2011 11 16 - vreeman - corralling creativity with standards

Challenges and Successes with Community-wide Laboratory

Data Exchange Corralling Creativity with Standards

Daniel J. Vreeman, PT, DPT, MSc Assistant Research Professor, Indiana University School of Medicine Associate Director of Terminology Services, Regenstrief Institute, Inc

11.16.2011 © 2011 [email protected]

IQPC 9th Forum on Laboratory Informatics

Overview

photo via Vernio77

1.  Indiana Network for Patient Care 2.  LOINC® - the global master file 3.  Challenges, success, and lessons

Biomedical Informatics at Regenstrief Institute Why do we care about this stuff?

40+ Years of Canopy Computing making a forest out of individual trees of data

McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.

photo via nosha

photo via nosha

e rain forest canopy is a seamless web through which arboreal creatures efficiently

move to reach the edible fruits without any attention

to the individual trees.

photo via nosha

e rain forest canopy is a seamless web through which arboreal creatures efficiently

move to reach the edible fruits without any attention

to the individual trees.

Individual healthcare computer systems are rich with patient

data, but rather than a canopy linking all the trees in the

forest, the data “fruit” come from a diverse forest of

individual computer “trees”.

Arboreal Informatics Pioneers 40 years of EMR work

Indiana Network for Patient Care Nation’s most comprehensive and longest tenured HIE

Regenstrief – the neutral 3rd party convener

A “Humongous” Database

200+ source systems 11.9 million patients

3.9 billion results 76.9 million text reports

1 million transactions per day

41% of ED visits are for patients with

data at another institution

Finnell JT, Overhage JM, Grannis SJ. All Health Care is Not Local: An Evaluation of the Distribution of Emergency Department Care Delivered in Indiana. AMIA Annu Symp Proc. 2011;:409-416.

Connectedness among IN EDs

Finnell JT, Overhage JM, Grannis SJ. All Health Care is Not Local: An Evaluation of the Distribution of Emergency Department Care Delivered in Indiana. AMIA Annu Symp Proc. 2011;:409-416.

Nearly every ED in IN shares

patients with every other ED

in the state.

Indiana Network for Patient Care

St. Vincent

St. Francis

IU Health

Wishard Health

Community

IUMG

Public Health

Global Patient Index Concept

Dictionary

Referral Labs, RxHub, etc…

Global Provider Index

Institutional Repository

A

A Message Processor

MSH|^~\&|HOSPITAL_A|SAMPLE_HOSPITAL_A|||$YearMonthDay||||||||||||||| PID|||$patientId$||$patientName$|||||||||||||||||||| PV1|||||||$attendingDoctor$||$consultingDoctor$|||||||| OBR|1|||012^CBC/Auto Diff^HSPA^57021-8^CBC W Auto Diff^LN||$reqDate||||||||| OBX|2|NM|123^WBC^HSP_A^26464-8^Leukocytes [#/volume] in Blood^LN||10.8|K/MM3|||||F| OBX|3|NM|234^RBC^HSP_A^26453-1^Erythrocytes [#/volume] in Blood^LN||4.82|MIL/MM3|||||F| OBX|4|NM|345^HGB^HSP_A^718-7^Hemoglobin [Mass/volume] in Blood^LN||15.7|GM/DL|||||F| OBX|5|NM|456^HCT^HSP_A^20570-8^Hematocrit [Volume Fraction] of Blood^LN||45|%|||||||F|

HL7 v.2.X Message

LocalCode^LocalName^CodeSystem^LOINCcode^LOINCname^CodeSystem

Indiana Network for Patient Care

A Unified Patient Record

photo via kimubert

Public Health Uses

Overhage JM, Suico J, McDonald CJ. Electronic laboratory reporting: barriers, solutions and findings. J Public Health Manag Pract. 2001 Nov;7(6):60-6. PubMed PMID: 11713754.

4X greater detection rate than MD-based reporting.

Same day versus 2-5 day

reporting.

Quality Reporting

photo via paskukaru76

Clinical Research

photo via jurvetson

Origins of LOINC The lingua franca of clinical observation exchange

Fundamental challenge: local systems have idiosyncratic ways of identifying similar concepts

Vocabulary standards provide the linuga franca.

Logical

Observation

Identifiers

Names and

Codes A universal code system that facilitates exchange,

pooling, and processing of results

Soda or Pop?

Lab A Test Name: Lyme Disease Serology

Measures: B. burgdorferi Ab IgG

Method: ELISA Scale: quantitative

e.g.: Titer 1:40

Lab B Test Name: Lyme Disease Antibody

Measures: B. burgdorferi Ab IgM

Method: Immune blot Scale: qualitative

e.g.: Positive

what you see in the order list

LOINC Code = 5062-5 LOINC Code = 6321-4

Similar name, different meaning…

meerkat meerkat mere cat meerkat photo via Caption Time

If an observation is a question and the observation value is an answer…

LOINC provides codes for questions

Other vocabularies provide codes for the answers

What is my patient’s hemoglobin level? 718-7:Hemoglobin:MCnc:Pt:Bld:Qn

How fast does my patient usually walk? 41959-8:Walking speed:Vel:1W^mean:^Patient:Qn:Calculated

photo via Ed Yourdon

5671-3:Lead:MCnc:Pt:Bld:Qn::

5671-3 LOINC Code

Lead

MCnc

Pt

Bld

Qn

Component

Property Measured

Timing

System

Scale

Method

There are six major LOINC axes

Anatomy of a LOINC Term

Laboratory LOINC

Clinical LOINC

Lots More Cooking… Genetic testing

Lots of forms and assessments More radiology reports

Structured document titles

…

photo via liber

The LOINC Community Open. Nimble. Pragmatic.

Open Development Worldwide distribution at no cost

End-user content additions Welcome all comers

Volunteers

Regenstrief Institute Steward Developer of content

Developer of tools Developer of community Distributor

Voice

LOINC Codes Over Time By Release

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000 LOINC Codes

Lab Codes

laboratory terms only

Slope = 600

Slope = 2200

0

2,000

4,000

6,000

8,000

10,000

12,000 loinc.org members

14 new members per day 410 new members per month

14,100+ users in 145 countries

search.loinc.org

International Adoption participation, translation, implementation

LOINC Translators

18 organizations

Large Implementations

SIGA Saúde project Canada Health Infoway ePSOS Assistance publique - Hôpitaux de Paris Hong Kong Hospital Authority Red Agrolab BiTAC

Lots more…success is often silent

US Adoption A few key highlights

US Federal Agencies NLM VA

DoD IHS NCI

CDC

Other Key US Adoptions

HITSP eLINCS

NAACCR CDISC

NCQA/HEDIS, NQF

HL7

HIPAA

HIE’s

EHR Incentive Program

a.k.a. “Meaningful Use”

Lessons learned along the Health Information Exchange road

photo via IMLS DCC

Lesson 1

Lesson 1 Iterate and leverage.

Be nimble, willing to iterate.

Start with what gives information and saves time.

Build critical mass by prioritizing high volume producers of data.

Live and Learn

Collect once. Use many.

Clean water act

photo via Fishking_1

ivdconnectivity.org

Lesson 2 Prioritize trust.

Regenstrief serves as a neutral 3rd party convener.

McDonald CJ, Overhage JM, Barnes M, Schadow G, Blevins L, Dexter PR, Mamlin B; INPC Management Committee. The Indiana network for patient care: a working local health information infrastructure. Health Aff (Millwood). 2005 Sep-Oct;24(5):1214-20.

Start small. Build incrementally.

McDonald CJ, Overhage JM, Barnes M, Schadow G, Blevins L, Dexter PR, Mamlin B; INPC Management Committee. The Indiana network for patient care: a working local health information infrastructure. Health Aff (Millwood). 2005 Sep-Oct;24(5):1214-20.

Governance provides the framework. Stakeholders have their say. Everyone contributes.

Policies reinforce the goals.

McDonald CJ, Overhage JM, Barnes M, Schadow G, Blevins L, Dexter PR, Mamlin B; INPC Management Committee. The Indiana network for patient care: a

working local health information infrastructure. Health Aff (Millwood). 2005 Sep-Oct;24(5):1214-20.

Lesson 3 Life is messy.

HL7 messages can be syntactically correct but semantically bastardized. Everything is an OBX.

Everything in the NTE.

Units of measure are unruly.

Sometimes missing (or in NTE). Variation runs wild.

(>20% of Qn LOINCs had different units)

Lin MC, Vreeman DJ, Huff SM. Investigating the Semantic Interoperability of Laboratory Data Exchanged Using LOINC Codes in Three Large Institutions. AMIA Annu Symp Proc. 2011;805-814.

Non-quantitative results are the wild wild west. Mostly unstandardized.

Choose your own value set.

Lin MC, Vreeman DJ, Huff SM. Investigating the Semantic Interoperability of Laboratory Data Exchanged Using LOINC Codes in Three Large Institutions. AMIA Annu Symp Proc. 2011;805-814.

Lesson 4 Mapping is hard, but don’t let perfect be the enemy of good.

Mapping might not be rocket science, but it requires both expertise and effort that is easy to underestimate.

Baorto DM, Cimino JJ, Parvin CA, Kahn MG. Combining laboratory data sets from multiple institutions using the logical observation identifier names and codes (LOINC). Int J Med Inform.1998 Jul;51(1):29-37.

photo via eye of einstein

A brief aside… Putting Zipf’s Law to work for you

A Few Tests Give Most Results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 500 1000 1500 2000 2500 3000 3500 4000 Number of Laboratory Observation Codes (N)

Cum

ulat

ive

Labo

rato

ry O

bser

vati

on V

olum

e (%

)

Vreeman DJ, Finnell JT, Overhage JM. A Rationale for Parsimonious Laboratory Term Mapping by Frequency. AMIA Annu Symp Proc. 2007;:771-775.

loinc.org/usage

“Top 2000 Results”

a.k.a. “Top 300 Orders”

a.k.a. “Common Units of Measure”

We now return to our regularly scheduled program…

Centralized mapping consolidates, but doesn’t eliminate the effort.

Vreeman DJ. Stark M, Tomashefski GL, Phillips DR, Dexter PR. Embracing Change in a Health Information Exchange. AMIA Annu Symp Proc. 2008;:768-772.

A journey. Not a destination.

Ongoing vigilance of HL7 flows for new terms, units of measure exceptions.


Post-Implementation Terms Since Go-live

0

100

200

300

400

500

600

700

800

900

0 2 4 6 8 10 12 14 16 18 20 22 24

New

Pos

t-Im

plem

enta

tion

Loc

al T

erm

s (n

)

Months Post Initial System Implementation

Add half as many terms after go-live.


Most new local terms could be mapped to existing LOINCs.


Closing Thoughts

photo via janeandd

Interoperability is a journey not a destination

Jump In!

photo via Justin Ornellas

The Race is On!

Happy LOINCing! photo via ryarwood

Acknowledgements LOINC Development Team Clem McDonald, Kathy Mercer, Jaci Phillips, Jami Deckard, David Baorto, Sara Chonaiew

RELMA Development Team John Hook, Mark Fisher, Karen Ahmed, Anandhi Sowmyan, James Dennis

LOINC Committee Regenstrief Biomedical Informatics Supporters: NLM, Regenstrief Institute, Regenstrief Foundation

photo via milos milosevic

[email protected]

2011 11 16 - vreeman - corralling creativity with standards

Health & Medicine