CHDR and Terminology Mediation Services

Veterans Health Administration

IHS Briefing24 April 2007

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Introduction System Description CHDR Interoperability Requirements Standards & Terminology Services Mediation Strategy CHDR Production Testing at El Paso Issues and Challenges Next Steps

Outline

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Clinical Data Repository/Health Data Repository (CHDR) is a patient data exchange project between

the VA and the DoD, mandated by Congress. It aims at computable data exchange

Standards & Terminology Services (STS) is the authoritative source of standard

terminology content and services, including mediation services for CHDR

About CHDR & STS

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Pharmacy Benefits Management (PBM) NDF data management & current pharmacy

applications. Pharmacy Re-Engineering: new enterprise product list & management system

Remote Data Interoperability (RDI) Retrieves patient data from HDR, including DoD data,

and conducts cross-site Pharmacy/Allergy checks Remote Data View (RDV)

Retrieves patient data from HDR, including DoD data, and displays to clinicians within CPRS

VistAWeb Activated through CPRS, it retrieves patient data from

HDR , including DoD data, and displays to clinicians through new Web interface

About PBM, RDV, RDI, and VistAWeb

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About CHI and SDOs Consolidated Health Informatics (CHI) is a

government-wide health IT governance council

Standards Development Organizations (SDOs) involved in the CHDR Phase II project include: UMLS (National Library of Medicine – NLM) RxNorm* (NLM) SNOMED CT (College of American Pathologists) LOINC* (Regenstrief Institute) NDF-RT* (VHA)

* CHI designated standards

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VACHDR

HDR

VistA

VETS

DoDCHDR

TSB

CDR

CHCSDecisionSupport

DecisionSupport

IEN = 76ABACAVIR SO4 300MG TAB

VUID = 4013382ABACAVIR SO4 300MG TAB

VUID = 4013382

RxCUI = 242679Abacavir 300 MG Oral Tablet

NCID = xxxxxxx

IEN = 455ABACAVIR SULFATE (ZIAGEN EQ.) TABLET 300MG ORAL

NCID = xxxxxxxABACAVIR SULFATE (ZIAGEN EQ.) TABLET 300MG ORAL

CHDR Information Flow

RxCUI = 242679Abacavir 300 MG Oral Tablet

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CHDR Interoperability Requirements

1. Standardized & coded patient data exchange

2. Computable data in support ofa) Decision support: drug-drug interactions,

drug-allergy interactions, and duplicative therapy

b) Organization and retrieval: display, trending, verification, grouping, indexing

c) Translation to a different human languaged) Research, outcome analysis, reporting,

project management

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CHDR Interoperability Factors

VACHDR

HDR

VistA

VETS

DoDCHDR

TSB

CDR

CHCSDecisionSupport

DecisionSupport

DataStandardization

Transmission

Transmission

Transmission

DataStandardization

Transmission Transmission

Mediation Mediation

Computability Computability

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Data standardization Pharmacy (4 files), Allergy, Lab

(chem/hem) VUID assignment

Mediation strategy Terminology content and maintenance

plan VETS Mediation Server Mediation success rates

Standards & Terminology Services for CHDR

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1. Select a common mediation terminology compliant with CHI standards (if possible)

2. Map each agency’s terms to the mediation standard

3. Exchange the mediation codes4. Coordinate content maintenance

plans

Mediation Strategy

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DomainMediation Terminology (CHI

Standard)

Pharmacy RxNorm Jun 2005

Drug Allergens UMLS Jan 2005AA

Allergy Reactions SNOMED CT Jan 2005

Lab (chem & hem) LOINC 2.14 Jan 2005

CHDR Phase II Domains and Mediation Terminologies

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VUID VUIDTextRXCUI

RXNorm STR

4007038

RANITIDINE HCL 150MG TAB 198191 Ranitidine 150 MG Oral Tablet

4007047

RANITIDINE HCL 150MG TAB,UD 198191 Ranitidine 150 MG Oral Tablet

4010153

SIMVASTATIN 40MG TAB 198211 Simvastatin 40 MG Oral Tablet

4002651

HYDROCHLOROTHIAZIDE 25MG TAB 310798 Hydrochlorothiazide 25 MG Oral Tablet

4006597

ALBUTEROL 90MCG/SPRAY INHL,ORAL,6.8GM

307782 Albuterol 0.09 MG/ACTUAT Inhalant Solution

4006594

ALBUTEROL SO4 90MCG/ACTUAT (CFC-F) INHL,ORAL,6.7GM

307782 Albuterol 0.09 MG/ACTUAT Inhalant Solution

4005733

ASPIRIN 325MG TAB,EC 198467 Aspirin 325 MG Enteric Coated Tablet

… (TOTAL = 16,784)Mapping established by RxNorm group at NLM

Pharmacy

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VUID VUIDText UMLS CUI

4024394 IPECAC SYRUP C1177130

4022112 INFLUENZA C1176537

4024280 PERFLEXANE C1176320

4021412 FOSAMPRENAVIR C1176315

4021391 APREPITANT C1176306

4021508 NATALIZUMAB C1172734

4024238 NOVASOURCE C1170833

4021356 ESCITALOPRAM OXALATE PREPARATION C1170746

4022498 DEXTROSE/DOPAMINE C1170214

… (TOTAL = 7,660)

Mapping established partly by UMLS group at NLM and partly in-house using Apelon TermWorks mapping tool

Drug Allergens

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Allergy Reactions

VUID VUIDTextSNOMED CT

ID SNOMED CT Text

4637123 BLISTER 339008 Blister (morphologic abnormality)

4637048 APNEA 1023001 Apnea (finding)

4637014 DELUSIONS 2073000 Delusions (finding)

4637129 ANURIA 2472002 Anuria (finding)

4637008 DISCOLORATION OF SKIN 3253007 Discoloration of skin (finding)

4637116 CYANOSIS 3415004 Cyanosis (finding)

… (TOTAL = 814)

Mapping established in-house using Apelon TermWorks mapping tool

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Mapping established in-house using auto-assignment of VUIDs

Lab (chem/hem)

VUID LOINC code LOINC Fully Specified Name

4651683 10412-5 PLATELETS GIVEN:TYPE:PT:^PATIENT:NOM:

4651680 1041-3 G AG:ACNC:PT:RBC:ORD:

4651684 10413-3 RH IMMUNE GLOBULIN GIVEN:VOL:PT:^PATIENT:QN:

4651685 10414-1 TRANSFUSE ALBUMIN:VOL:PT:^PATIENT:QN:

4654917 13452-8 IRON/TRANSFERRIN:MCRTO:PT:SER/PLAS:QN:

4654918 13453-6

GLUCOSE MEAN VALUE:ACNC:PT:BLD:QN:ESTIMATED FROM GLYCATED HEMOGLOBIN

4654919 13454-4 CALCIUM-PHOSPHORUS PRODUCT:ACNC:PT:SER/PLAS:QN:

… … TOTAL = 38,306

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Maintenance Plan

VACHDR

HDR

VistA

VETS

DoDCHDR

TSB

CDR

CHCSDecisionSupport

DecisionSupport

1. Updates to VA NDF

3. Update to Mediation Terminology

4. Updates to DoDPharmacy files

2. Exception handling

The sources of change that are addressed by the Maintenance Plan are shown in yellow

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1. Update NDF in current NDF management system2. Update VistA through the patch process3. Extract global and produce Access database of all NDF +

diff4. Synchronize NDF and NDF-RT (Apelon)5. Send NDF data to RxNorm6. Download new RxNorm from NLM Web site

http://www.nlm.nih.gov/research/umls/rxnorm/index.html7. Extract mapping data from RxNorm files8. Update mapping spreadsheet on VA CHDR SharePoint site9. Check and import mapping data into VETS10. Test content by STS and by SQA11. Deploy VETS to CHDR in AAC12. Test by CHDR SQA13. Share updates with DoD so they can evaluate and add as

needed

1. Updates to Agency’s Term Files

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2. Exception Handling(VA side, symmetrical situation on the DoD side)

VACHDR

HDR

VistA

VETS

DoDCHDR

TSB

CDR

CHCSDecisionSupport

DecisionSupport

VUID is not

recognized

Mediation Code from DoD is not recognized

by VA

VUID is recognized, but

no Mediation Code is found

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Agencies Need to Sync Updates to Mediation Standards

From RxNorm’05

to RxNorm’06

Comments

Count of VUIDs RxCUIs mappings

16,784 No new mapping was done between June’05 and June’06

Retired RxCUIs 689 These are RxCUIs with a mapping to a VUID – e.g., duplicates, better match, …

New RxCUIs 633 These are also RxCUIs with a mapping to a VUID – e.g., RxNorm created a better defined term and gave it a new RxCUI.

VUIDs with changed RxCUI mapping

740 265 were a change to an RxCUI introduced in '06.475 were a change to an RxCUI that already existed in

‘05

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Domain CHI standard (release) Target CHDR schedule

Pharmacy RxNorm (monthly) 4x per year

Drug allergies UMLS (3x per year) 3x per year

Allergy Reactions

SNOMED CT (2x per year) 2x per year

*proposed, not yet confirmed

CHDR Content Update Schedule*

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VETS Mediation Server

Mapping information is checked upon import into VETS Mediation Server Import reports provide record counts and type of

updates made Data consistency – e.g., 1 VUID mapped to 2

mediation codes

Mediation/Translation APIs tested through J-unit test Tests every translation record against input data Tests SQA test cases

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CHDR terminology content (spreadsheets) http://vaww.teamshare.va.gov/VETSProject/ETS

/CHDR/

Terminology portal (Web interface) http://vhaislbll1:7792/portal/

VETS (Terminology APIs) Development environment in Salt Lake City Staging environment in Austin Automation

Center (AAC) Production environment in AAC

Data Location

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CHDR Content Web Site

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Terminology Portal

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Mediation Success Rates

Unmapped Terms

DoD

2

3

4

Unique VATerms

Unique DoD Terms

Common Terms

Unmapped Terms

VA

Inbound Mediation Success Rate (VA DoD)= Sum of Freq (3) / Sum of Freq (3+4)

Outbound Mediation Success Rate (VA DoD)= Sum of Freq (3) / Sum of Freq (2+3)

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Mediation Success Rates (illustration)

INBOUND Mediation Success Rate

OUTBOUND Mediation Success Rate

WITHOUT the use of frequency data

2/4=50% 2/3=66%

WITH the use of frequency data 35%+55%=90% 45%+50%=95%

VA DoDTerm Frequency

Apple 45%

Pear 50%

Loquat 5%

Term Frequency

Apple 35%

Pear 55%

Cumquat 4%

Lemon 6%

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Mediation Success Rate Projections

Inbound mediation

success rate (DoD VA)

Outbound mediation

success rate(VA DoD)

Pharmacy Medications

96% 97%

Drug Allergies --% 61%

Allergy Reactions

100%* 100%*

* This domain started at 100% but unilateral updates have been made since

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VA (unique) DoD (unique)

Pharmacy 2793 (206) 10565 (369)

Allergy Reactants 92 (27) 77 (30)

Allergy Reactions 118 (19) 56 (9)

TOTALS 2993 (252) 10698 (408)

CHDR Production Testing at El Paso

ADC patient count is about 150 per week

244 ASPIRIN

243 ACETAMINOPHEN + HYDROCODONE BITARTRATE

202 IPRATROPIUM 0.2 MG/ML INHALANT SOLUTION [ATROVENT]

180 OMEPRAZOLE 20 MG EXTENDED RELEASE TABLET [PRILOSEC OTC]

308 IPRATROPIUM BR 17MCG/SPRAY AEROSOL,INHL

171 LEVALBUTEROL TARTRATE 59MCG/SPRAY INHL,ORAL,15GM

30 CALCIUM ACETATE 667MG (CA 169MG) CAP

Inbound

Outbound

Inbound

Outbound

OMEPRAZOLE 20MG CAP,SA 763

TABLET CRUSHER 627

MENTHOL 2%/METHYL SALICYLATE 10% OINT,TOP

452

CYCLOBENZAPRINE--PO 10MG TAB 116

HEPARIN *OMNICELL*--INJ 5,000U/1ML SYRN

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CEPACOL SORE THROAT LOZENGE 62

DoDVA

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Exceptions AnalysisPharmacy

Differences in formularies (which can be mitigated partially using RxNorm relationships), incorrect DoD mappings (which is being corrected), incomplete VA mapping (submission to RxNorm needs to be more timely), and supplies (which can be omitted as out of scope for this phase)

Allergens Brand names/generics and different salt forms (which can

be mitigated if we switch mediation terminology from UMLS to RxNorm and use RxNorm relationships), incorrect DoD mappings (which should be corrected), incomplete VA mapping (need to improve submission process)

Reactions Some mapping from NCID to SCTID is missing, VA inactive

terms need to be added, need a standard SNOMED CT based subset for allergy reactions

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Staff Skilled in terminology informatics and subject

matter Good background knowledge in VistA, HDR, CHDR,

… Content

Availability of CHI/National Standards (e.g., no allergens subset yet)

Quality of mapping, smart mapping Coordinated maintenance plan between agencies

and with SDOs* (e.g., standard formats and tools for submissions, requests for new terms, releases, etc.)

* Health-related Terminologies and Classifications: The United States Action Agenda for Global Coordination. AHIMA and AMIA Terminology and Classifications Policy Task Force.

Issues and Challenges

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Issues and Challenges cont.

Communications and training Clinical usefulness even if interoperability

is less than 100% If mediation fails, then exchange free-

text or nothing? Display text needs to be clinician-friendly

and may need to include original text to allow clinicians to see and validate the translation

Review interoperability issues with users and Patient Safety Council

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Improve mediation & coordination with SDOs

Add new domains Lab, Problem list, TIU

Support migration to HealtheVet VHIM, HDR-II, CDS RDV, RDI, VW, Delivery Services

Next Steps