Terminology Services to Reduce Avoidable CT Imaging F2F Meeting | 2015 10 14

Challenges and successes in managing

local healthcare terminologies in a
community-wide HIE
Daniel J. Vreeman, PT, DPT, MSc
Associate Research Professor, Indiana University School of Medicine
Associate Director for Terminology Services, Regenstrief Institute, Inc

2015 CC-BY-NC

Overview
1. We want fluid, comprehensive
health data everywhere
2. We love standards
3. We love our local terminology
4. Five lessons weve learned
photo via Vernio77

Informatics Pioneers
40 years of EMR work
Indiana Network for Patient Care
Most comprehensive and longest tenured Health Information
Exchange (HIE) in USA

Regenstrief is the Data Switzerland

Crash Test Dummies

Informatics Pioneers
40 years of EMR work
Indiana Network for Patient Care

Most comprehensive and longest tenured Health Information

Exchange (HIE) in USA

Regenstrief is the Data Switzerland

Patients typically
move faster and
further than their
health information

41%
of ED visits are for patients with
data at another institution
Finnell JT, Overhage JM, Grannis SJ. All Health Care is Not Local: An Evaluation of the Distribution of Emergency Department Care Delivered in Indiana. AMIA Annu
Symp Proc. 2011;:409-416.

Connectedness among Indiana EDs

Finnell JT, Overhage JM, Grannis SJ. All Health Care is Not Local: An Evaluation of the Distribution of Emergency Department Care Delivered in Indiana. AMIA Annu
Symp Proc. 2011;:409-416.

Nearly every ED in
Indiana shares
patients with
every other ED in
the state

A Humongous Database
200+ source systems
16+ million patients
5.6 billion results
164 million text reports
more than 1 million transactions/day

Fundamental challenges:
Local systems have different ways of
identifying the same concept.
Things that look alike arent the same.

Standards let us (re)use the

data for everything
Clinical care, public health reporting, quality
management, clinical and epidemiological research, etc
photo via pagedooley

Data Standards R Us
Getting the data when and where it is needed

Long History
ASTM 1238-88
HL7 (O&O, V3, etc)
LOINC
UCUM
Collaborator with other SDOs
HL7, IHTSDO, RSNA, SCO

You might be thinking

LOINC, SNOMED CT, RxNORM, etc are
all pretty mature now

Only crazy people would

manage their own terminology!

photo via Tatiana Gerus

LOINC has Pretty Good Coverage

Early studies found 91-92% content
type coverage for a typical hospital
radiology system.

Vreeman DJ, McDonald CJ. A comparison of Intelligent Mapper and document similarity scores for mapping local radiology terms to LOINC. AMIA Annu Symp Proc. 2006;809-813. PMID: 17238453.
Vreeman DJ and McDonald CJ. Automated mapping of local radiology terms to LOINC. AMIA Annu Symp Proc. 2005;769-773. PMID: 16779144.

LOINC has Pretty Good Coverage

Early studies found 91-92% content
type coverage for a typical hospital
radiology system.
Theres a fair bit of highly localized content
in most systems.

Vreeman DJ, McDonald CJ. A comparison of Intelligent Mapper and document similarity scores for mapping local radiology terms to LOINC. AMIA Annu Symp Proc. 2006;809-813. PMID: 17238453.
Vreeman DJ and McDonald CJ. Automated mapping of local radiology terms to LOINC. AMIA Annu Symp Proc. 2005;769-773. PMID: 16779144.

The Regenstrief Dictionary

photo via muffet

Indiana Network for Patient Care

Referral Labs, RxHub, etc

St. Vincent

IUMG

St. Francis

Public Health

IU Health

Community
Wishard Health

Indiana Network for Patient Care

Referral Labs, RxHub, etc

St. Vincent

St. Francis

Global Patient
Index

IUMG

Concept
Dictionary

IU Health

Global Provider
Index

Community
Wishard Health

Public Health

Regenstrief Dictionary
Core interface terminology
HIE services and CPOE at one institution

Progenitor of LOINC
More than 43,000 terms
Questions, answers, and units

Term Attributes
ID

26189

Universal Name

Liver CT WO&W Contr

Description

CT without and with contrast of the liver.

Units
Type (data type)

Code (class)

Source

METHODIST RADIOLOGY

Synonyms

Liver CT WWO Contr; Liver CT WOW Contr; CT Liver WWO

Contr

Mappings
Mapped to standard vocabularies
(ICD, LOINC, SNOMED CT, etc)
All source codes from local institutions
are mapped to Dictionary terms

Pros and Cons

Weighing the benefits and costs of
maintaining a local master dictionary

photo via neurmadic aesthetic

Pros
1. Ultimate control
2. Single code system for
applications across all
content domains

Pros

Hugely valuable

1. Ultimate control
2. Single code system for
applications across all
content domains

Cons
1. Expensive
2. Cant easily use tools from
others
3. Others cant use our innovation
applications as easily

Lessons Learned
Along the Way
photo via IMLS DCC

Lesson 1.
Life is messy.

HL7 messages can be

syntactically correct but
semantically bastardized.
Everything is an OBX.
Everything in the NTE.

HL7 messages can be

syntactically correct but
semantically bastardized.
68 different terms for

Everything is an OBX.
Everything in the NTE.

Pathologist Name

Radiology term names are more

descriptive than lab tests, but
Local nomenclature is still the
wild wild west.
photo via mikemartelli

Variations in kinds of specificity

laterality, views, contrast, etc

Many systems invent multiple

codes for the same test to
distinguish facilities
ZXR1234

STERNOCLAVICULAR JOINTS MIN 3V

CXR1234

STERNOCLAVICULAR JOINTS MIN 3 V

VXR1234

STERNOCLAVICULAR JOINTS MIN 3VWS

XRW1234 STERNOCLAVICULAR JOINTS MIN 3 VI

photo via mikemartelli

Lesson 2.
Terminology management is hard.

A short history of modernist painting (part 2) by Mark Tansey

photo via brainblogger

It might not be brain

surgery, but it requires both
expertise and effort that is
easy to underestimate.
Baorto DM, Cimino JJ, Parvin CA, Kahn MG. Combining laboratory data sets from multiple institutions using the logical observation identifier names and codes (LOINC). Int J Med Inform.1998 Jul;51(1):29-37.

A journey, not a
destination.

For radiology terms, in 2

years after go live we saw
71% as many new local
terms appear as what we
started with.
Vreeman DJ, Stark M, Tomashefski GL, Phillips DR, Dexter PR. Embracing change in a health information exchange. AMIA Annu Symp Proc. 2008 Nov 6:768-72.

New Post-Implementation Local Terms (n)

900
800
700
600
500
400
300
200
100
0
0

6
8
10
12
14
16
18
20
Months Post Initial System Implementation

22

24

Meanwhile, weve always

struggled to find adequate
funding for this work.

photo via Vincent Anderlucci

Lesson 3.
Clear descriptions are king.

photo via JD Hancock

Descriptions are King

Humans need to choose terms accurately
Clear, concise text descriptions for each
term are essential.

photo via _fxr

Descriptions are King

Humans need to choose terms accurately
Clear, concise text descriptions for each
term are essential.
We didnt always understand this.

photo via _fxr

Good Descriptions
Distinguishes this concept from others
Describes what the heck it is

photo via _fxr

Good Descriptions
Distinguishes this concept from others
Describes what the heck it is
What does it measure?
What is it used for?
What is the clinical relevance?
How is the test performed?
photo via _fxr

Lesson 4.
Work smarter, not harder.

photo via consumerist

Pareto Principle
Not every term has equal value

Vreeman DJ, Finnell JT, Overhage JM. A rationale for parsimonious laboratory term mapping by frequency.
AMIA Annu Symp Proc. 2007 Oct 11:771-5. PubMed PMID: 18693941.

Pareto Principle
Not every term has equal value
Cumulative Laboratory Observation Volume (%)

100%
90%
80%

In INPC, 80 codes

70%
60%

made 80% of lab

50%
40%
30%

test volume

20%
10%
0%

500

1000

1500

2000

2500

3000

3500

4000

Number of Laboratory Observation Codes (N)

Vreeman DJ, Finnell JT, Overhage JM. A rationale for parsimonious laboratory term mapping by frequency.
AMIA Annu Symp Proc. 2007 Oct 11:771-5. PubMed PMID: 18693941.

Ongoing exploration of how/

what can be automated.
Bootstrap mappings for similar
names from same institution.

Vreeman DJ. Keeping up with source system changes in a local health information infrastructure: running to stand still. Stud Health Technol Inform.
2007;129:775-779. PMID: 17911822.

Ongoing exploration of how/

what can be automated.
Bootstrap mappings for similar
names from same institution.
In INPC, 46% of new radiology terms were
exact dupes of existing names!
Vreeman DJ. Keeping up with source system changes in a local health information infrastructure: running to stand still. Stud Health Technol Inform.
2007;129:775-779. PMID: 17911822.

Lesson 5.
Standards that get used get better.

Sharing is Caring
Standards will get better if users help
improve them through new term requests.

Most local vocabulary work is done in

isolation at each institution and not shared.
Even among users of the same vendor.
Fidahussein M, Vreeman DJ. A corpus-based approach for automated LOINC mapping. J Am Med Inform Assoc. 2014 Jan 1;21(1):64-72. PMID: 23676247.

Sharing is Caring
Standards will get better if users help
improve them through new term requests.
We built this concept into LOINC license & culture from the beginning.

Most local vocabulary work is done in

isolation at each institution and not shared.
Even among users of the same vendor.
Fidahussein M, Vreeman DJ. A corpus-based approach for automated LOINC mapping. J Am Med Inform Assoc. 2014 Jan 1;21(1):64-72. PMID: 23676247.

Sharing is Caring
Standards will get better if users help
improve them through new term requests.
We built this concept into LOINC license & culture from the beginning.

Most local vocabulary work is done in

isolation at each institution and not shared.
Even among users of the same vendor.
On the mapping front, see https://loinc.org/community/mappings
Fidahussein M, Vreeman DJ. A corpus-based approach for automated LOINC mapping. J Am Med Inform Assoc. 2014 Jan 1;21(1):64-72. PMID: 23676247.

We love local terms!

We love standards!

Were trying to find

harmony using local terms
and standards together

photo via scarlatti2004_images

danielvreeman.com/speaking

photo via milos milosevic