Special Topics in Vendor-Specific
Systems
Vendor Strategies for Terminology,
Knowledge Management, and
Data Exchange
This material (Comp14_Unit6) was developed by Columbia University, funded by the Department of Health and Human
Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.
Vendor Strategies for Terminology,
Knowledge Management, and Data
Exchange
Learning Objectives
• Define what is meant by interoperability
• Describe commercial EHR vendor
strategies for terminology and knowledge
management, and how these impact
interoperability
• Describe how these concepts facilitate the
use of personal health records
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Interoperability
• If I’m faxed a discharge summary which I can read, is that
interoperable, since it’s human interpretable? If I’m sent an
electronic note via email that notes “Allergy to MS”, is that
interoperable? Of course MS could mean Morphine Sulfate,
Magnesium Sulfate, or even Minestrone Soup. If I’m sent an
electronic message which has an agreed upon format, a standard
vocabulary, and a set of business rules which enable me to take
action, is that interoperable? i.e. Your patient is allergic to
medication NDC Code 123456789. Administration will cause a
SEVERE reaction with HIGH CONFIDENCE. My e-Prescribing
software could use this information to display a warning alerting me
to the issue and could suggest an effective alternative medication.
– John D. Halamka MD, MS, Chair, Health Information Technology
Standards Panel (HITSP)
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Three Types of Interoperability:
•
Technical
–
•
physical conveyance of a ‘payload’
Semantic
–
•
communication of consistent meaning
Process
–
integration into an actual work setting
assuring the systems’ usability and
usefulness
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Technical Interoperability
• If I’m faxed a discharge summary which I can read, is that
interoperable, since it’s human interpretable? If I’m sent an
electronic note via email that notes “Allergy to MS”, is that
interoperable? Of course MS could mean Morphine Sulfate,
Magnesium Sulfate, or even Minestrone Soup. If I’m sent an
electronic message which has an agreed upon format, a standard
vocabulary, and a set of business rules which enable me to take
action, is that interoperable? i.e. Your patient is allergic to
medication NDC Code 123456789. Administration will cause a
SEVERE reaction with HIGH CONFIDENCE. My e-Prescribing
software could use this information to display a warning alerting me
to the issue and could suggest an effective alternative medication.
– John D. Halamka MD, MS, Chair, Health Information Technology
Standards Panel (HITSP)
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Technical Interoperability:
Messaging Standards
• Health Level Seven (HL7)
– All-volunteer, non-profit organization involved in development of international
healthcare standards
• HL7 and its members provide a framework (and related standards)
for the exchange, integration, sharing, and retrieval of electronic
health information.
MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4|200202150930||ORU^R01|CNTRL-3456|P|2.4<cr>
PID|||555-44-4444||EVERYWOMAN^EVE^E^^^^L|JONES|19620320|F|||153 FERNWOOD DR.^
^STATESVILLE^OH^35292||(206)3345232|(206)752-121||||AC555444444||67A4335^OH^20030520<cr>
OBR|1|845439^GHH OE|1045813^GHH LAB|15545^GLUCOSE|||200202150730||||||||| 555-555555^PRIMARY^PATRICIA P^^^^MD^^|||||||||F||||||444-44-4444^HIPPOCRATES^HOWARD
H^^^^MD<cr>
OBX|1|SN|1554-5^GLUCOSE^POST 12H
FST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F<cr>
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Semantic Interoperability
• Health Level Seven (HL7)
– All-volunteer, non-profit organization involved in development of
international healthcare standards
• HL7 and its members provide a framework (and related standards)
for the exchange, integration, sharing, and retrieval of electronic
health information.
MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4|200202150930||ORU^R01|CNTRL-3456|P|2.4<cr> PID|||555-444444||EVERYWOMAN^EVE^E^^^^L|JONES|19620320|F|||153 FERNWOOD DR.^
^STATESVILLE^OH^35292||(206)3345232|(206)752-121||||AC555444444||67-A4335^OH^20030520<cr>
OBR|1|845439^GHH OE|1045813^GHH LAB|15545^GLUCOSE|||200202150730||||||||| 555-55-5555^PRIMARY^PATRICIA
P^^^^MD^^|||||||||F||||||444-44-4444^HIPPOCRATES^HOWARD H^^^^MD<cr>
OBX|1|SN|1554-5^GLUCOSE^POST 12H FST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F<cr>
HL-7 Table: Sex
Value
Description
Item #
F
Female
1
M
Male
2
O
Other
3
U
Unknown
4
Table 1.1
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Semantic Interoperability
• If I’m faxed a discharge summary which I can read, is that
interoperable, since it’s human interpretable? If I’m sent an
electronic note via email that notes “Allergy to MS”, is that
interoperable? Of course MS could mean Morphine Sulfate,
Magnesium Sulfate, or even Minestrone Soup. If I’m sent an
electronic message which has an agreed upon format, a standard
vocabulary, and a set of business rules which enable me to take
action, is that interoperable? i.e. Your patient is allergic to
medication NDC Code 123456789. Administration will cause a
SEVERE reaction with HIGH CONFIDENCE. My e-Prescribing
software could use this information to display a warning alerting me
to the issue and could suggest an effective alternative medication.
– John D. Halamka MD, MS, Chair, Health Information Technology
Standards Panel (HITSP)
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Special Topics in Vendor-Specific Systems
Vendor Strategies
8
Semantic Interoperability:
Terminology Standards
• How many ways to say “heart attack”?
– Easy for clinicians, hard for computer systems
– Communication among & within electronic systems  must speak common
“language”
• Richness & variety of medical concepts are barriers to formulating
standardized clinical terminologies:
– ICD-9 (International Classification of Diseases) [WHO]: Diagnoses & billing
– CPT-4 (Current Procedural Terminology) [AMA]: Procedures/billing
– SNOMED-CT (Systematized Nomenclature of Medicine) [College of American
Pathologists]: Medical concepts
– LOINC (Logical Observation Identifiers Names and Codes) [Regenstrief Inst.]:
Laboratory tests
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ICD-9 Codes
(ICD-9 Data, 2011).
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Transition to ICD-10
• October 1, 2013 is the day ICD-10 CM
(International Classification of Diseases, Tenth
Revision, Clinical Modification) and ICD-10 PCS
(Procedure Coding System) will take effect,
replacing the 30-year-old ICD-9 system
• This change will impact every paper-based
system and software application, information
system, and functional department that currently
uses or generates ICD-9 codes
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LOINC
MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4|200202150930||ORU^R01|CNTRL-3456|P|2.4<cr> PID|||555-444444||EVERYWOMAN^EVE^E^^^^L|JONES|19620320|F|||153 FERNWOOD DR.^
^STATESVILLE^OH^35292||(206)3345232|(206)752-121||||AC555444444||67-A4335^OH^20030520<cr>
OBR|1|845439^GHH OE|1045813^GHH LAB|15545^GLUCOSE|||200202150730||||||||| 555-555555^PRIMARY^PATRICIA P^^^^MD^^|||||||||F||||||444-44-4444^HIPPOCRATES^HOWARD H^^^^MD<cr>
OBX|1|SN|1554-5^GLUCOSE^POST 12H FST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F<cr>
(LOINC, 2011).
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Process Interoperability
• If I’m faxed a discharge summary which I can read, is that
interoperable, since it’s human interpretable? If I’m sent an
electronic note via email that notes “Allergy to MS”, is that
interoperable? Of course MS could mean Morphine Sulfate,
Magnesium Sulfate, or even Minestrone Soup. If I’m sent an
electronic message which has an agreed upon format, a standard
vocabulary, and a set of business rules which enable me to take
action, is that interoperable? i.e. Your patient is allergic to
medication NDC Code 123456789. Administration will cause a
SEVERE reaction with HIGH CONFIDENCE. My e-Prescribing
software could use this information to display a warning
alerting me to the issue and could suggest an effective
alternative medication.
– John D. Halamka MD, MS, Chair, Health Information Technology
Standards Panel (HITSP)
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Special Topics in Vendor-Specific Systems
Vendor Strategies
13
Process Interoperability
• Process interoperability is the most
complex and difficult to achieve, but it is
the most important for patients and
clinicians
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Example: Cerner
• Nomenclature tool - The tool permits the creation and modification of
nomenclature values and includes ability to use and link to standard
vocabularies
• Rules Editor – allows for the creation of expert rules and can import
standard based rule formats, e.g. MLMs
• Clinical knowledge sources - Advanced clinical automation systems
– XML import tool for linking to external evidence based systems to
supply expert rules and reminders
• Clinical Measurement – several levels of support, from Discern
Expert (rules engine) to HealthFacts (aggregated client data)
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Example: Allscripts
• Uses HL7 2.3 messaging to exchange messages with other
systems containing results, documents, observations, and
tasks
• Has a vocabulary manager module to map internal concepts
to terminologies such as ICD-9, CPT-4, SNOMED
• Has partnerships with third-party terminology solutions such
as Multum (for medications) and Intelligent Medical Objects
(for problems)
• Supports send/receive of patient summary information
encoded using the HL7 Continuity of Care Document (CCD)
standard
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Example: eClinicalWorks
• Uses a semi-uniform structured data model that
permits identification of common data elements
across multiple installations
• Has predefined mappings for internal codes to
LOINC, ICD-9, CPT-4, NDC, etc. and manual
mapping capability for custom added codes
• Uses Continuity of Care Record (CCR) and CCD
standards for clinical document sharing with
health information exchanges (HIEs)
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Examples of Third-party
Terminology Products
• Several vendors provide tools for managing and
updating standard and localized medical terminology
– Intelligent Medical Objects, Inc.
– Health Language, Inc.
• Vendor systems specific to medication management
–
–
–
–
First Databank
Micromedex
MediSpan
Multum
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Personal Health Records
• Electronic health records are beginning to
support data exchange with personal health
records
– Vendor-specific “patient portals”
– Microsoft HealthVault
– Dossia
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Accuracy of EHR->PHR Data
(Wagsness, 2009).
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Benefits of PHRs
• PHRs may draw their information from a
variety of sources sent by hospitals,
pharmacies, and laboratories, insurers, etc.
• Supplying this information to patients has
benefits:
–
–
–
–
–
Greater sense of empowerment
More engaged in their care
Higher satisfaction
Increased adherence to their care plans
Better health outcomes
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Barriers to Linking EHR and PHR
Data
• Logistics to work out to prevent misinformed
patients
– Presentation of medical diagnoses, laboratory
and radiology results before physician review
• Clinicians concerned that they would have to
change they way they document
• Privacy concerns for patients, institutions
– Web-based applications
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Vendor Strategies for Terminology,
Knowledge Management, and Data
Exchange
Summary
• Defined Interoperability and Technical Interoperability
• Technical Interoperability: Messaging Standards and
Semantic Interoperability
• ICD 9 codes and transitions to ICD 10
• LOINC-search/ example
• Process Interoperability and various vendor examples
• EHR data accuracy and PHRs benefits
• Finally Barriers to linking EHR and PHR data
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Vendor Strategies for Terminology,
Knowledge Management, and Data
Exchange
References
References:
1.
2.
3.
Halamka, D.J. (2011). Interoperability. Retrieved from Health Information Technology Standards Panel (HITSP) on
September 4th, 2011. http://www.hitsp.org/Halamka.aspx
Walker et al. Inviting patients to read their doctors' notes: patients and doctors look ahead: patient and physician
surveys. Ann Intern Med. 2011 Dec 20;155(12):811-9.
Health Level Seven (2007). Data definition tables: Final Standard. Retrieved on September 5th, 2011 from
http://www.hl7.org/special/committees/vocab/V26_Appendix_A.pdf.
Charts, Tables, Figures:
1.1 Table: Health Level Seven (2007). Data definition tables: Final Standard. Retrieved on September 5th, 2011 from
http://www.hl7.org/special/committees/vocab/V26_Appendix_A.pdf.
Images:
Slide 10: Retrieved on August 20th, 2011 from http://www.icd9data.com/2012/Volume1/390-459/410414/410/default.htm
Slide 12: Retrieved on August 20th, 2011 from http://search.loinc.org/search.zul?query=glucose
Slide 20: Wagsness, L. (2009). Electronic health records raise doubt. Retrieved on August 20th, 2011 from The Boston
Globe. http://www.boston.com/news/nation/washington/articles/2009/04/13/electronic_health_records_raise_doubt/.
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