Healthcare Standards? What a Concept!
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Presented at Cambridge Semantic Web Monthly Meetup on September 8, 2015 http://www.meetup.com/The-Cambridge-Semantic-Web-Meetup-Group/events/223161012/
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Healthcare Standards? What a Concept!
- 1. Healthcare Standards? What a Concept! Tomasz Adamusiak MD PhD @7omasz
- 2. Tomasz Adamusiak MD PhD • Chair AMIA Knowledge RepresentaEon and SemanEcs WG • Past: postdoc at NLM, bioinformaEcian at EBI
- 3. Conflict of interest disclosure • Pre-‐sales and post-‐sales support for Thomson Reuters Data Fusion
- 4. Learning ObjecEves • Describe the Meaningful Use requirements and its data standards • Recognize the value of structured clinical informaEon • IdenEfy challenges in interoperability of clinical informaEon systems
- 5. $30 880 000 000 Total payments for Medicare and Medicaid Electronic Health Record (EHR) IncenEve Programs (2011 -‐ July 2015)
- 8. US. health care system is the most expensive and underperforms on most dimensions of performance AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US OVERALL RANKING (2013) 4 10 9 5 5 7 7 3 2 1 11 Quality Care 2 9 8 7 5 4 11 10 3 1 5 Effective Care 4 7 9 6 5 2 11 10 8 1 3 Safe Care 3 10 2 6 7 9 11 5 4 1 7 Coordinated Care 4 8 9 10 5 2 7 11 3 1 6 Patient-Centered Care 5 8 10 7 3 6 11 9 2 1 4 Access 8 9 11 2 4 7 6 4 2 1 9 Cost-Related Problem 9 5 10 4 8 6 3 1 7 1 11 Timeliness of Care 6 11 10 4 2 7 8 9 1 3 5 Efficiency 4 10 8 9 7 3 4 2 6 1 11 Equity 5 9 7 4 8 10 6 1 2 2 11 Healthy Lives 4 8 1 7 5 9 6 2 3 10 11 Health Expenditures/Capita, 2011** $3,800 $4,522 $4,118 $4,495 $5,099 $3,182 $5,669 $3,925 $5,643 $3,405 $8,508 COUNTRY RANKINGS Top 2* Middle Bottom 2* EXHIBIT ES-1. OVERALL RANKING Notes: * Includes ties. ** Expenditures shown in $US PPP (purchasing power parity); Australian $ data are from 2010. Source: Calculated by The Commonwealth Fund based on 2011 International Health Policy Survey of Sicker Adults; 2012 International Health Policy Survey of Primary Care Physicians; 2013 International Health Policy Survey; Commonwealth Fund National Scorecard 2011; World Health Organization; and Organization for Economic Cooperation and Development, OECD Health Data, 2013 (Paris: OECD, Nov. 2013).
- 9. 2004 à 2009 HITECH/ARRA à 2010 PPACA
- 10. $30 880 000 000 Total payments for Medicare and Medicaid Electronic Health Record (EHR) IncenEve Programs (2011 -‐ July 2015)
- 11. Meaningful Use: it paid to start early h_p://www.cms.gov/RegulaEons-‐and-‐Guidance/LegislaEon/EHRIncenEvePrograms/Downloads/Beginners_Guide.pdf
- 12. Each stage has its own set of requirements Final rule, September 4, 2012
- 13. Achieving Meaningful Use CerEficaEon is not straighiorward
- 14. InformaEon exchange is at the heart of Meaningful Use h_ps://www.cms.gov/RegulaEons-‐and-‐Guidance/LegislaEon/EHRIncenEvePrograms/Downloads/EHR_Medicaid_Guide_Remediated_2012.pdf Stage 2 Core Measures: 12. Provide paEents with an electronic copy of their health informaEon, upon request 13. Provide clinical summaries for paEents for each office visit 14. Capability to exchange key clinical informa>on Menu Measure: 8. The EP (…) should provide summary care record for each transiEon of care or referral
- 15. “unstructured document” is explicitly prohibited in transiEon of care Electronic Access Clinical Summaries InformaEon exchange in MU Stage 2 PaEents Referring provider Receiving provider Receiving provider
- 16. Blue Bu_on Get It • Find out what kinds of health informaEon are available via Blue Bu_on and which providers offer it . Check It • Get advice about what to look for in your health record, and your right to correct it. Use It • Discover what you can do with your health informaEon and ways to safeguard and protect your health informaEon
- 18. Structured Summary of Care Problem lists • SNOMED CT MedicaEons • RxNorm Laboratory tests • LOINC Procedures • SNOMED CT • HCPCS + CPT-‐4 • CDT • ICD–10–PCS
- 19. Consolidated CDA provides templates for care summaries Medication Information ManufacturedProduct Medication Activity SubstanceAdministration Medication Supply Order ManufacturedProduct Immunization SubstanceAdministration By ﺍاﻝلﺏبﻱيﻁطﺍاﺭر ﺇإﺏبﻥن own work - [Public domain], via Wikimedia Commons
- 20. Only structured informaEon allowed in MU TransiEon of Care <manufacturedProduct classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.23"/> <manufacturedMaterial> <code code="310965" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Ibuprofen 200 MG Oral Tablet"> </code> </manufacturedMaterial> </manufacturedProduct>
- 21. Only structured informaEon allowed in MU TransiEon of Care <manufacturedProduct classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.23"/> <manufacturedMaterial> <code code="310965" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Ibuprofen 200 MG Oral Tablet"> </code> </manufacturedMaterial> </manufacturedProduct> MedicaEon InformaEon Template RXCUI Normalized Drug Name
- 22. Fast Healthcare Interoperability Resources • Aims to simplify implementaEon without sacrificing informaEon integrity • Derived from HL7 RIM and other important content models • Intended to address the most common (80%) interoperability needs of implementers • Because v3 is hard
- 23. Medical expert systems date back to the 1970s
- 25. Computer-‐Assisted Diagnosis à Clinical Decision Support
- 26. CDS is difficult because computers do not understand text very well HISTORY OF PRESENT INQUIRY: Mr. Smith is a 34-‐year old gentleman who presents at our branch to obtain a car loan secondary to growing maintenance costs of his current vehicle. He otherwise reports doing well. His past financial history is insignificant.
- 27. {vitamin supplements, loEon, hand saniEzers} à {baby-‐related products}
- 28. Target isn't just predicEng pregnancies: expect more savvy data-‐mining tricks (Hill, K. 2012, February 24)
- 29. Mining associaEons in Electronic Health Records Diabetes mellitus Yes No Glucohemoglobin measurement Yes 1509 5442 No 881 99 PosiEve associaEon Background reference EHR-‐based phenome wide associaEon study in pancreaEc cancer. Adamusiak T, Shimoyama M, AMIA Jt Summits Transl Sci Proc. 2014 Apr 7;2014:9-‐15
- 30. Expansion + associaEon 31 CPT-‐4 83036 ICD10 E08-‐E13
- 31. What is in a paEent EHR? 32 0% 10% 20% 30% 40% 50% 60% 70% Other Labs MedicaEons Procedures Problems Concepts (7k) ObservaEons (2M)
- 32. Hierarchical expansion: all DVT terms in ICD-‐10-‐CM 33 Child Concepts
- 33. Caveat: flat hierarchy results in disconnected clinical contexts Find paEents with tuberculosis? • 010-‐018.99 TUBERCULOSIS • 137 Late effects of tuberculosis • 647.3 Tuberculosis complicaEng pregnancy childbirth or the puerperium 34
- 34. More difficult in SNOMED CT 35 MulEple inheritance Child Concepts
- 35. Gap between clinical and billing terminology standards
- 36. In pursuit of a single language Pieter Brueghel the Elder (1526/1530–1569) [Public domain], via Wikimedia Commons
- 37. IntegraEng terminologies with Unified Medical Language System Donald A.B. Lindberg, M.D Clinical Terminologies UMLS
- 38. UMLS Exanthema C0015230 SNOMED CT ICD-‐10-‐CM UMLS establishes equivalence mappings across biomedical terminologies SNOMED CT rash NOS ICD-10:R21 Cutaneous eruption SCT:112625008 Eruption SCT:1806006
- 39. UMLS Exanthema C0015230 SNOMED CT ICD-‐10-‐CM UMLS establishes equivalence mappings across biomedical terminologies SNOMED CT Cutaneous eruption SCT:112625008 rash NOS ICD-10:R21 Eruption SCT:1806006
- 40. Expansion in UMLS across MU sources 41 Diabetes mellitus without menEon of complicaEon, type II or unspecified type, not stated as uncontrolled ICD-‐9 ICD-‐10 SNOMED CT NDF-‐RT SituaEon with explicit context Metabolic diseases roots:
- 41. Ontological six degrees of Kevin Bacon Acute myocardial infarcEon Myocardial ischemia Vascular Diseases Disorder of so€ Essue Collagen Diseases ConnecEve Tissue Diseases Epidermal and dermal condiEons Skin and subcutaneous Essue disorders Dermatologic disorders
- 42. Open issue: reconciling lab orders with results Clinical Laboratory Hemoglobin A1c/ Hemoglobin .total in Blood by HPLC LOINC:17856-‐6 Hemoglobin; glycosylated (A1C) CPT-‐4:83036 43
- 43. ExtracEng geneEc informaEon out of EHR is a major challenge 44 • PLEASE INFORM **NAME[ZZZ] OF MTHFR MUTATION. • WE WILL NEED ADDITIONAL TESTING: FOR NOW, FOLATE, SAME, MTHFR. • MARGINAL PLACENTA PREVIA MTHFR MUTATION, HETERO X 2 C677T AND A1298C • UTI COMPLICATING PREGNANCY HOMOZYGOUS FOR C677T POLYMORPHISM OF MTHFR 1 COPY OF MTHFR MUTATION A1298C DETECTED
- 44. LOINC is complex 45 1 result
- 45. LOINC is an ideal candidate for DL because of its composiEonal structure 46 Part Type Part Name Component Crea>nine Property MCnc Time Pt System Ser/Plas Scale Qn 2160-‐0 CreaEnine [Mass/volume] in Serum or Plasma (has_component some Crea>nine) and (has_property some MCnc) and (has_5me_aspect some Pt ) and (has_system some Ser/Plas) and (has_scale some Qn) Code: Parts: DL defini>on:
- 46. Used SNOMED CT to enrich LOINC hierarchy 47 Urine 78014005 Body fluid 32457005 Body Fluids C0005889 Urine C0042036 owl:EquivalentTo owl:EquivalentTo ISA Body fluid LP30504-‐2 Urine LP7681-‐2
- 47. MulEaxial Inferred OBS Glucose OBS Glucose| Urine Separated codes and parts and defined corresponding observaEons 48 Protein & Glucose panel in Urine by Test strip Glucose Glucose | Urine Urine ≡ ≡ Glucose in 10 hour Urine Glucose in Urine by Test strip ≡ ≡ ≡
- 48. 1. Created logical definiEons 2. Classified the ontology with a reasoner 49 OBS Glucose | Urine ≡ Glucose in 10 hour Urine ≡ has_component some Glucose and has_property some Arbitrary Concentra5on and has_Eme_aspect some Point in 5me (spot) and has_system some Urine and has_scale some Ord and has_method some Test strip has_component some Glucose and has_system some Urine DL definiEon DL definiEon Inferred
- 49. Query expansion with subsumpEon reasoning 50 DL: 189 results Sugars / sugar metabolism Carbohydrat es Carbohy drates | Urine 16550-‐6 Glucose Glucose | Urine 2350-‐7 Carbohydr ates Carboh ydrates | Urine Glucose | Urine 2350-‐7 Fructose | Urine 16550-‐6 1 result
- 50. 9 006 concepts 693 256 connecEons Quality assurance in LOINC using descripEon logic PMID:23304386
- 51. SNOMED CT as possible universal language of healthcare • Updated Technology Preview of the LOINC-‐SNOMED CT CooperaEve Project – September 2015 15k LOINC – SNOMED CT expressions h_p://www.nlm.nih.gov/research/umls/licensedcontent/ snomedciiles.html • Integration with ICD-11 h_p://www.ncbi.nlm.nih.gov/pubmed/23920573
- 52. COST?
- 53. $1.3 trillion
- 54. Thank You