Health and Human Services: 990329td

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Testimony of Wes Rishel 29 March 1999

0

Message Formats, Models, and Syntax

Testimony for the National Committeeon Vital & Health Statistics

29 March 1999

Wes Rishel

Technical Vice-Chair, Health Level-Seven

Primary Affiliation: Wes Rishel Consulting

Alameda, CA

[email protected]




1

3/29/1999 1Testimony of Wes Rishel

([SHULHQFH

Standards/Experience Cycle




2


Versions 2.x

Strengthsbroad functional

coverage

highly adaptable

• IS environments differ

• system capabilities

variationsvocabulary independent

least commondenominator technological base

Difficultiesbroad functional

coverage

highly adaptable

• “Seen one? Seen one.”

• vendor capability

mismatchvocabulary independent

least commondenominator technological base




3


Functions of Comparable PMRI

• Extending the efficiency and efficacy of individual providers and organizations

• Extending the efficiency and efficacy of healthcare

Extending the efficiency and efficacy of individual providers andorganizations

availability of current information at the point of care

across provider organizations

within rapidly changing provider organizations

decision support

support for standards of assessment and care

support for the somewhat bewildering array of administrativeconstraints on decision making and requirements for supporting data

Extending the efficiency and efficacy of healthcareevidence-based medicine

public health

public policy




4


Interfaces Within an Organization

Clinician

Admin

Provider Organization

Clinician

Information

System

Information

System

Admin

Information

System

Governmental or societal interest less direct

assurance of quality

assurance of availability of information




5


Interfaces Among Organizations

Provider

Organization

Payer

Organization

Sponsor

Organization

Aggregating

Organization

Provider

Organization

Payer

Organization

Governmental or societal interest is direct

cost containment with quality

assurance of availability of information

barriers more difficult without government intervention




6


Prerequisites for Exchanging Comparable PMRI

Technologies and Syntaxes

Kinds of Information Interchange

Information ContentRIM, Vocabulary,

Clinical Templates

Messages, Documents, Rules

Version 2 Syntax, XML, MIME (email/Web),

Component Technologies

Technologies and syntaxes are important, but the primary challenges are in

specifying information content.

Technology and syntax are interrelated

Appropriate combinations of technology and syntax reduce the cost and other

barriers to acceptance within the industry

e.g.,

reduced programming, debugging, and customization costs

use if the Internet with suitable safeguards for

interorganizational information transfer




7


How Comparable is Comparable?

• What does it mean not to be comparable? Communicate less information?

Communicate less precisely?

Tolerate a percentage of error?

• acceptable for statistical applications

Have bilateral implementation agreements

• costs measured on a “per system” basis

• inconsistent with previous HIPAA requirements




8


What Does Comparability Cost?

• There is now, and for the foreseeable future, a costbarrier to full exchange of comparable fine-grainedinformation

• The barriers are not primarily attributable to the syntaxor technologies of information exchange

• They are attributable to:

the need for combined standardization on• information structure

• vocabulary

• The cost of initially collecting the information to beexchanged




9


HL7 Contributions

• Information Structures Reference Information Model

Clinical Templates

Semi-definitive approach toVocabulary

• Expanded Applications

• All Appropriate

Technologies

Technologies and Syntaxes

Kinds of Information Interchange

Information Content

RIM, Vocabulary,

Clinical Templates

Messages, Documents, Rules

Version 2 Syntax, XML, MIME (email/Web),

Component Technologies




10


The Approach

• The HL7 Vocabulary TC is committed to using

existing vocabularies (coding systems) as values for

coded fields in HL7 messages, rather than creating

a new terminology.

• We need a solution that allows HL7 to reference

and use proprietary vocabularies (SNOMED, Read,

etc.) in a manner that is equitable to all vocabulary

creation/maintenance organizations.




11


HL7 Assumptions

• Should not choose a single proprietary scheme

• Free-for-use coding systems preferred

• “Market model” will assure responsivemaintenance

• Proprietary vocabulary use requires a license




12


ORU: The usual result message

Element LoopAnswer Part Loop

ORU Observational Results (Unsolicited)

MSH Message Header

PID Patient Identification

{OBR Observations Report ID

{OBX} Observation/Result

}




13


How much meaning to put in a code?

HL7 OBX Segment (simplified)OBX | Observation Id | Value | UnitsOBX | 123^Ser Na Conc | 138 | mmol/L

Possible Codes for Observation Id123 Serum Na Concentration456 Serum Na Concentration (mmol/L)

Code meanings must be consistent with the datastructure within which they will be used !




14


The Missing Link: Clinical Templates

• Universal “trading partner agreements”

• More specific

• More costly




15


An instance of an ORU message

MSH, EVN, PID, PV1, ORC,

OBR||8974-9^BP Battery^LN|

OBX|1|CE|8357-6^METHOD^LN|M^Manual|

OBX|2|CE|8358-4^DEVICE^LN|1|AC^Adult Cuff|

OBX|3|CE|8359-2^SITE^LN|1|RBA^Rt Brachial Artery|

OBX|4|CE|8361-7^POSITION^LN|1|SIT^Sitting|

OBX|5|NM|8479-8^SBP^LN|1|138|mmHg|

OBX|6|NM|8462-4^DBP^LN|1|85|mmHg|




16


A BP Battery Template

Battery Level ConstraintBPBattery ::= SET {

obr {

universalServiceID (8974-9^BP Battery) }

obxs {

MethodObs,

DeviceObs,

SiteObs,

PositionObs,

SystolicBPObs,

DiastolicBPObs }




17


Observation Template

Observation level constraint

PositionObs ::= SET{

observationId (8361^POSITION^LN),

value (PositionDomain) }

SystolicBPObs ::= SET{

observationId (8479-8^SBP^LN),

value (Numeric, “DDD”) },

units (mmHg) }




18


The RIM and Clinical Templates

P a tie n t_ slo t

R e fe rr a l

au tho riz ed_vis i t s_ qtyde s cre aso n_ txt

D i eta r y _in te n t_o r _o r de r

die t_t yp e_c ddie tar y_ inst ruc tion _d escdie tar y_ tra y_t ype _cd

s e r v i c e _pe r i od _c ds e r v i c e _t y pe_ c d

I nd ivi d ua l _h ea lt hc a re _p r ac tit io n er _sl ot

Ob se rv a tio n _in te n t_ or _o r de r

pa t i en t _ haz ar d _c d

re aso n_ for_ stu dy_ cdre levan t_c linica l_in fo rm at ion_ txt

re por tin g_p rior ity_ cdsp ecim e n_a ctio n_c d

T r ea tm en t_ ser vi ce _e ve n t

pr es c r i p t i on _i dr e f i l l s _r em ai n i ng_ qt yno tes _t xtP Tr out

P Tc om pi nd i c at i on _c dex pira tio n_d ttmsu bst an ce_ lot_ n um b er_ txt

sub st an ce_ ma nufa c t ure r_c d

T re a tm e n t_se r vic e_ a dm i ni str at io n

ad min ist ere d_r ate _ tx tco mp let ion_ sta tus _c d

su bst an ce_ refu sal_ re aso n_c dsu bst itu tion _cdsy ste m _en try _dt tm

T re a tm e n t_se r vic e_ d isp en se

dis pen se _pa cka ge_ m et hod_ cddis pen s e_pa ck age_ si ze_ amtne eds _h um an_ review _indr ejec tio n_r easo n_ txt

s u bs t i t ut i on _c ds u ppl i e r s _s p ec i a l _di s pe ns i n g_ inst ru ction _c dto tal_ da ily_d ose _am t

T re a tm e n t_se r vic e_ g ive

ad m i n i s t r at i on_ des c

gi v e_ pe r _t i m e _un i t _c dgive_ qu ant ityt imin g_q tgive_ ra te_ am tm ax _ gi v e_ am tm i n_g i v e_a m t

nee ds _h um an_ review _indsub st itut ion _st atus _c ds u ppl i e r _ s pe c i al _ adm i n i s t r at i o n_i n s t r uc t i on _c d

Go a l

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cu rre nt _re vie w _st atu s_ dtt mep isod e_ of_c are _ides tab lish ed_ dtt mev al u at i on_ c d

ev al u at i on_ c om m ent _t x tex pec te d_a chie ve me n t _dt tmgo al_lis t_ prio rity _am tlife_ cyc le_ dtt m

life_ cyc le_ sta tus _cdm ana ge m e nt _ di s c i pl i n e_c d

ne xt_ re vie w _dt tmpr eviou s_r eview _d ttm

re vie w _in ter va l_cdta rge t_ txtta rge t_ typ e_c d

go al _c d

C li ni ca l_ ob se rv at io n

ab nor m al_r esu lt_in d

las t_o bs erved _no rm al_ va lues _dt tmna tur e_ of_a bno rm al_ tes ting _cdclin ical ly_r eleva n t_b eg in_d ttmc l i n i c al l y _r el ev an t _e nd _dt t mob ser va tio n_m et hod _c d

ob ser va tio n_s tat us_ cdob ser va tio n_s tat us_ dt tmob ser va tio n_s ub_ id

ob ser va tio n_valu e_t xtpr oba bilit y_a mtre fere nc es_ ran ge_ txtun ive rs al_s ervice _ide nt ifier_ suffix _t xtus er_ de fined _ac ces s_ che ck_ txt

v al ue _t y pe _c dv al ue _u ni t s _c d

P a tie n t_ a oi nt m e nt _

C o nse n t

C a re _e v en t

A sse ssm e nt

R e sou r ce _r e qu e st

allo w ab le _s ubs t i t u t i o ns _ c d

du rat ion _qt yst art _d ttmst art _o ffset _qt yst atu s_ cd

A p po i n tm e nt_ r eq u e st

ap poin tm en t_r qst _re as on_ cd

ap poin tm en t_r qst _ty pe _ cdequ i p_s e le ct ion_ crit er ia_p vidloc atio n_ sele ctio n_c rit eria _pvoc c ur en c e_ i d

pr iorit y_ cdre pea ting _int er va l_du ra ti on _qt yre que st ed_ ri

rq st_ even t_r eas on_ cdrq sted _ dur atio n_q tyst art _d tt i m e_ s e l ec t i on_ c r i t er i a_p v

0

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D u ra b le _m e d ica l_ e qu ip m e nt _sl ot

D u ra b le _m e d ic a l_ e qu i m e nt

ids l ot _s i z e _i nc r em en t _ qt y

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qua nt ity_ am tty pe_ cd

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o pera ti ng_ reim bur se m e nt _am tre imb ur sem en t_a mts tand a rd_d ay _qt ys tand a rd_t ot al_c har ge _ am tt r i m _ hi gh_d ay _qt y

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P a tie n t_ de p ar tu r e

ac t ua l _d i s c h ar g e_d i s p os i t i on_ c ddis cha rg e_d ttmdis cha rg e_lo cat ion_ id

ex pec t e d_di s c h ar g e_ di s p _c d

P a ti en t_ a dm i s si o n

ad m iss ion_ dtt mad m i s s i on_r ea s on _c d

ad mi ssi on_r efe rra l_ c dad m i s s i on_s ou r c e _c dad m i s s i on_t y pe _c d

pa t i e nt _v al ua bl es _de s cpr e_a d mit_ te st_ indr eadm i s s i o n_i n dv al u abl es _ l oc a t i on _d es c

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pr act itio ne r_t ype_ cd0

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do sag e_ txtea rlies t_ disp ens e_d tI nd i c at i on _c dno n_fo rm _a uth oriz ed _indpr ovide rs_ tre atm en t_ in st ruc tion _tx t

re ject ion _re aso n_c dre que st ed_ give_r ate _a mtre que st ed_ give_ s tre ng th_ am t

su bst itu tion _allo w ed_ inds u ppl i e r _ s pe c i al _ di s p en s i ng _i ns t r u c t i on_ c dverific at ion_ req uire d_ ind

T re a tm e n t_i nt e n t_ o r_ or d er _r e vi sio n

dis pen se _pa cka ge_ m eth od_ cddi s pen s e _pa c k a ge_ s i z e_a m tgi v e_ i nd i c at i on_ c d

gi v e_ pe r _t i m e _un i t _c d

give_ ra te_ am tlas t_r efille d_d ttmm ax _ gi v e_ am tm in_g ive_a mt

ne eds _h um an_ review _indor der _r evision _P Tc om por de r_r evision _P Tr ou t

or der _r evision _qu ant ity tim ing_ qtor der ed _ad min istr ati o n_ me tho d_c dpr es c r i p t i on _i dpr ov i de r s _ adm i ni s t r a t i o n_i n s t r uc t i on _c dre fills_a llow e d_q ty

re fills_d os es_ disp ens ed _qt yre fills_r em ain ing_ qtysu bst itu tion _st atu s_c ds u ppl i e r s _di s pen s i ng _i n s t r uc t i on_ c d

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id1

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C o nd it io n _n od e

ac tua l_r eso lutio n_d tt mes tim at ed_ res olut i on _dt tm

life_ cyc le_ sta tus _dt tmlifec ycl e_s tat us_ cdm ana ge m e nt _ di s c i pl i ne_c don set _t ime _tx ton set _d ttm

r a nk i n g_ am tem plo ym en t_r elat ed_ ind

P ro ce d u r e

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pr oc e du r e_ c dpr oce du re_ dtt mpr oc edu re _fun ction al_ ty pe_ cd

pr oce du re_ min ute _ qt ym odi f i e r _ c d

P a tie n t_ ser v i ce _lo c at io n_ slo t

P a tie n t_ ser v ice _lo c at io n_ r eq u e st

ty pe_ cd

P a tie n t_ ser vi ce _l oc at io n_ gr o u p

id

0

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is_ re que st ed_b y0

m ay _ r e que s t

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S e rv ic e_ in te nt _o r_ o rd e r_

rel ation s hip_ type _c dre fle x_ te stin g_t rigg e r _ru les_ des c

co nst rai nt_ txt

qua nt it yt im in g_ qt

P r ea u th o ri za tio n

au tho riz ed_ enc o u nte rs_ am tau t ho r i z ed _per i od _be gi n _dt

au th oriz ed _pe riod _en d_ dt

idi s s ued _ dt t m

re que st ed_ dtt mr estr ict ion _de sc

st atu s_ cd

st atu s_ cha ng e_d ttm

A d m in ist ra ti ve _b ir t h_ eve n t

ba by _ de t ai n ed_ i ndbir th_ ce rtific ate _idbi r t h_ m et h od_ c d

bi r t h_ r e c or ded _c o unt y _ c dbi r t h_ r e c or ded _dtne w bor n_ day s_q tyst illbor n_ ind

P a tie n t_ ar r iva l

ac ui t y _l e v e l _c dar rival_ dtt mar rival_ typ e_c d

m edi c al _ s er v i c e_i dso urc e_ of_a rrival_ cdm ode _c d

R isk _m a n ag e m en t_ in ci de n t

i nc i den t _ c d

inc iden t _dt tmin cide nt _se ve rity _cdinc iden t_ ty pe_c d

A o in t m en t

ap poin tm en t_d ispo sit ion_ cdap poin t men t_d ura ti on _ qtyap poin tm en t_r eas on_ cd

ap poin t men t_r equ e st _r ea son_ cdap poin tm en t_t imin g_ tqap poin t men t_t ype _cd

ca nce llat ion_ dtt mca nce llat ion_ rea son _c des tim at ed_ dur atio n _a m teven t_r ea son _cdex pec t e d_e nd_ dt t m

ex pec t e d_s er v i c e _de s cex pec te d_s tar t_d ttmidoc c ur en c e_ i dov er boo k _ i nd

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Root

Stakeholder Service Event

AssessmentOrderOrganization Person

Rx Order

Service Order

Observation

Goal

LytesChem7

HctCBC

Vitals

ABGsLiverUA

CoagDiff Retics

ChestHeartEye

HgbNaCrPO2O2 Sat

120+

1,000+




19


What are clinical templates?

• “Constraint of an existing information model”Reference Information Model (RIM)

• Constraint of specific RIM classes:

clinical assessment

clinical observation

service event

service order

others

• Can be applied to Version 2.X or version 3.0




20


What Kinds of Data Will Templates Describe?

• Clinical laboratory batteries

• Physical exam findings

• Microbiology culture results

• Immunization queries and results

• Claims attachments

• Medical Records Documents (transcription)

• And hundreds more ….




21


Clinical Template Work Items

• Define the formal notation for templates

• Define a process for creating, approving, andmaintaining templates

• Define a mechanism for participating withprofessional societies or other clinical experts in the

creation of template content

• Create a repository for storing and allowing accessto templates




22


Where Will Clinical Templates be Used?

• Messages with fine-grained,comparable, clinical data

• Documents

• Rules




23


HL7-HIPAA Claims Attachments

• Collaborative team: HCFA, X12, HL7

• HL7 version 2.3 syntax embedded within X12275 transaction Rigid pattern of segments

Variability through LOINC codes

• No bilateral trading partner agreements

• Varying degrees of granularity

• Comparability requires more or less human judgement

• This is a primitive form of clinical template




24


The Other Cost of Fine-Grained Information

Clinician

Admin

Provider Organization

Clinician

Information

System

Information

System

Admin

Information

System This is not a

solved problem

Much of the most valuable information comes from providers making care

decisions

Capturing information requires provider interaction with the computer at or

near the time of making the decisions

The time of the provider is itself a major cost

We rely on medical record designs to co-optimize physician time and

information quality

This is not a solved problem




25


( [ S H U L H Q F H

Co-Evolution of EMRs and Standards

ClinicianInformationSystem

The issues are not wholly separable

The latency time for improvements is substantial

standards development

system engineering cycles

provider implementation cycles

The situation has similarities to automobile mileage and pollution regulation




26


What Can the Government Do?

• Establish Time-Based Goals With Teeth

• Require no trading partner agreements foraggregation requirements

• Don’t let the perfect be the enemy of the good early on: emphasize selective achievements consistent with

current systems and extant standards

• Don’t let the good be the enemy of the better long term: raise the bar to promote finer-grained standards in

time frames consistent with industry product cycles





Specific Governmental Actions

• Support the creation of clinical templatesMethodology

Outreach to clinical specialty groups

• Strongly influence in the business of providingvocabulariesSelect, sponsor, negotiate public rates for a few

important vocabularies• Drugs

• Signs, symptoms, diagnoses, history, physical exam

• Laboratory findings

• Observation identification