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RAPID Core Data Element Development in LOINC
Susan Matney, PhD, RNC-OB, FAAN
Stan Huff, MD, FHL7, FACMI
Why standard models and codes?
• So that there is a standard, computable, and publicly known meaning for the data elements
• We can use the same models and definitions for sharing data with:• MDEpiNet RAPID (and other MDEpiNet projects)
• Direct patient care
• Quality and disease specific registries
• Research
• Patient data to CMS
• Public health reporting, including to CDC
• FDA for device and product approval
Graphic of a Detailed Clinical Model
data 138 mmHg
SystolicBPSystolicBPObs
quals
data Right Arm
BodyLocationBodyLocation
data Sitting
PatientPositionPatientPositionSNOMED CT
LOINC or SNOMED Observable
3
The structure of the data plus the codes make the representation complete.
The Interoperability Development Process
Project Needs
• MDEpiNet RAPID• OPA Data Collection• Skin and Wound Assessment• Neonatal Bilirubin• PCORI• ACC registries
TerminologyServer
(SOLOR)
Domain Analysis
Create Logical Models (CIMI)
Approve Models
Model Repository
Create Physical
Artifacts (FHIR
Profiles)
Artifact
Repository(FHIR Profiles)
Create Software
(Apps, Services, CDS)
Conformance Testing
Information Requirements
Inception to Model
Domain Analysis Model
Model Request Spreadsheet
Design Patterns
SNOMED CT Concept Model
ISO 13606
openEHR
Clinical Quality Information
CIMI Requirements Specification Design
Information model
Constraint templates
Terminology
Current Status (from Susan Matney)
• Working as time and resources permit
• 67 data elements in a model request spreadsheet
• 4/67 (6%) match of RAPID data elements to LOINC
• Some of the modeling issues:• Modified Rutherford, Wound Grade (Wlfl) and Infection Grade (Wlfl) scales
not in LOINC (submitted)
• Devices listed as data elements (Cryo-Balloon, Scoring Balloon, Drug-Coated Balloon) which are values
• Yes/No questions for Assertions and Procedures (Graft, Lower Extremity Bypass, Hematoma, Hemorrhage)
Data Entry Styles
Device Use
Cryo-Balloon
Scoring Balloon
Drug-Coated Ballon
Yes No Unk
Device Used
Cryo-Balloon
Scoring Balloon
Cryo-Balloon (repeating field)
(handles pertinent
negatives)
Clinical Information Interoperability Council
1St Meeting July 13, 2017NIH Clinical Center, Masur Auditorium,
Bethesda Maryland
Goals for the meeting
• Develop a common understanding of problems to be addressed
• Make a plan for defining common data elements that can be shared and used across all of healthcare
• Obtain commitments across stakeholders to collaborate to share resources to reduce duplication of efforts and adopt common data elements
• Agree on a process for prioritizing the work
• Determine how we delegate responsibility for subject domains to specific organizations or groups
• Agree on a process for governing the work and making decisions
• Develop a plan for moving forward
Discussion
Process• Domain Experts Submit Use Case
• Use Case Reviewed by CIMI – CIMI agrees
• Domain Analysis Model
• DAM used to populate CIMI model template spreadsheet
• Review the Questions and Answers in the Spreadsheet
• Align Questions with CIMI Patterns• Wound = assertion• Wound measurements = EvaluationResults
• Use high level BMM patterns to model Detailed Clinical Models (DCMs)
• Encode with Standard Terminologies (LOINC, SNOMED CT, RxNorm, …)
• Create the DCMs
• Transform to other structures (e.g. FHIR profiles)
Wound DAM (Skin Risk Assessment)class Wound
Exudate
Dressing
«enumeration»
PeriwoundCondition
Tunnel
- direction: int- length: PQ
Undermining
- depth: PQ- direction: int- length: PQ
Wound
- bedAppearance: WoundBedAppearance- closureType: WoundClosureType- depth: PQ- edgeAppearance: WoundEdgeAppearance- length: PQ- periwoundCondition: PeriwoundCondition- type: WoundKind- width: PQ- Wound Number: PQ
«enumeration»WoundBedAppearance
«enumeration»WoundClosureType«enumeration»
WoundEdgeAppearance«enumerati...
WoundKind
Pressure Ulcer
«enumerati...ExudateQuantity
«enumeration»ExudateAppearance«enumerati...
ExudateColor
«enumerati...DressingPosition«enumerati...
DressingKindhasUndermining
hasDressinghasTunneling
exudes
Assertion
• Key = a code meaning “assertion”
• Code (was name) = a code representing what’s being asserted (“rash”, “auto accident”, “hypertrophy”, etc.)• Concepts from SNOMED CT
“Clinical Finding” hierarchy
• Finding site for the assertion (“nose”, “elbow”)• Concepts from SNOMED CT
“Body Location” hierarchy
Assertion Example
Finding Site Assertion String Syntax
The patient has a diabetic ulcer on the
right foot
WoundAssertion
key: WoundAssertion
Code: Diabetic foot ulcer (disorder)
bodylocation: Foot structure (body structure)
body side: Right (qualifier value)
Context: Confirmed present (qualifier value)
Evaluation Result
Key = a code meaning “Evaluation Result”
Code = the item being observed Concepts from SNOMED CT
“Observable Entity” hierarchy OR LOINC
Result = the result of the observation
EvaluationResult Examples
Physical Evaluation String Syntax
The patient’s skin turgor is
friable
SkinTurgorEval
key: EvaluationResult
Code: Skin turgor (observable entity)
result: Fragile skin (finding)
evaluationProcedure: Inspection (procedure)
Context: Confirmed present (qualifier value)
Wound Assertion Development Process
• High level pattern identified (if created)• Wound Assertion is a specialization
of Finding Site Assertion• Data Type and cardinality identified for
each data element• Terminology bindings created for data
elements and values in enumerated value sets
• Archetype Definition Language (ADL) created for each detailed clinical model
CIMI Model Data Elements
Element Display NameData
TypeCardinality Optionality
Assertion Wound Present Coded 0..1 Mandatory
PhysicalEval Wound Type Coded 0..1 Mandatory
Property Body Location Coded 0..* Conditional
CIMI Model Data Elements
Element Display NameData
TypeCardinality Optionality
Assertion Wound Present Coded 0..1 Mandatory
PhysicalEval Wound Type Coded 0..1 Mandatory
Property Body Location Coded 0..* Conditional
Panel Grouping Wound Size 0..1Conditional
PhysicalEval Wound Width Eval PQ 0..1
PhysicalEval Wound Length Eval PQ 0..1
PhysicalEval Wound Depth Eval PQ 0..1
CIMI Model Data Elements
Element Display NameData
TypeCardinality Optionality
Assertion Wound Present Coded 0..1 Mandatory
PhysicalEval Wound Type Coded 0..1 Mandatory
Property Body Location Coded 0..* Conditional
Panel Grouping Wound Size 0..1Conditional
PhysicalEval Wound Width Eval PQ 0..1
PhysicalEval Wound Length Eval PQ 0..1
PhysicalEval Wound Depth Eval PQ 0..1
PhysicalEval Periwound Condition Eval Coded 0..* Conditional
Encoding The DCM
22
Type Text Terminology Code FSN
Finding Wound Present SNOMED CT 416462003 Wound (disorder)
Observation Wound Type LOINC 72300-7 Skin Alteration:Type:PT:Skin:Nom:::
Value Diabetic Foot Ulcer SNOMED CT 371087003 Diabetic foot ulcer (disorder)
Encoding The Patient Story
23
Type Text Terminology Code FSN
Finding Wound Present SNOMED CT 416462003 Wound (disorder)
Observation Wound Type LOINC 72300-7 Skin Alteration:Type:PT:Skin:Nom:::
Value Diabetic Foot Ulcer SNOMED CT 371087003 Diabetic foot ulcer (disorder)
Observation Body Location LOINC 39112-8Body location
qualifier:Find:PT:^Patient:Nom::
Value Foot SNOMED CT 56459004 Foot structure (body structure)
Encoding The Patient Story
24
Type Text Terminology Code FSN
Finding Wound Present SNOMED CT 416462003 Wound (disorder)
Observation Wound Type LOINC 72300-7 Skin Alteration:Type:PT:Skin:Nom:::
Value Diabetic Foot Ulcer SNOMED CT 371087003 Diabetic foot ulcer (disorder)
Observation Body Location LOINC 39112-8Body location
qualifier:Find:PT:^Patient:Nom::
Value Foot SNOMED CT 56459004 Foot structure (body structure)
Panel/Grouping Wound Size LOINC 72287-6 Wound Size Panel::PT:Wound::
Question 1 Wound Width LOINC 39125-0 Width:Len:PT:Wound:Qn::
Value 3 centimeters SNOMED CT 258672001 centimeter (qualifier value))
Question 2 Wound Length LOINC 39126-8 Length:Len:PT:Wound:Qn::
Question 3 Wound Depth LOINC 39127-6 Depth:Len:PT:Wound:Qn::
LOINC Wound Assessment Panel
Conclusion
• Identify Requirements and Use Case
• Develop the DAM
• Complete the DCM Template
• Determine Model Patterns
• Bind to the Appropriate Standard Terminologies
• Create the Detailed Clinical Models (DCMs)
• Transform to FHIR
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