health it standards committee · november 21, 2016 presentation operator all lines are bridged....

2017 Interoperability Standards Advisory Task Force, November 21, 2016 1

Health IT Standards Committee 2017 Interoperability Standards Advisory Task Force

Final Transcript November 21, 2016

Presentation

Operator All lines are bridged.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Thank you. Good morning everyone, this is Michelle Consolazio with the Office of the National Coordinator. This is a meeting of the Health IT Standards Committee’s 2017 Interoperability Standards Advisory Task Force. This is a public call and there will be time for public comment at the end of the today’s call. As a reminder, please state your name before speaking as this meeting is being transcribed and recorded. I’ll now take roll. Kim Nolen?

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Hey, Michelle, I’m here.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Hi, Kim. Rich Elmore?

Richard Elmore, MA – President, Strategic Initiatives – Allscripts Good morning, Michelle.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Hi, Rich. Christina Caraballo?

Christina Caraballo, MBA – Senior Healthcare Strategist – Get Real Health Good morning, I’m here.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Hi, Christina. Chris Hills?

Christopher J. Hills – Team Lead, Standards Engagement Team – DoD/VA Interagency Program Office Good morning, I’m here.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Hi, Chris. Clem McDonald?


Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine I’m here.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Hi, Clem. Dale Nordenberg? Dan Vreeman?

Daniel J. Vreeman, PT, DPT, MSc – Research Scientist – Regenstrief Institute Here.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Hi, Dan. David McCallie?

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Here.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Eric Heflin? Oh, you’re here, hi, David. Eric Heflin? Kin Wah Fung? Leslie Kelly Hall? Mark Roche? Michael Buck? Michael Ibara? Russ Leftwich? Susan Matney?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I’m here.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Hi, Susan. Tone Southerland? And from ONC we have Chris Muir and Papia Paul. Is there anyone else from ONC on the line? Okay, with that I’m going to turn it over to you Kim and Rich.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Thanks everybody and thanks everybody for joining on our Thanksgiving week. We have a packed agenda so we’re just going to go straight to the slides and I wanted to thank Susan for putting together an overview of the nursing standards for us to review and to hopefully develop a piece that goes within the ISA document moving forward. Then from there we’ll jump into Section II and III we don’t have Brett today because he’s out but I believe Chris is going to help us with that and then we will talk about the next scheduled meeting which we changed the week of November 28th after Thanksgiving. Rich, did you have any comments?

Richard Elmore, MA – President, Strategic Initiatives – Allscripts Good summary Kim, thanks, we’re good to go.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Okay, perfect. So, if we could jump to the nursing discussion slides. And Susan thank you so much for putting all this together.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Sure, my pleasure, it’s my passion. So you want me to start?


Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Yes.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Okay and then I’ll just tell you next slide when we go to the next slide. So, I’m Susan Matney and probably the reason I’m on this committee is because of all of the work that I’ve done in the standards space with SNOMED and LOINC and nursing and I’m the Chair of the Nursing LOINC Subcommittee and past Chair of the SNOMED Nursing Sig.

So, there’s been a lot of efforts nationally regarding nursing and so I thought I would take you through what’s happening nationally and then we’ve had many nurses review the nursing piece of the ISA and I met with them on Friday and reviewed their comments and so then at the end of the slides I will go through the comments and recommend the changes/additions that we would like in our section. So, next slide. So…

M This looks…between the columns here.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So, four years ago there was a Nursing Knowledge and Big Data Science Conference that started at the University of Minnesota, if you go to the next slide, and the vision is to be able to share data across systems not just within the electronic health record but within systems to, you know, prevent diagnose, treat and evaluate health conditions. So, this was their main focus for the whole conference. If you go to the next slide.

The first year they had an invitational conference only which was a think tank and at that time we developed a bunch of different working groups one of them was a group that was developed to work on public policy, we decided our goal was sharable comparable nursing data, I and Tess Settergren we lead a group that are standardizing nursing assessments and we have completed a head-to-toe basic nursing assessment using LOINC as the questions and SNOMED as the answers.

The policy group has worked with the different organizations that I’m going to talk about in the upcoming slides to develop policy around nursing terminologies and how they are used in systems, so if we go to the next slide.

So, the goal is to create a National Action Plan and I think nursing is probably leading the charge when it comes to trying to standardize what we’re doing in practice and, you know, Dave, Dr. McCallie, did say that this is not in systems and we’re very, very aware of that but the goal is if we’re getting it out of the system then we want to get it out and messaged in a standard way.

So, if you go to the next slide, so the first thing that we talk to for the Policy Committee was the American Nurses Association and the American Nurses Association has recognized 12 different terminologies, seven of which can be used within an EHR to document nursing care and a care plan.

So, they want to continue the support of the use of the recognized terminologies within the care plan but promote the integration and facilitate interoperability and so if you go to next slide they came out with a white…a position statement that…and when this came out in 2015 we didn’t have FHIR and I’ve talked to the ANA and we’re going to revise this, but what they said, when exchanging a C-CDA that the problems and care plans, SNOMED and LOINC should be used for exchange.


LOINC should be used for coding, nursing assessments and outcomes, and SNOMED CT for problems, interventions and observation findings and there are going to be a few edits to this and I’ll talk about that when we go into the ISA. So, this is the first place that we saw a position statement coming out as to how nursing should be interoperable, okay, next slide.

The next thing that has happened, and they have met now four years, is the CNO, CNIO vendor roundtable for HIMSS, and you have to be a high-level member, I can’t remember the names, to be part of the CNO, CNIO vendor roundtable, and so they developed guiding principles and this was led by Ellen Harper from Cerner and Gail, used to be from Siemens, I don’t know if she’s retired now, but Roy Simpson was on the committee, Emily Barry from EPIC is in this group, I have attended this group once, Michelle Troseth from Elsevier, so what they say is that…if you go to the next slide it’s easier to read.

They came out with 10 guiding principles and so they want to promote the use of standardized and accepted terminologies that address documentation. And again, they say that the nursing recognized terminologies should be mapped to national standards such as SNOMED CT or LOINC. So, again, we’re saying that SNOMED and LOINC, and this is coming out of the CNOs of the vendors. So, next slide.

So, because of all the action happening with nursing and us coming out to say that we need to document using LOINC and SNOMED the National Library of Medicine came to us and we worked pretty closely with them, Vivian Auld and Suzy Roy, and this is…and Betsy Humphreys, and they came and said “we’re getting a lot of requests from nursing to be doing the mapping” and so we worked with the National Library of Medicine to develop a nursing resources for standards and interoperability webpage that describe LOINC and SNOMED and gives information about the other nursing terminologies and what’s happening nationally, and then they gave a demonstration, there is a video on how you can find out what the mapping is between the other nursing terminologies and SNOMED and LOINC.

So, if you go to next slide this is just a picture of the webpage with a URL that you can see, it’s kind of small, but this is another effort that’s something that has come out of our efforts. So, next slide.

So, the Alliance for Nursing Informatics is an organization that is sponsored by AMIA and HIMSS and it has many different members you can be a terminology developer, you can be a vendor, you can…there are 70 members, all of the EHR vendor organizations are members, all of the nursing terminology organizations are members, some facilities, we’re starting to get other nations, Taiwan just came in as a member, and their goal is to transform healthcare through nursing informatics and information and their main charge is to respond to calls in the industry that are related to nursing informatics and so the comments, the main bulk of the comments was the ANI had a Subgroup that was run by Sarah Collins who reviewed the ISA nursing portions and gave comment to the ONC. So, if you go to the next slide.

Okay, so now we’re going to talk about…any questions, comments about that? Where we are in the industry?

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation This is David, nice presentation, you refer to LOINC and SNOMED as, you know, kind of the target but you also mention the “nursing vocabularies” and I assume that’s things like NIC, NOC, NANDA and some of the other ones. Are you suggesting a migration to LOINC and SNOMED or just LOINC and SNOMED for use in the CDA and those other vocabularies still for operational use? I wasn’t sure what that recommendation was.


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So, what the recommendation is is that the nursing terminologies can still be used within an EHR. So, there is CCC and then in the home health setting there is also the Omaha System and then there is NANDA, NIC and NOC and those can be used within an EHR and then some of these slides we’ll talk about that coming up, but when they’re messaged to another setting they need to be transformed to LOINC or SNOMED for messaging.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation And what about the…I apologize that I’m not deeply familiar with things like the Omaha System, but I think they include not only just lists of terms but assessment instruments and such, are those to be just mapped one-to-one to the equivalent LOINC code or parallel assessment instruments being developed and if so are there patterned or copyright issues?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare You know let me talk about this a little and then Dan maybe can answer this a little more. The nursing terminologies don’t have any scales or validated instruments inside of them, they’re more classifications for assessments for the nursing process, you know, which is the problems, interventions, assessments, outcomes and goals, but we are really trying hard to get standardized instruments and they are being put in LOINC and when you see this come up you will see that we’re recommending LOINC as the question and LOINC is the only place we’re recommending this is the answer because it’s copyrighted and LOINC obtains permission for them to put it in.

The biggest issue, the biggest issue that we have found across the industry, and I’ve talked until I’m blue in the face of how to fix it, is those that are proprietary and charge a fee cannot be mapped to any standard because of the fee that is charged and so a workaround that Dr. Vreeman has suggested is that maybe we can at least get the totals. An example of that is the Johns Hopkins Fall Scale is proprietary and we can’t get into LOINC. Dr. Vreeman did you want to say anything about that?

Daniel J. Vreeman, PT, DPT, MSc – Research Scientist – Regenstrief Institute I think that’s a good summary. So, Dave, for example, the CCC which has a portion of that relate to things that are stored in the observation, observation value pattern but you’d probably call that a classification, you know, so there is sort of a rollup or sort of an overall assessment that’s transformed into this sort of classification but it’s not an actual like scale per se not like you might think of as a standardized assessment instrument but that other track of those things that are sort of the instrument level, you know, we’re pursuing, you know, a couple of strategies to get some of that stuff into LOINC.

One of the things that Susan mentioned there was that, you know, sometimes you do need the whole thing, the whole package and the whole set of questions and so forth, but there are some use cases that can be served just by having total scores and so that’s a path that sometimes the more stringent sort of IP holders are willing to allow without, you know, getting down to the level of each specific question being representative.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare And I think the other thing that I would say is for those systems that are…you know like Cerner where you have your local codes I would suggest doing the mapping to LOINC and SNOMED and not having an intermediary other nursing terminology in the middle. I mean, if you’re going to do mapping you might as well be mapping to the one that you’re going to transform to for messaging anyway and there’s a lot of work that’s been done but there’s so a lot of work to do. So…


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation So…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare But as far as scale…go ahead Dave.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, I was going to…that makes sense to me, your last recommendation, the question is, how many of these assessment instruments would be considered sort of mandatory for any semblance of best practice? I mean, are there dozens of them or is there just one or two roadblocks? I’ll say one or two that are causing people to stumble? I don’t know how pervasive…does it need…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare As far as assessment instruments goes there are hundreds that are using in nursing and so far I was trying to think how many we’ve come across so far that we can’t get in, we can’t get in the NIPS, we can’t…probably about four that we’ve had so far but we haven’t done any of the abilities and functions yet.

But what’s in LOINC now is like the Morse Fall, all the pain scales are in there, the faces scale, the FLACC score, the, you know, pain severity, Braden things that are commonly used we’re trying to get them in there and there are some that are commonly used that are not in.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Okay so it sounds like it’s a little bit better than it was 10 years ago when I last looked at this but not completely resolved.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I think it’s a lot better than 10 years ago, I hope.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Good.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So, I’ve been working on it really hard. All right, so let’s go into the discussion of the different portions for nursing, if you go to the next slide.

In general, and I tried to look at, is it in the other places, I think they recommended when it says…they used the word “converted” instead of…oh, I’m missing a quotation mark…and converted to which makes it sound like you’re losing the source and getting…and we want to be able to make sure that we still have a source and a target and so we recommend that the words in the four sections wherever it says “converted” be changed to “translated to” so it implies that the original concept is still there but it has been translated.

They had a big discussion about should it say “mapped” and I said, you know, mapping facilitates the translation but that’s not what we’re doing for interoperability we’re translating it and putting it in the message.

The other informational piece is the adoption level fields, we can’t complete them at this time but Rebecca Freeman had some extra money in the beginning of the year and so she had a study done to


find out what nursing terminologies were done in systems and that is forthcoming and will influence the population of this field. Any questions about that slide?

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation This is David again, I would quibble a little bit about your concern about the word “mapping” I think you’re being very precise and that’s obviously a good thing, but I think people use the word “mapping” in the sense that you’re using the word “translated to” and we should…in the ISA I don’t know how many other times that word is used, but I would hate to introduce a new word that has a meaning different than the way we’re currently using mapping. So, we should just watch for that and make sure we’re not trying to…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah, yeah and I…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Slide in some words…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Go ahead.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, yeah, that you’ve got…you got my point, yeah.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare And I…and the nurses came back and said they wanted to change “converted” to “mapped” and we’re fine if we…but we do need to be consistent across all of the ISA and decide whether we want it to say “translated to” “converted to” or “mapped to” and so that’s probably something that if we should make a general across the board decision for all of the ISA.

Richard Elmore, MA – President, Strategic Initiatives – Allscripts Susan, the important point here though is that you’re not losing the original concept in the process of mapping, converting or translating and so is that the key point?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yes.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation And when you mean…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare But the nurses they had heartburn over the word “converted.”

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation When you talk about the original concept what is that to you? Is that an arbitrary local code or are you talking about some of these, I’ll call them traditional nursing nomenclatures like NIC or NANDA? What do you mean by…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Both, both.


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Maintaining the original?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Both and we are going to…and we want to change…right now it says “other nursing terminologies” and we want to change it to say “local” or “other nursing terminologies” so if your Cerner code, you know, for a blood pressure then it should be translated to LOINC, so, “local” or “other nursing terminologies.”

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Is there any value in retaining the other nursing terminologies other than the fact that they’re already in use? In other words do they add additional value…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yes, yes, the nursing terminologies have a knowledge structure within them that links the problems, the interventions and outcomes, and, I mean, we’re not even able to do that right now in CIMI. So, I mean, you’ve got your information but the piece that has a linkage between the problem and the intervention is lost if you don’t have that nursing terminology.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation But then if you map it, map it or translate it into a system that also doesn’t have that you’re throwing away knowledge.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah, but you’re getting something, I mean, at least you’re going to be able to send the problem or the intervention, or the outcome. Yeah, I mean, and that’s the same with EHRs, you’ve got decision support rules and you’ve got knowledge within your system but when you send a problem you’re going to send a problem and the problem field whether it has linkages, you know, to what you need to do about it or rules or any of that, that’s knowledge, but when you’re messaging it you’re messaging what’s in the structure.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah, I’m just not sure what it would land in on the receiving system that could take advantage of the structure…I mean, if you try to reassemble it back into what it looked like from the original system you’re going to need to send that additional knowledge.

If you’re not going to reassemble it what’s the value of it being structured? I mean, its limited value, obviously there’s some value. It’s a conundrum…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Right.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Not unique to nursing for sure.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah, for sure.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation But it’s kind of a mess frankly and it doesn’t help that we have to use LOINC and SNOMED as we discussed on our previous call that’s also a strange artifact of our history of evolution of nomenclatures.


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah but it’s not going away. I mean, for laboratory it’s that way too so we just need to figure out how to have the information model structured and get it out with the binding to LOINC and we’re getting there.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Dave I’d suggest there’s no…we don’t know the perfect way of doing anything so I wouldn’t describe existing methods as strange. The future always tells us something different.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah, but, I mean, again, this is a rabbit hole we probably don’t need to go down, but, you know, LOINC and SNOMED have so little in common.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, yeah, but they don’t…but they’re different pieces of the information, you know, what…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation I don’t…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine If you…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation I don’t think they…I don’t think in these assessments or these instruments that that’s an advantage and, you know, the powerful ontology and inferencing that’s in SNOMED is missing in LOINC and then LOINC has many more precise classifications that are missing in SNOMED. Clearly they’re not the same thing but it is really inconvenient to have to split our knowledge models or information models across separate vocabularies and in the nursing setting where we have these historical vocabularies in use also each with their own information model we’re just asking for, you know, mistranslation and misunderstanding of the meaning as you go from, you know, a traditional nursing vocabulary mapped somewhat accurately to SNOMED and LOINC split across two information models, wrapped in a message, sent to another system, doesn’t know how to unwrap it into local codes in that system, it’s not surprising that people haven’t found a whole lot of value in all the structured assessments that we do. It’s…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, there…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation There’s so many…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine There’s a whole ton of them…there’s a whole ton of them in the world, I mean, the assessments, psychologic, psychosocial instruments are all that type and I guess it’s true that a lot of times the answers aren’t very complicated it’s just a lot, a little, not too much, but, you know, if you’re talking


about having difficulty within a question why is it not also difficult to cross question spaces, you know, if someone does a survey in one world but if they are a nurse they do it in a different world why is that not a problem?

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, I think it could be a problem. My point is that, you know, if you have a complex assessment that’s internally consistent, something like a Braden score or, you know, many of the other ones that are more complex than that, it’s pretty clear what things mean because you…it’s all internally consistent let me just use that phrase.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Yeah, well, the Braden score is…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation You have to split it up and say the questions come from one nomenclature and the answers come from another now it’s not internally consistent anymore and only…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, in the case…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Because you…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine The example you’ve taken…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Refer back.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine The example you’ve taken is the exception that Susan notes that the answers are LOINC answers.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, I…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Because…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare But…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation I think that preserves a lot of the value. I think that’s a great thing the fact that it’s internally consistent.


Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Okay.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare But to…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation The other ones that aren’t consistent is where we get into…we’re going to lose…there will be information leakage every time you do these mappings and try to reconstruct them on the other end.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare And to your point, I mean, I agree and I think most of you know I work for Stan Huff and when I started creating these models and when we first did the skin and wound assessment, which is very well done and adopted by the ONC, I went to him and I’m like “I need to publish this” and he said “I don’t know any place to publish information models that’s a reference or a logical model.”

And because, you know, when you have qualifiers and how you qualify a key concept that’s what’s happening with CIMI and so I think in the next couple of years you’re going to really see some things happen where you can pull out the structures with LOINC as the question and SNOMED as the answer.

I’m hopeful or we’re not…or CIMI is not going to live because it’s happening and doing a…we’re doing a lot with it right now so…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well and that…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare But right now you’re totally right there’s no place to see that binding between the question and the answers and when I create that I give the answer list to LOINC and they make LOINC answers, I create the SNOMED codes that are missing in SNOMED and create a value set in VSAC and so then that LOINC question for skin color has all of these colors of the skin and somehow they need to be linked up and so, yeah, you’re exactly right and it’s an issue across the industry that needs to be addressed from a logical information modeling perspective.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Would you…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah and CIMI holds out great hope, I mean, I’m not crossing my fingers because people have been trying that for two decades as well, but…or something equivalent, and, you know, CIMI has many competitors and if you look back across the last, you know, 10 years, but once you get CIMI or something like CIMI then you’ve got a self-consistent internally consistent model and it makes a ton of sense and in fact at that point it kind of doesn’t matter whether it’s mapped to LOINC or SNOMED, or just cardinal numbers starting with zero, or ordinal numbers starting with zero because it’s an internally consistent model.


What we’ve got now are these models that, you know, we start with a model but it’s proprietary so it gets mapped to non-proprietary codes, the model is lost, it gets translated to another system, that system doesn’t know how to reconstruct it. So, it’s just…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, Dave…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation An issue.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Just to clarify one more time though, LOINC’s surveys are all internally consistent, they don’t…and they may have a SNOMED code additionally but because it’s international we have to have a local code and if you read…we’ve got 2000 survey instruments everything from PROMIS to lots of nursing ones and they’re all a…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well and…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Total package.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah, don’t get me wrong the internal consistency is what I’m arguing for here.


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation If it’s internally consistent and managed inside of LOINC in a trackable way, which, you know, LOINC in the past has suffered from sometimes being, you know, not very trackable because with no ontologies and doesn’t have an underlying information model, but if it’s internally consistent that’s far better than splitting it across vocabularies and far, far better than splitting it across proprietary and non-proprietary vocabularies. So, I totally agree if it’s consistent then it’s a step in the right direction, a big step.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah, yeah, I mean, and what nursing is doing is, you know, complying with what is stated in the industry and we’re doing it, now how the nurses are going to get it out with the name and the value linked to them…we need to give guidance and so right now they’re not all in one terminology and they’re not going to be for a while but, I mean…so, I mean, so that’s just where we’re at and so that’s where we’re going, we’re…this is the state of the state today and that’s what we’re addressing today in the ISA. Once we get a new state then we’ll update it.

So, if you go to the next slide. So, the first thing on the ISA is the nursing assessment discussion, is nursing assessments and so what we’re recommending is that we have LOINC for the question and SNOMED for the answers and that’s just following assessments across all disciplines. What they have


asked for, the nurses, is that we remove the sentence under the limitations where it says “they are not represented in other terminologies” that’s just confusing and just say “assessments are represented as a specific question and answer pair.” And then LOINC is…



David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Oh, I’m sorry, I didn’t…I thought you had finished your sentence, go ahead and finish and then I’ll have a question for you.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Well, I’m going to the next suggestion so go ahead and ask your question.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Oh, okay. So, I wanted to reference back to Clem’s statement about LOINC, question LOINC answer, are you saying that even if LOINC has a LOINC code answer it should be mapped to SNOMED according to this slide Clem?

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Yes. Well if it’s used in the US.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Except for scales. If you go to the…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Oh, boy.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Go to the next slide.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Hey, Dave, scales are things with weightings on them just to clarify. So, the answer has…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation The…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Weights that get added up.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Oh, okay…


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So, when we say that SNOMED…go ahead David.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Oh, I’m sorry, I’m just…I’m just…never mind, keep going.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So, when we say that SNOMED should be used to represent the answers we’ve kind of added verbiage that goes along with the other sections in the ISA that says what axis they should be chosen from and it’s interesting that they have events in the problems because I don’t know why…I wish Kin Wah Fung was here to understand why they have a SNOMED CT event, but the codes for the answer should come from clinical finding and situation with explicit context those are the two hierarchies they should come from SNOMED. And then this is…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation But, you know…


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, even there, I mean, I…there’s very little, if any, power to be derived from selecting an arbitrary answer to an unknown question from a particular SNOMED access because you can’t infer anything from it. I mean, if the answer is yellow and the question is “what’s the color of the skin” it’s a completely different clinical meaning than if the question is “what’s the color of the urine” right? I mean it’s all lost.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Well and the meaning is…you get the meaning from the name and the value.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yes, exactly.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I mean the name and the value pair or the result is where you get your meaning not the question and the answer…I mean, so together you get your meaning.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation I agree, to get…you need them both which makes it kind of pointless to pick and axis from which to select the answer by itself you’re not selecting that axis based on the combination of the question and the answer. You could make up a random arbitrary number and it would be just as informative. So, the axis just doesn’t matter which is why mapping answers to SNOMED is such a…somewhat of a pointless exercise.

I mean, okay, we want to code it, and we might as well, because we need a code, but there’s no information contained in that. The information is in the combination of the question and the answer in the context of a particular assessment and all of that’s lost when you just have a code floating around. I don’t think know that there’s anything…


Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, that’s…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation We can do different it is just my frustration that we aren’t doing anything different. I mean, CIMI…


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Can’t get here fast enough.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Yeah. Well, I was…

Daniel J. Vreeman, PT, DPT, MSc – Research Scientist – Regenstrief Institute There’s another…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Always bothered by the fact that we started the Meaningful Use with the addition of…answer lists because they don’t tend to happen out in nature, you know, they usually come along with a question or something to give it context.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah, yeah, you need the package, you need that internal consistency.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Yeah.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation I mean, you know, yellow urine and yellow skin are completely different things, right?


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation One is normal and one is very abnormal.

Daniel J. Vreeman, PT, DPT, MSc – Research Scientist – Regenstrief Institute So…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah, yeah…


Daniel J. Vreeman, PT, DPT, MSc – Research Scientist – Regenstrief Institute So I have some…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I mean…go ahead.

Daniel J. Vreeman, PT, DPT, MSc – Research Scientist – Regenstrief Institute Sorry, this is Dan, I was going to say, I do have some slightly good news on this front which is just that it’s been, I don’t know, several years or so that we’ve been discussing what I should say about this, but we’re quite close to having the agreement, meaning I think it’s been signed on one side and just is waiting to be signed on the other, which would let us, i.e., Regenstrief, LOINC distribute SNOMED CT codes connected to the LOINC answer list across all domains where SNOMED is a reasonable choice for that code which would include these sort of kind of weird things which might be qualifiers or, you know, the yellow that you mentioned.

But what that would allow though is that you do have sort of, in one place, you know, sort of in the LOINC distribution you would have like the question code and then the list of, you know, possible answers represented as either, you know, LOINC answer codes but mapped also to SNOMED codes where appropriate. So, that’s taken a really long time to…for something that actually really wasn’t that controversial but…and there’s still the work to do of actually figuring out what those mappings and what those codes should be but it gives me some hope that we’re at least making some baby steps in this direction.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare We can start with nursing.

Daniel J. Vreeman, PT, DPT, MSc – Research Scientist – Regenstrief Institute Exactly, exactly.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. …

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Susan, don’t get discouraged you’re doing a lot of good packages.

Daniel J. Vreeman, PT, DPT, MSc – Research Scientist – Regenstrief Institute Yeah, we didn’t forget those mappings.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. This is Kim, can we go back to the slide before?


Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. So, just listening to the conversation, so Susan and David y’all tell me if this is accurate. What I heard y’all discussing was that at the local system there could be local codes and nursing terminologies and it’s not until the exchange of the information that the LOINC and the SNOMED come into matter. So, does that need to be listed as a limitation or stated somehow in the…


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Well, that’s the limitation for everything that’s coming out of an EHR not just nursing. I think in general we should say that…I mean, when you look at your vended systems they’re mostly their local code still they’re not mapped to standards, the problems are, the assessments are not. So, that’s not just a nursing thing that’s a generalized…you can generalize that across the EHR.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah, I think the problem with the mappings goes up when the local instrument is mapped to different vocabularies like we’re doing here, which I agree is certainly not unique to nursing, any question/answer assessment in the EHR be it, you know, the physical exam or review of systems, or anything, the problems go up when you split the knowledge across different vocabularies because you’re…whatever internal knowledge, at the point of capture, that links these things together as a unit so that the question and the answer make sense in context with each other is lost when you map it to these large sea of coded strings like SNOMED or LOINC.

So, you know, come back to my example of yellow, you know, if the answer is “yellow” well is that good or bad for the patient? You have no way of knowing until you know all of the rest of the context and it’s just the way it is, we don’t have consistent assessments.

All the vendors have built their own internally consistent assessments for structured clinical documentation or forms but all that’s lost by the time we map to these vocabularies and send it across the wire. That’s one reason why narrative text needs to be preserved because sometimes that’s the only place you can actually figure out what’s really going on.

Now if the assessment is a single answer alone then it works pretty well like if it’s a…if the lab test is urine sodium, you know, it’s reasonably clear that the number in urine sodium are meaningful together you don’t need anything more than that but when we start having…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah, but, you know, if…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Go ahead.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare If I say E. coli, you know, that’s…all your lab nominal answers are SNOMED as well. So you have a blood culture and it comes back E. coli you’ve got LOINC and SNOMED it’s how…that’s how it’s being done.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation I agree and I’m just pointing out the limitations of doing that and if people are surprised that this stuff is hard and doesn’t work as well as they thought it would work once we got it all coded these are some of the reasons why, in particular with complex assessments or even simple assessments, even, you know, a Braden score, I mean…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah, yeah, I mean, and I can give you examples of where things have worked when we’ve created them in the standards space and where they have been broken. But right now we’re trying to set the bar and get it so that we can have sharable comparable data across nursing and this is what the standards have been and like I said, this is the current state of where we are and we’re aligning with that and creating a


lot of standard assessments. Right now we’re working on IVs to assess IV assessments. So, I mean, we’re trying to find the pain points which is pain and IVs, and wounds, and, you know…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation So, what…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So, anyway…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation So, and I agree…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Just…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation That is the state-of-the-art and it’s a good step. Where are you capturing the value sets associated with the range of legal answers if you’re taking a SNOMED…a LOINC question and answering it with SNOMED, like where’s the value set being communicated that gives the pick list of legal answers, so, it’s, you know, the question is urine color, you know, there’s what 300,000 concepts in SNOMED presumably most of them aren’t relevant to urine color, where is the value set being captured and managed that would say, you know, these colors are acceptable answers?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare They’re not all…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Dave…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Put in there yet but some of them are, so like all the wound types are in VSAC so we’re putting them in VSAC.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine

But aren’t they in LOINC?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare The hardest part now, you’re talking about governance and you’ve got to have a steward and somebody is going to govern it and who has the…is being paid. I mean, I’ve got now probably 100 value sets.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation And where’s the mapping to the VSAC value set? I mean, how do you know in the LOINC assessment for urine color that it maps to a particular VSAC value set?


Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Just to clarify, the urine color is a lab and I had been under the impression that all the answer lists that were not great extents like bacteria names we don’t try to keep them, but they were, you know, modestly sized discrete answer lists were all in LOINC somewhere other Dan, and maybe I’m wrong now, but Dan can you speak to that?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I think you’re muted Dan.

Daniel J. Vreeman, PT, DPT, MSc – Research Scientist – Regenstrief Institute Yeah.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine He is?

Daniel J. Vreeman, PT, DPT, MSc – Research Scientist – Regenstrief Institute Yes, I was unmuting. So, yeah, there’s two approaches, one is there’s a structure within LOINC that hooks sort of a traditional LOINC code to an answer list and that answer list can be either an enumerated set of values, entries or it can be sort of a pointer to a value set defined elsewhere and that can be, you know, through an OID or whatever and so for the things that have really big potential value sets the idea is that we wouldn’t try to replicate that at all in LOINC and we would just have a pointer to whatever the preferred value set was that could be stored and maintained in something like a VSAC.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine But Dave…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So it’s my…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, this…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Assumption that we can link to the OID but if it’s an intentional value set like for breath sounds and cardiac rhythms we’ve said we want it to be a range underneath the SNOMED codes, we’re not there yet.


Daniel J. Vreeman, PT, DPT, MSc – Research Scientist – Regenstrief Institute Yes that’s a trickier thing.


Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Dave, to give you some examples, so you can link to, you know, the whole file of ICD-9 codes, you can link to the whole file of ClinVar genetic variations and these things there’s not any challenge there’s a file there and if the codes in there you can use it. I know with the SNOMED it’s more challenging because they’ve got…you need a subset for some of these. The small subsets I think LOINC wants to make them enumerated in LOINC underneath the LOINC question but I’m not sure…


Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Everyone agrees.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation So, but you see my concern here is that this slide that we’re looking at now that says “question LOINC” you know “answer SNOMED” it’s a useless slide. I mean, it’s true in some very vague sense of truth but it doesn’t help you at all. You actually need a specific list of acceptable answers whether that’s a limited range or an open-ended range like, you know, any microbe versus the colors that are appropriate for describing urine, you still need that list of answers somewhere to have any meaningful interoperability.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Yes, I think…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation So, I…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine I think that this…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation It sounds like LOINC is…it sounds like LOINC is where we’re going to…at the moment LOINC is where most of these are being accumulated which I think is great but we should say that here and maybe it’s all…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, there’s…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation On one of the subsequent slides but this, you know, this slide just doesn’t have very much helpful information on it.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well…


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Well, I don’t want to use the LOINC answers because LOINC answers is just a lexical string and clear is clear whether it’s urine or whether it’s breath sounds it’s the same string…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation No, no.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I don’t want to use LOINC.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation No clear is not…that’s a great example, clear sound and clear color are completely different meanings.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare And the LOINC answer is exactly the same ID.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation I…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare But there are different SNOMED codes.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Hey, let’s… just clarify…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation You won’t know which SNOMED codes matter without LOINC, right? I mean…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine What Dave is saying…he’s talking about having the list there and I think we can satisfy both needs by having a SNOMED code as a concept code as well as what you might call the dumb LOINC code but they’re in a structure that says they all are part of the list. I don’t know if that helps.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, it’s a structure that says, these answers belong to this question or I would…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Correct.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Most people would specify it’s the other way around, this question has the following range of legitimate answers.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Correct but that…


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation That information needs to be preserved somewhere otherwise the fact that the answer is a SNOMED code it might as well say the answer is in Russian, I mean, who cares, right? The question is…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, Susan is saying they can be…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation To the question.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Yes. I don’t know. Well, I agree, I mean that’s how it is in LOINC but the SNOMED codes can be the answers which are concept codes rather than string codes which has an advantage.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, it has a very limited advantage because…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Yes, okay, yeah.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation The SNOMED concept is in an ontology that may or may not be relevant whatsoever to that question answer.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Yes.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation One hopes that turbid is not a legal answer for breath sounds but I don’t know. I mean, you know, it’s a valid SNOMED code somebody has to specify that turbid is not a valid answer to breath sounds but it is a valid answer for urine.


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So, we just…

Christina Caraballo, MBA – Senior Healthcare Strategist – Get Real Health This is Christina…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I mean, really we’re just saying it’s coming under the range of these two hierarchies you still need to be able to…I mean, we can’t get down to the specificity of saying that…but it is a finding or a situation with


explicit context. So, I don’t know what you’re arguing for. I know what you’re arguing against but I don’t know what you’re arguing for.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, so it may come in…

Christina Caraballo, MBA – Senior Healthcare Strategist – Get Real Health Hey, guys, this is Christina, can I jump in really quickly? First of all, Susan great…really great overview, this is extremely helpful. I wanted to come back to Kim’s point and I think something that David is trying to get across. This slide I don’t think really portrays some of the problems we have with interoperability issues within the limitation section.

I think a lot of the information Susan that you presented on knowledge being missing when in what we have in standards is missing here. To me when I look at this I come in and I’m thinking I need to fill my nursing needs and I look and I see LOINC asks a question, SNOMED gives an answer, to me it seems like that would just work but in reality it doesn’t and I think that’s what is missing on this slide. I think that’s kind of what David you’re trying to say as well, correct?

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah.

Christina Caraballo, MBA – Senior Healthcare Strategist – Get Real Health Is that we’re not defining the real problem.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, could I…could I defend Susan a bit, you know, in some areas things are pretty well defined, you know, a lot of lab tests are defined, the formal survey instruments are well defined but clinical care is still kind of a wooly, you know, wild west, you know, people haven’t agreed on what the spectrum of answers should be or how to construct the relationship between various kind of questions they might do in narrative versus real life.

So, I think in nursing there is still some of that, they haven’t got it all tamed yet and I think in general she’s saying, this will be the direction and in some spaces it is pretty well tamed and they are enumerated and connected, I think, is that correct, Susan?

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, Clem…


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Clem, that last sentence is what I’m suggesting is missing. I’m not happy about the current state-of-the-art but I think the current slide is absolutely correct for the current state-of-the-art and it’s a good slide, but it’s missing all of that additional information that you just referred to which is those things where we do have agreement on what the question and answer pairs look like.



David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation A naïve person coming to this space who wanted to build a nursing assessment in a, you know, SMART App for a phone or something would have…this is not sufficient information to get them down the right path. We need to say that LOINC has…

Christina Caraballo, MBA – Senior Healthcare Strategist – Get Real Health I think…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Hundreds of assessments that pair LOINC question with LOINC answer (also SNOMED mapping) or something like that because just saying, start with LOINC end with SNOMED is not sufficient.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I like that. I mean and if we want to say the applicable value sets we’ve got some high-level, we’ve got the basic nursing assessment panel in LOINC, we’ve got the skin and wound assessment in LOINC. I mean, there are some but you’re going to end up getting lots of panels, but we’ve got a head-to-toe assessment that’s the basic physiologic nursing assessment in LOINC that we could use as a starter set…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah, so let’s…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare That have the LOINC answers.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Let’s refer to that even if you just refer to it as, you know, nursing assessment panels, you know, pointer to LOINC. I mean, something that gets you closer than just this.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah, yeah, I like…let’s add the assessment panels as starter sets because they don’t all…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine And maybe…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Have to be nursing, because the pain assessment panels don’t say nursing but the assessment…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah, that’s…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare The assessment panels in LOINC of which there are getting to be quite a few now, is a good place for a starter set and then we probably need to say somewhere, and I don’t know who to say this David, that the, you know, issues with getting the SNOMED values from the LOINC answers is…


Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine I don’t think that’s a deep problem Susan I think it’s just the work isn’t finished for many spaces in nursing and clinical care to associate any answer list, specific answer list, with a specific question or even how to formulate the question. I mean, if you just say that there are spaces in nursing and clinical care that haven’t maybe been worked through yet.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation But she was worried…Clem, I think she was raising my earlier concern which is if LOINC is maintaining question and answer inside internally consistent LOINC but you still have to map to SNOMED why the mapping to SNOMED that was kind of one of my earlier questions…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, it will have advantages to queries in many cases like where bacteria or general diagnoses are the answers.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, sure if you’re mapping to an open-ended set like, you know, like bacteria or microbes, sure, map to an appropriate open-ended space but if you’re a closed value set, like most of these assessments are, where there’s an enumerated pick list the fact that the enumeration is defined and managed by LOINC but then mapped to SNOMED for transmission is just kind of funny because you’re only mapping half of it, right, and we’re not going to change that…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Yes.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation So, we shouldn’t waste any more time talking about it. I’m happy to…


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Just have the assessment instruments that are in LOINC mentioned here in one of these slides so that people don’t make the naïve assumption that they can just arbitrarily pick a LOINC question and a SNOMED answer and be interoperable.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Oh, okay.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Right?


Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine No, I agree. I think some of it is actually there are political decisions which are stable and we shouldn’t mess with.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah. So, I want to raise another political question if I can shift the…because I think Susan you were comfortable with the notion of adding some kind of a pointer to the LOINC assessments. But, so let me just…maybe we should just run away from this question, but, are these nursing assessments or are they just clinical assessments? And are nurses…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare They…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation The only ones who are going to be using these tools because I don’t think so. I think it’s going to be a whole range of people that would use these assessments.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare These…many of the assessments are clinical assessments. I mean, what the nurses have done for the basic head-to-toe and we did it from the bottom up, we took systems and looked at their questions and answers and harmonized it and came up to a consensus on the answers for nursing and there are answers that may be more specialized for other disciplines like physicians. So, there is a basic nursing assessment but the pain assessment, the wound assessment, you know, other assessments are basic clinical assessments.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Right, so I’m just wondering if the title of this section should be just clinical assessments. I mean, some of them are relevant to nursing. And where I’m headed…or the reason I would raise that is if we moved away from the traditionally nursing centric vocabularies, which we have, we haven’t mentioned any of those in this slide, maybe we should move away from the notion…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare There isn’t any that do assessments.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Right, so…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare That’s the…


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation So, maybe this is just clinical assessments.


Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine I think the…but there’s an issue here that’s more subtle because nursing is developed…they should get credit, and there is an importance in highlighting that, so if there is a way we could say, clinical/nursing or some way to keep the connection because they’re working them, you know, it’s a little bit like the issues of different depression surveys we identify in the panel where it came from or who initiated it, or created it. But I agree with what you’re saying, but we maybe need to accommodate the political sensitivities somehow.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. So, is everybody good with the clinical/nursing assessment?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I am if it stays in the nursing section.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, we can…yeah, we can keep it in the nursing section. Dave what about…I mean, you’re not wrong, but there is reality of personal feelings we may have to deal with.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah. I mean, we’re probably imputing far too much importance to this document for this to be an argument that we should spend any time on. I don’t think it matters. But my point is…

Richard Elmore, MA – President, Strategic Initiatives – Allscripts Hey, Susan?

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation I think you get the…I think you agree with the general point is that these assessments are not limited in some semantically meaningful…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Correct.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Way to just nurses they could be completely relevant for a whole host of caregivers.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Right, right. I mean and you’re vital signs panel is an assessment.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Right.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So, I mean, all the assessment panels that are in…I think we should say clinical/nursing if we’re going to put the starter sets of the assessment panels, I think it needs to be there.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah, that’s fine but I…


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Okay and hopefully, we’ll get other clinicians on board to do it.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah, but like pain assessment, I mean, I assume the physicians would use the same pain scale as the nurses would use it would be kind of…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah, yeah, and the wound assessment, you know, when you look at the depth and the width, and the length it’s the same no matter who is doing it so…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Right, right and that’s goodness to converge on, you know, clinically meaningful and accurate descriptors that are based on the clinical meaning and accuracy rather than on their historical source of origin with groups that wanted to make money because they were the first to codify a wound assessment.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare And I’m cool with that too. So, I hope you guys are taking notes because I don’t have all these recommendations written in my slides that he’s coming up with. But I’m okay with having it clinical…

Richard Elmore, MA – President, Strategic Initiatives – Allscripts Hey, Susan, could you…could you comment on the implementation maturity? I mean, it sounds like to call it production doesn’t, you know, kind of fully capture a lot of the conversation we’ve had about the state of this.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Implementation, when we have…the assessment group has three subgroups there’s the analysts, the terminology’s group and the implementation group. When I met with the implementation group just to start doing even like skin assessment they were not ready, they said, you know, Susan we’re trying to get vital signs mapped and so it’s very…it’s not mature at all, real low.

Richard Elmore, MA – President, Strategic Initiatives – Allscripts Do we need to kind of make that clearer? I mean, right now it just basically says “production.”

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah, I would say for this as far as maturity in systems I would use the scale that we have and put it on the lowest one.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, and maybe the distinction here again is back to our sort of core vocabulary versus use case. So, the core vocabulary of LOINC and SNOMED are obviously mature and in production but the specific use case to do clinical assessments as captured in, you know, LOINC packages referring to the value set center that use SNOMED and LOINC those are not highly in production.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare That’s right, that’s right.


Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine It’s the same through a lot of the basic versus, you know, all across the board.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Right but it’s a pattern we’ve seen over and over again. The core vocabularies are pretty strong but the particular use of those core vocabularies is not.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare That’s right, I agree. I mean, there’s only one on here that’s mature…that’s a little more mature that we’ll talk to and that’s the problems when we get to them. So, I agree we probably want to change the implementation maturity and the adoption level.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Or yeah, go back to, you know, core, I don’t remember exactly how we’re handling the distinction between core things and use cases, but if this is an interoperability need representing clinical/nursing assessments then, you know, the key package here to list would be the LOINC assessments that reference LOINC and SNOMED, and the maturity there would be, you know, low for implementation or whatever the…

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Susan…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Adoption level is low.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. How many of these panels are available? These assessment panels?

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Clem you said hundreds.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Fifty, maybe about 50 if you look at all the sub…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Oh, there’s…

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Is there…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Oh, there’s way more than…there’s more than that, Dan might…because Medicare is building all their assessments as LOINC structures and we have things like OASIS and MDS, and they’re all full of assessments.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Well, how many of them, I guess, my question is, have this LOINC and SNOMED defined well?


Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, they all have strict answer lists and whether they have SNOMED in them or not is…they usually…many of them do not because we just, I think, yesterday got permission to put them in in addition to the LOINC codes. So, all of the assessments…

Daniel J. Vreeman, PT, DPT, MSc – Research Scientist – Regenstrief Institute Right.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Have strict enumerations.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Is there a…Susan is there like a website where you can go and look at all the assessment panels in one place?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Sure, you can just go into search.loinc.org and type assessment panel, there’s 231.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. So, I wonder if we should have a link to that somewhere in here for people to go to see.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation I think that’s what I was trying to describe earlier is the LOINC assessment panels, I like the phrase assessment panels and I would think that belongs right here with nursing/clinical assessment.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Okay.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation

And the maturity is, you know, it’s based on very mature core standards but the maturity of the use of the panels is limited.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine And it’s quite variable because like the vital signs panel is part of the Meaningful Use and I mean there’s just a very wide spectrum.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah. I think we make…I think this is a good improvement. I think this is…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I…you were my biggest fear.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Oh, poor Susan.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare But I love what we’re coming up with so it’s great dialogue, I’m enjoying the discussion.


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Good, good. Good, I’m not trying to cause trouble I’m just…Monday morning, you know…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare No, it’s good. So, let’s keep going. So, we have the changes, I’ve added a few things on the next slide. Go to the next slide because this is the one…I’ve added the things that we’ve suggested on my slide deck here, but now we need to talk about the…when representing validated scales we only want to use LOINC answers and not SNOMED because the instrument developers have such contextual answers that would not fit into SNOMED that we want this as a package.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, also the weighting is in there too, the scale weighting is in the LOINC…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah, yeah, it’s just…so we want to add when represented validating scales LOINC should be used for the question and LOINC answers should be used for the answers.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Could we get an example of that Susan just so people can understand?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Sure. The Braden scale they have or Morse Falls, when they have, do you have any kind of a like IV device, they’ve got weird answers that you wouldn’t find in SNOMED and SNOMED wouldn’t put in there because they don’t meet the ontological format that you need to have it in.


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation I think, you know, this…what’s missing on the current slide that’s showing is this…and I know it’s missing because I mean I’m not criticizing that it’s missing because we just kind of evolved it in this discussion, but for purposes of ONC’s going forward we need a statement in here that the definition of the panel itself is currently in LOINC. The mapping between question and appropriate answers is in LOINC.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Okay.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Right, but when…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare …

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Stored or transmitted the LOINC codes, for some historical reason, should be translated to SNOMED codes. You can leave out the parenthetical comment for historical reasons.


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Okay, so let’s go to the next one which is nursing interventions and a nursing intervention is a procedure like I’m starting an IV so here we need to totally take off LOINC. What we have in the limitations is incorrect, you can see it says LOINC should be used for assessment, this isn’t an assessment this is interventions so we need to remove LOINC and add SNOMED in the limitations.

And then…go to the applicable value sets, you know, there is a value set that’s being created with the International Classification of Nursing Practice they’ve just released their intervention mapping, I could probably see if it’s open source and we can get to it, but the intervention should come from the procedure hierarchy in SNOMED. So, that’s the main…this is not adopted well in EHRs yet at all.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation And is the same issue that we’ve been discussing true that in LOINC there’s a list of candidate interventions for a particular…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare There’s not…we’re not going to use LOINC at all. LOINC is just for observations in an assessment. So, LOINC is not for a procedure.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Okay.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Dave I think these are like treatments.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah, so this is…okay…

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. So…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation So, these are not treatments in response to some you know…they could occur anywhere, they’re just freestanding, they could be a part of a plan.


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Okay. And you’re saying use SNOMED pure and simple?


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Okay I’m comfortable with that.


Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. So, could we go back to the slide before, I just want to make sure I understand so we can correct it. Should we not have both those rows and should we rename the type to…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare It should be nursing interventions.


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare You could say nursing interventions/procedures and then you could say clinical if you want to but you’ve got procedures. Nurses can’t bill for procedures so we can’t use ICD-10 or CPT.


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So, we don’t really align with the clinical as much there because there’s no billing codes associated with it, it’s only the SNOMED codes unless it’s an, you know, advanced practice nurse, but we need to totally take off LOINC.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. And it sounds like we need to change the type too to what you just stated like nursing/clinical intervention or procedure. Is that correct?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I would call them nursing interventions/procedures. I wouldn’t make this clinical because you have one already in the ISA for procedures that includes…


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare The billing codes as well.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. And that should be SNOMED?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Just SNOMED.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation And there’s no value set in operation here. For example, saying the following things are nursing procedures as opposed to some other kind of procedure like nurses…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare There are…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Don’t do lumbar punctures.


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I mean the nursing…the SNOMED CT nursing sig there’s a harmonization agreement between the International Classification of Nursing Practice and they’ve harmonized their interventions and so there is an equivalency map between the International Classification Nursing Practice and I’ll check into that and see if it’s something that we can put in as a starter set.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Okay, that’s interesting and, you know, it also would raise eventually the question that, you know, who can perform a particular procedure is a policy question and could that vary radically across, you know, locals and countries for sure, but…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Oh, for sure, for sure, yeah and that’s why this one is specific to nursing and the ICNP is only nursing, you know, because I’m not doing any heart surgery. But all of these are within our scope of practice that’s just, you know, when you assign a nursing problem it’s within your scope of practice.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah. So, it’s open as to whether we might want…you could look into it, but we might want to mention the nursing groups harmonization effort there as a…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Right and let me add that to my slide because I’ll look into that.


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Because they are…they just finished…I don’t know if they’re in this release or the next release that they’ll be complete with the interventions except for abilities and functions because SNOMED’s not clean with abilities and functions.

Okay, so next slide talks about the recommendations that I talked to. So, then let’s go to the next set, let’s how…nursing outcomes.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Uh-oh.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah. So this should be…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation I’ll…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare This should be SNOMED as well as LOINC and this is where you can see where the other ANA terminologies should be converted, we want to say “local” or “other ANA nursing recognized terminologies” not just…and there is not a good starter set for outcomes.

If you go to the next slide I want to talk about outcomes as a name, value/pair versus outcomes as an assertion. So, LOINC…what we’re saying is LOINC should be used when the outcome is represented as a


name, value/pair so like systolic blood pressure less than 100, I shouldn’t have indented this next one, SNOMED CT should be used when the outcome is represented as a finding, e.g., they are normotensive.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation When you say name, value/pair is that a single LOINC code, systolic pressure greater than 100 or is that two LOINC codes?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare No it’s a LOINC code and then the value is numeric.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine It’s an observation…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare It’s an instantiated result is what it is.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine It’s an observation.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah, are EHR systems doing that? I’m not…I don’t think we do that. A question that has an answer that is both a question and an answer?

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine No, no Dave.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare No.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine No, it’s really just an observation, you’re saying you want the observation to reach this…the goal is the observation at a certain level.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Okay.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine And that was in version 3…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So, when you look at the quality measures and they give you a LOINC code and say, you know, we want the hematocrit above 8 then you’re going to look for the hematocrit LOINC code and then you’re going to look for the values so that could be stated just a little bit different. The LOINC code is the systolic pressure and then the value with a unit of measure…you’re looking for this is kind of a query across, are you looking…you’re looking for 100 mmHg…


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, clinical facts like, you know, that the hematocrit was 24% is, you know, EHRs can obviously store that that’s, you know, just, you know, an observation stored as a fact, but if you’re saying that the outcome, you’re tracking an outcome somewhere are you supposed to point back to the fact that’s stored elsewhere or do you restate the fact?

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, Dave, is the fact just an observation? I’m not sure what you mean by fact.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, this is what my question is, so this is, you know, systolic pressure greater than 100 that’s not an observation that’s a truth statement about an observation.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine It’s often described as a goal.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah, so maybe it’s a goal but is that one code?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare No.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation And this is a…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine No it’s two. It has the observation structure, it might be considered sort of a mood.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, so is it three codes because what if it was greater than or equal to 100 or less than 120, or…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine It’s as many…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Systolic pressure is one code, the operation is a code and then the value is a number? I don’t know of any EHRs that do it that way. I could be wrong but I don’t…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Well, and I can tell you as far as outcomes go across the board we are not well defined in the industry as how we’re going to be doing outcomes, goals and outcomes.



Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare That’s one area that needs a lot of work.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Yeah, yeah, I don’t think we’re…I mean, we would probably capture that as a statement of truth, you know, it would be that the form would say, systolic pressure greater than 100 question mark and you’d say true or false. I’m guessing.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Yeah that’s going to explode though, yeah…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, absolutely.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine So, it needs work I think that’s the general agreement.


Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. So, maybe…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine I think I’ve seen models where they’ve actually built stuff that has a logic statement that is kind of analogous to an observation in a different mood, I can’t remember v3 there was something like that in v3.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. But when I would get this, because I do a lot of stuff with outcomes, like I would just want the fact, as David’s calling it, what the blood pressure is and then based on whoever I’m working with and how they want to define it then you would do the outcomes based on that whether it’s greater than 100, greater than 120 or I would think this would be something that would be built through like some type of clinical decision support if you wanted to use it, but not necessarily need it as a core component.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine I think you’re right. I think effectively that’s what they do in checking on the quality measures, they take the data and then they check it against the rule.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Yeah.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So, some…so let’s go back, go back up now and let’s talk about this because it really is a rule but sometimes it could also…so when it has a value, name, value/pair in the rule then LOINC should be the question, the observation but then what if it’s a finding like normotensive then we want it to be


SNOMED but somehow in the…we need to say that the precondition or consideration, if you go up, we need to say somehow that this is going to take some computation…you can’t just…I mean, I don’t know how to say this, but what you just said is, you know, you’re not going to make something that says a code that says systolic pressure greater than 100 you’re going to have some kind of a predefined name and value that you’re going to go against and do a query and see if you have…if you’re greater than 100 when you look at all the patient instances, right?

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, I mean, I think, you know, there’s two separate issues here, one is, you know, what is the criteria that you’re trying to determine if you met or not, in other words, what’s the definition of the measure and that could be expressed in complex textual language or it could be something that’s codifiable as a rule and then there’s the representation of your assessment as to whether that measure was met or not which is, you know, a judgement. So, there may be systolic pressures in there that are greater than 100 but it was an artifact of the fact that the cuff wasn’t put on properly and your assessment is no we didn’t meet the measure.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So, I think what we need to do with this is go…the biggest place this is done right now is quality measures.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Right, right.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare And we don’t have that in here.


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare And we may want to just change this to be outcomes measures not nursing and then align with how they’re doing it with the quality measures.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine I think that’s a good idea.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation So, is there…I mean, there used to be…which was the nursing outcome vocabulary NOC?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Oh, NOC is a Likert scale and it was…so it would be an ordinal.


Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine It would be observation again.


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Is that…is that gone away, the need for something like that or…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Well, Cerner’s got it built into their system for nursing right now.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation No, I’m sure…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare But it’s not…it is not electronically available and it is proprietary and so I really don’t want to recommend, you know, CCC, the Clinical Care Classification, she has outcomes which is improved, deteriorated, stabilized. Omaha has outcomes which are Likert scale 1-5 like we’re really inconsistent and so what we need to do is probably look at the quality measures and have outcomes just say “outcomes” and write to how the outcomes are done in the quality measures.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Well, my concern a little bit is that an outcome and a quality measure might not be the same thing. The quality measure has a criteria, an outcomes is just the fact.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Yeah.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Well, it’s the fact or a value of something either categorical or numeric and very often...

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare So…

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine It’s a value.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I’m going to need you to go to the next one real fast because they’re going to open up for comment in two minutes.


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare The last one is easy.

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Good.


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Go to the next slide. The nursing problems we have defined a nursing problem subset of SNOMED CT which includes all the nursing problems that are in the UMLS and that is freely downloadable, if you go to the next slide you can see the recommendations, add SNOMED CT.

We want to add the clinical finding and situation with explicit context and when we do that we validate…I’m involved with…you can see this article that’s down at the bottom, we want to add local to the other…and with the other ANA we don’t always just say “other” because it needs to be local and the starter set is the nursing problem list subset of SNOMED CT and it’s available on the NLM website.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. And is there…

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare And it is better adopted. Go down to the next slide, it just shows that it’s part of Meaningful Use and a nursing problem can be used and it is probably the most wide adopted of all the nursing content that we have in the industry because it was the easiest to map. They are apples and apples.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Susan, is there an OID that goes with that which we could add on this?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I tried to find it.


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare I need to ask Kin Wah and he’s not…


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation I would suggest we purposely not list the OID because they’re so stupid. Okay.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Well…

David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Who would know if you got it right or wrong?

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Well that…the website is right there you can go to the website. So, that’s…wow the nursing discussion took way longer than I thought it would but you need to be able to open it up for comment so…

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Thank you, Susan.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Thank you, everybody.


David McCallie, Jr., MD – Senior Vice President, Medical Informatics – Cerner Corporation Thanks, Susan.

Clement J. McDonald, MD, FACMI – Director, Lister Hill National Center for Biomedical Communications – National Library of Medicine Thank you, Susan.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. All right.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Are we ready to open up for public comment?

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Yes and Michelle once you do that maybe we can talk about the change next week.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Okay, operator can you please open the lines?

Public Comment

Lonnie Moore – Virtual Meetings Specialist – Altarum Institute If you are listening via your computer speakers, you may dial 1-877-705-2976 and press *1 to be placed in the comment queue. If you are on the telephone and would like to make a public comment, please press *1 at this time. Thank you.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology While we wait for public comment hopefully most of you saw that we rescheduled the meeting that was scheduled for next Monday to December 1st. Kim I believe you’re not available for that but I think Rich is.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. That’s correct.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Okay.

Christopher Muir, MPA – Director, HIT Infrastructure & Innovation – Office of Standards & Technology – Office of the National Coordinator for Health Information Technology Michelle, this is Chris, the challenge is some of us in ONC might not be available that day.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Yeah, I think we still need to have the meeting so we’ll have to figure that out if, you know, I have to step in or whatever it is. So, we’ll figure that out offline but I just think that we’ve lost some time. It was a good discussion today but I think that we just need to do some catch up so we’ll figure out how we make that possible and adjust schedules accordingly. In the meantime it looks like we have not public


comment and I just want to thank you all for all of your contributions and wish you all a very Happy Thanksgiving!

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Happy Thanksgiving.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Thank you.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Thank you everyone and we’ll be in touch soon with next steps.


Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Okay.

Richard Elmore, MA – President, Strategic Initiatives – Allscripts Thanks, again, Susan, terrific discussion.

Michelle Consolazio, MPA – Federal Advisory Committee Program Lead – Office of the National Coordinator for Health Information Technology Thank you.

M Yeah.

Richard Elmore, MA – President, Strategic Initiatives – Allscripts Thank you.

Daniel J. Vreeman, PT, DPT, MSc – Research Scientist – Regenstrief Institute Yes, thank you, Susan.

Susan Matney, PhD, RNC-OB, FAAN – Senior Medical Informaticist – Intermountain Healthcare Thank you, bye-bye.

Kim Nolen, PharmD – Clinical Informatics Medical Outcomes Specialist – Pfizer, Inc. Bye.

health it standards committee · november 21, 2016 presentation operator all lines are bridged....

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