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Vocabularies: Critical Software Infrastructure for Interoperability and Adoption American Health Information Management Association Workshop Andrew S. Kanter, MD MPH Intelligent Medical Objects, Inc. ©2005 Intelligent Medical Objects, Inc.
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Page 1: Vocabularies: Critical Software Infrastructure for

Vocabularies: Critical Software Infrastructurefor Interoperability and AdoptionAmerican Health Information Management Association Workshop

Andrew S. Kanter, MD MPHIntelligent Medical Objects, Inc.

©2005Intelligent Medical Objects, Inc.

Page 2: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005

Overview

Interoperability and Role of VocabulariesWhere the Money is…

The Interoperability-Adoption tug-of-warStandards—reference terminologiesUsers—interface terminologies

Mapping from Clinical to FinancialManaging the Madness

Page 3: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005

Interoperability

Definition:In healthcare, interoperability is the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged.

NAHIT Interoperability Definition. Adapted from the IEEE definition of interoperability, and legal definitions used by the FCC (47 CFR 51.3), in statutes regarding copyright protection (17 USC 1201), and e-government services (44 USC 3601).

Page 4: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005

HIEI National Net Cost-Benefit

Net return over 10 yr

implementation

Annual Net return after

implementationLevel 2 $141B $22B

Level 3 -$34B $24B

Level 4 $337B $78B

Middleton, Blackford. Deriving Value from IT: Designing for Quality and Patient Safety. www.vipcs.org/conf2004/middleton.pdf

Page 5: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005 Middleton, Blackford. Deriving Value from IT: Designing for Quality and Patient Safety. www.vipcs.org/conf2004/middleton.pdf

Page 6: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005

Decision-Support Examples

Interactions Meds-Meds/Nutraceut.Contraindication/Indic. Medications-ProblemsMonitoring Medications-LabsMedical Necessity Procedures-ProblemsCorrect Coding Init. Procedures-ProceduresInteractions Social Hx-Medications

Page 7: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005

The Interoperability-Adoption Tug-of-War

Interoperability requires standards and limited scopeAdoption favors customization and local preferences producing broad scope

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IMO©2005AHIMA 2005

The Standard Terminology Problem

Despite tremendous effort, there is no standard vocabularyDomain-specific vocabulariesICD-9-CM/CPT®/HCPCS/CDTMedications (FDB, Medi-Span™, Multum™)LOINC® for LabsUMLS (Unified Medical Language System)SNOMED® CT

Page 9: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005

HIPAA-dictated Vocabulary Standards

ICD-9-CM for diseases/problemsICD-P/CPT™/HCPCS for proceduresCDT for dental proceduresNDC for medicationsDRG for inpatient hospitalizations

Page 10: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005

SNOMED- Solving the Reference Problem

Began in 1965 as a Pathology Nomenclature1998 SNOMED 3.5 had 156,000 terms in 12 different modules2000 SNOMED RT w/190,000 terms and 350,000 relationships2002 SNOMED CT combines with the NHS READ codes and has >800,000 terms2004 SNOMED CT was added to UMLS2006 SNOMED CT goes global?

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IMO©2005AHIMA 2005

The User Vocabulary Problem

Like politics, all health care is localDoctors have preferences, and they use them (and want to if you let them)Different doctors have different preferencesDifferent types of users require different vocabularies (doctors, patients, HIM, etc.)

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IMO©2005AHIMA 2005

Interface TerminologyPHT = Personal Health Terminology™>160,000 disease/problem termsPreferred mappings from terms to ICD-9 codes (every term has a billable code) and from codes to termsDifferent mappings for coders, clinicians and patients/enrolleesMapped to SNOMED® CT, MeSH, UMLSIncludes context

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IMO©2005AHIMA 2005

Capturing the Clinical Intent

Synonyms that allow docs to think like docs—not like billers…

“Transaminitis”“Athlete’s foot”“SVT (Superventricular Tachycardia)”“GERD (Gastroesophageal Reflux Disease)“Crohns”“UC (Ulcerative Colitis)”“Heart block”“Cold sore”“Pink eye”

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IMO©2005AHIMA 2005

Weill/Cornell Experience

Production since 6/04Integration of clinical and financial Improved physician acceptanceMore accurate billing (ICD-9/CPT)SNOMED® CT for interoperability

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IMO©2005AHIMA 2005

It is easier for me to find appropriate clinical terms.

0%

10%

20%

30%

40%

50%

Resp

onse

Per

cent

age

"Stro

ngly disa

gree"

"Disa

gree"

"Neu

tral/n

o opinion"

"Agree

""S

trongly

agree

"

Percentage

Source: Weill Cornell Physician Organization

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IMO©2005AHIMA 2005

I can enter more meaningful clinical documentation (more closely describe the true clinical situation, or capture more detailed information).

0%

10%

20%

30%

40%

50%

Resp

onse

Per

cent

age

"Stro

ngly disa

gree"

"Disa

gree"

"Neu

tral/n

o opinion"

"Agree

""S

trongly

agree

"

Percentage

Source: Weill Cornell Physician Organization

Page 17: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005

I spend less time searching for and/or documenting diagnoses/problems in EpicCare.

0%

10%

20%

30%

40%

50%

Res

pons

e P

erce

ntag

e

"Stro

ngly disa

gree"

"Disa

gree"

"Neu

tral/n

o opinion""A

gree"

"Stro

ngly ag

ree"

Percentage

Source: Weill Cornell Physician Organization

Page 18: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005

I am more satisfied with EpicCare.

0%

10%

20%

30%

40%

50%

Resp

onse

Per

cent

age

"Stro

ngly disa

gree"

"Disa

gree"

"Neu

tral/n

o opinion"

"Agree

""S

trongly

agree

"

Percentage

Source: Weill Cornell Physician Organization

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IMO©2005AHIMA 2005

Getting from Clinical to Financial

Not going to replace HIM professionalsClinical concepts do not always have all the “context” required for codingEven having more than one code per concept can be a problemRules-based systems on the horizon but harder to implement and maintainNeed oversight and validation for the maps

Page 20: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005

Mapping from Clinical to Financial

Interface Terms

AmyotrophicLateral Sclerosis

ALS

Lou Gehrig’sDisease

Concept LevelTerminology

AmyotrophicLateral Sclerosis

SNOMED® CTReference

Terminology

AmyotrophicLateral Sclerosis

86044005

ICD-9-CMCoding

AmyotrophicLateral Sclerosis

335.20

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IMO©2005AHIMA 2005

Mapping from Clinical to Financial

SNOMED® CTReference

Terminology

Hemiparesis

20022000

ICD-9-CMCoding

Unspecified Hemiplegiaand Hemiparesis AffectingDominant Side, LE CVA

438.21

Unspecified Hemiplegiaand Hemiparesis Affecting

Nondominant Side, LE CVA

438.22

Clinical Context:Dominant or Nots/p CVA or Not?

?

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IMO©2005AHIMA 2005

Mapping from Clinical to Financial

Interface Terms

Hemiparesis due to CVA, Dominant Side

Hemiparesis AffectingDominant Side, Late Effectof CerebrovascularDisease

Concept LevelTerminology

HemiparesisAffecting

Dominant Side, Late Effect of

CerebrovascularDisease

SNOMED® CTReference

Terminology

Hemiparesis

20022000

Clinical Context:Explicit

ICD-9-CMCoding

Unspecified Hemiplegiaand Hemiparesis AffectingDominant Side, LE CVA

438.21

Unspecified Hemiplegiaand Hemiparesis Affecting

Nondominant Side, LE CVA

438.22

Page 23: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005

Managing the Madness

Clinical users are not happy with administrative terms and have preferencesManaging all the dictionaries is hard workFocus on more frequent regulatory releases means more updates and more workGrace periods disappearingConsequences of failure higherOutsourcing makes sense

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IMO©2005AHIMA 2005

Conclusions

Application Interoperability ROI requires both standards and flexibility in vocabulariesIt’s the data, data, data…Do not underestimate the work if you are going to take it on yourselfGet ready by having a terminology strategy now

Page 25: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005

Intelligent Medical Objects, Inc.

Homepage: http://www.e-imo.comEmail: [email protected]

Page 26: Vocabularies: Critical Software Infrastructure for

IMO©2005AHIMA 2005

Business Intelligence

Page 27: Vocabularies: Critical Software Infrastructure for

Clinical Vocabulary Mapping Methods Institute Saturday, October 15, 2005