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AHLTA: How Physicians See Our Lab(s!) Now Society of Armed Forces Medical Laboratory Scientists (SAFMLS)Boston, 28 February 2007
Michael P. Fitch, Lt Col, USAF (ret), [email protected]
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Purpose
Full disclosure First AHLTA presentation to lab
professionals Presented from a laboratory (i.e., CHCS,
CoPath, DBSS, and eventually PathNet®) perspective
Share knowledge Gather feedback
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02/28/2007 3
Objectives
Learn the concepts behind AHLTA Understand the basic interactions between CHCS
Lab and AHLTA Order entry Result reporting
Become aware of its most significant differences relative to CHCS Lab
Discuss strategies to take advantage of AHLTA to enhance our lab business model and improve communication
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02/28/2007 4
AHLTA Concepts
AHLTA in its present form is a longitudinal electronic medical record (EMR) a clinical documentation tool
02/28/2007 4
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02/28/2007 14
AHLTA Concepts
AHLTA in its present form is a longitudinal electronic medical record (EMR) a clinical documentation tool a single database for clinical events (CDR) a CHCS front-end for direct-care providers a whole enterprise, not just a single product NOT a replacement for laboratory or other
ancillary functionality
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02/28/2007 15
How CHCS Works with AHLTA
Nightly data collectionTable synchronizationDelta data capture
Data mapping through the Health Data Dictionary (HDD)
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Overview of Lab/CHCS-AHLTA Architecture
16
CHCS
CoPath
CDR
Clinics(AHLTA
Workstations)
Labs
CoPath
CHCSDBSS
DBSS
Facility 2
Facility 1 Montgomery, AL
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Purpose of the Health Data Dictionary (HDD)
NCID20947395
DISA MegacenterHDD
•Purpose: To provide a Common MedicalVocabulary of standardized medicalterminology, where applicable, for linkingmultiple like concepts to a single concept•AHLTA uses the 3M Health InformationSystems Healthcare Data Dictionary® as the Common Medical Vocabulary
Fort Bragg SGOT
Portsmouth AST
Minot AFBAspartate
Aminotransferase
AspartateAminotransferase
CHCS ILab test
Mapping
Mapping
Mapping
Mapping
AspartateAminotransferase
AHLTADisplay
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Data Mapping Delta Management
Every change to Lab files is captured and sent to Chantilly by an overnight task Files monitored: Lab Test, Lab Method, Antibiotic Susceptibility,
Collection Sample, Etiology Field, Topography Field Every change will be evaluated by the Data Standardization
Team the next business day, communicating as necessary with 3M and your lab Concept already mapped New concept and/or mapping required Concept invalid
Valid changes go into a daily HDD update Updates delivered each Wednesday, tested, and generally applied
the weekend following all approvals Ideally, the changes should be evaluated and the HDD update
installed before the first result arrives to avoid mapping errors
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Typical Delta Events
Often more than 2500 changes evaluated per person/day Each involves effort and therefore cost to the Government Invalid or questionable concepts require the most research and time
Majority of rejected changes represent invalid concepts Unrealistic specimen for the test
Actual examples: Vitamin K assay on tissue, fibrinogen on feces Documented causes
“Shotgunning” virtually all specimens onto new methods A collection sample without a default specimen, forcing HCP to
choose one Default specimen for a panel not available or appropriate for a
constituent test Adding or deleting constituent tests to/from panels Quality control test not identified as such
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Mitigation Strategies
Make sure all Collection Samples used for Clinical Chemistry tests have a valid default specimen defined
For each file change you make, evaluate each test:specimen:method combination for legitimacy Think LOINC—if the combination is in a valid LOINC code, it’s
probably good The Team and 3M usually use the units to determine the method For each test, consider every possible site/specimen associated
with it The default specimen for each Collection Sample Each site/specimen defined in every Method, including default methods as well as any Work
Element specific methods Avoid creating and using “blanket” methods—those containing
almost every conceivable site/specimen Make sure all the organisms and antibiotics you may
receive from a reference lab are already configured in your files02/28/2007 20
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02/28/2007 21
How CHCS Works with AHLTA
Nightly data collectionTable synchronizationDelta data capture
Mapping through the Health Data Dictionary (HDD)
Order entry
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02/28/2007 35
How CHCS Works with AHLTA
Nightly data collectionTable synchronizationDelta data capture
Mapping through the Health Data Dictionary (HDD)
Order entry Result retrieval02/28/2007 35
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02/28/2007 42
HDD
Lab-to-AHLTA Notional Design
CDRClinical Data Repository
AHLTA Workstation
DBSS
DEERSCHCS
CoPath
CDMClinical Data Mart
Orders
Results
Failover
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02/28/2007 43
Differences from CHCS
Nomenclature Formatting Supported patients Responses to CHCS F/T maintenance System interactions Lookup logic Enterprise-wide effects of the
CDR/CDM
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02/28/2007 44
Nomenclature
Different field length constraints 3M/DoD standards and conventions Mapping (again, think LOINC) Vernacular (e.g., “test” vs. “result,” “alert”
meaning of “Lab Section,” etc.)
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02/28/2007 48
Formatting
GUI opportunities and liabilities Fonts
Size Mono-spaced vs. proportional Color, underline, or other attributes may convey added meaning
Screen/window size 2D scrolling Mouse usage Select or hide fields Sort on demand Cut and paste
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02/28/2007 50
Formatting (cont’d)
Possibly invalid assumptions (e.g., “:” connotes label, space follows “=“, reformatting won’t affect meaning)
Column widths and enforcement
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02/28/2007 52
Formatting (cont’d)
Possibly invalid assumptions (e.g., “:” connotes label, space follows “=“, reformatting won’t affect meaning)
Columnar results window Selective autociting to encounter/SF600
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02/28/2007 55
Formatting (cont’d)
Possibly invalid assumptions (e.g., “:” connotes label, space follows “=“, reformatting won’t affect meaning)
Columnar results window Selective autociting to encounter/SF600 Microbiology presentation issues Comments and interpretations in a separate
window
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02/28/2007 57
Formatting (cont’d)
Possibly invalid assumptions (e.g., “:” connotes label, space follows “=“, reformatting won’t affect meaning)
Columnar results window Selective autociting to encounter/SF600 Microbiology presentation issues Comments and interpretations in a separate
window No analogous reports (e.g., Doctor’s Cumulative)
02/28/2007 57
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02/28/2007 58
Supported Patients
AHLTA is currently an outpatient system Inpatient lab results, however, are in the CDR along with
the patient’s outpatient results Order entry on an inpatient will likely be treated as an
outpatient in some respects
Only “real” patients in the CDR; others still maintained only in the associated CHCS QC Non-human specimens (e.g., veterinary patients,
environmental specimens, blood units) Officially, CDR is not to contain “test patients”
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02/28/2007 59
Response to CHCS F/T Parameters
Nightly—not immediate—table synchronization
Historical changes to the CDR or CDM require “repulling” the patient(s)
Some CHCS controls not supported Print/display order Print name
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02/28/2007 60
System Interactions
RNR and audit trail differences Lag time introduced by transactions Screen refreshes Partially-resulted panels (under
development) Remaining tests not seen Displayed results appear complete
Amendments and Intermediate results
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02/28/2007 61
System Interactions (cont’d)
Extra information screens Anatomic Pathology Order required data Blood Bank subscript still being developed
No direct access to CHCS help screens (e.g., ??, ?<test>, OLUM, LTI)
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02/28/2007 64
System Interactions (cont’d)
Extra information screens Anatomic Pathology Order required data Blood Bank subscript still being developed
No direct access to CHCS help screens (e.g., ??, ?<test>, OLUM, LTI)
Most urgent messaging still handled only by CHCS (e.g., ward/clinic auto-printing)
Associating orders with encounter becomes more important02/28/2007 64
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Lookup Logic
“Contains” vs. “Begins with” Prefixing with “x” or punctuation won’t “hide” tests Case (in)sensitivity
Contents and order of picklists Synonyms used but not displayed
Screening/filtering of some characters Support for wildcards No FileMan-unique cross-references
`IEN Soundex FileMan associations
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Enterprise-wide CDR/CDM
Local naming or business conventions Designations of sensitive results Panel constituents Use/non-use of standardized tests Inquiries and reports may encompass multiple
labs’ work Specimen/method-sensitive Potentially multiple reference ranges
Referral specimens (e.g., certification at both labs when Lab Interoperability not used)
Multiple time zones
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Lab COTS Issues
Details for integration of Cerner Millennium and AHLTA still under development
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Open Discussion
Questions Lab experiences related to AHLTA
Physicians’ comments Order entry issues Result correlation findings CAP/JCAHO/AABB/FDA inspectors’ comments
Physician/facility/patient perceptions Rumors Ideas