entity ID included in the
header will be converted into the DICOM
Patient ID before accessing the images
Study Instance UID
(Optional, nullterminated)
DICOM
Study
Instance
UID
0 – 9,
or
Period
64 character ASCII string (512 bits, nullterminated)
N/A
Series Instance UID
(Optional, only if Study
Instance UID is valid,
null-terminated)
DICOM
Series
Instance
UID
0 – 9,
or
Period
64 character ASCII string (512 bits, nullterminated)
N/A
SOP Instance UID
(Optional, only if Series
Instance UID is valid,
null-terminated)
DICOM
SOP
Instance
UID
0 – 9,
or
Period
64 character ASCII string (512 bits, nullterminated)
N/A
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Digital Images and Communication in
Medicine (DICOM)
Figure 5. Proposed Protocol Data Units for Digital Images and Communication in
Medicine (DICOM) Element Indicating Image Hierarchy
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Status and Plans
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Feedback being sought
– Healthcare user community
– Manufacturers
– Regulators/Decision Makers
Basic Life Form PDU being prepared for IEEE review & balloting
– Presented at IMSH (Jan ‘11)
– Presented at SIW (Apr ‘11)
Attribute PDU for physiology being prepared for IEEE review & balloting
– Presented at IMSH (Jan ‘11)
– Presented at SIW (Apr ‘11)
Prototyping underway with data converters
– General physiology model
– Simulator manufacturer’s model
Coding and DICOM being prepared for IEEE review & balloting
Tutorial for I/ITSEC being prepared for review
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Conclusions
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Short Term Benefits
– Increased VP Capabilities
• Transmit entity information
• Transfer an entity between multiple simulation applications
• Approximate impact on entity’s in proximity to a simulated explosion
– Flexible roadmap to incorporate medical coding systems that expand the
interoperability standards in healthcare simulation
– Restores capture of most condition information
• Potential to overcome inability to capture all written, verbal, and
interpretive information not presently translated in billing/payment driven
medical coding systems
Long Term Benefits
– Overcomes present inability to view dynamic body changes in patient injured
condition
– Growth as simulators grow
– Recognized standard body for developers, users, managers
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References
Advanced Technology Applications for Combat Casualty Care (ATACCC). Proceedings of the ATACCC
Conference August 16-19, 2010. St. Pete Beach, FL.
Alexander, S., Conner, T., & Slaughter, T. (2003). Overview of inpatient coding. American Journal of
Health-System Pharmacy, 60(21 Suppl 6): S11-4.
Cardillo, E., Eccher, C., Serafini, L. & Tamilin, A. (2008). Proceeding AIMSA '08 Proceedings of the 13th
international conference on Artificial Intelligence: Methodology, Systems, and Applications Springer-Verlag
Berlin, Heidelberg. doi>10.1007/978-3-540-85776-1_26 .
Centers for Medicare & Medicaid Services, Department of Health and Human Services. Medicare program;
hospital inpatient prospective payment systems and FY 2005 rates. Final rule. Federal Register 69, no. 154
2004a (August 11); 48916–49781.
Institute of Electrical and Electronics Engineers, Inc. IEEE Standard P1278.1/D15. (2010, April). IEEE Draft
Standard for Distributed Interactive Simulation—Application Protocols.
Pianykh, O. S. (2008). Digital Imaging and Communications in Medicine (DICOM): a Practical Introduction
and Survival Guide. Berlin: Springer.
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Back up Charts
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The Role of the Injury Severity Score
(ISS)
• ISS Primary role Pre-Treatment
– Triage
– Chief Complaint
– Review of Systems
• Comparable Acute Care Case Mix Complexity
– Assessment Post Treatment Historical Analysis
• Resource utilization
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Key Elements of Patient Information and
Medical Service
• Creation of a virtual chart
• PDU Data Source: 4 patient data elements
1. Chief Complaint
2. Review of Systems (body)
3. History of Present Illness
4. Medical History
• 1 & 2 focus of current efforts
• 3 & 4 verbal or scripted (technological gap in IEEE 1278)
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Digital Images and Communication in
Medicine (DICOM)
http://www.mfdigital.com/images/dicom.jpg
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