Terminology Services to Reduce Avoidable CT Imaging F2F Meeting | 2016 11

Best Practices for Terminology Management

in a Health Information Exchange

Daniel J. Vreeman, PT, DPT, MSc

Regenstrief-McDonald Scholar in Data Standards, Indiana University School of Medicine
Director, LOINC and Health Data Standards, Regenstrief Center for Biomedical Informatics

@djvreeman

2016

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

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

MO DATA MO PROBLEMS

It's like, the more money

we come across
The more problems we see
MO DATA MO PROBLEMS

data

It's like, the more money

we come across
The more problems we see
MO DATA MO PROBLEMS

Proportional Relationship Between

Data and Problems

DATA

PROBLEMS

Proportional Relationship Between

Data and Problems

DATA

PROBLEMS

Problem 1
Variation abounds

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

Problem 2
Youre never done

Across many INPC

institutions, in 2 years after
go live we saw half 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.

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

Why all the change?

Source system testing may have
changed
Source system codes may have changed
Standard terminologies evolve over time

Why all the change?

Source system testing may have
changed
Source system codes may have changed
Standard terminologies evolve over time
More on that later

Top 5 Tips for

Managing
Terminology in an
HIE

Adapted/expanded from

danielvreeman.com/loinc-essentials

Disclosure
Im the author of the book.
This isnt likely to be a NYT Best Seller.
Im hoping to cover hosting/development costs.

Not all juice is worth

the squeeze
In standards, Pareto principle > Long Tail

photo via elwillo | cc-by

A few tests account for most

result volume
70% of the tests take 30% of your
mapping time (and vice versa)
Not every variable will have a
LOINC code

Cumulative Laboratory Observation Volume (%)

100%
90%
80%
70%
60%
50%
40%
30%
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. PMID: 18693941.

Cumulative Laboratory Observation Volume (%)

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

500

1000

1500

2000

2500

3000

3500

4000

Number of Laboratory Observation Codes (N)

In INPC, 80 codes made 80% of volume

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

Keep the end in mind

What are your goals?

photo via janeandd | cc-by

Work smarter, not harder.

photo via consumerist

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.

Dont make assumptions

photo via Tatiana Gerus

Common Mapping Issues

Ambiguous local test names are the norm
No indication of whether quantitative or qualitative
Lab tests with no specimen identified
Everybody knows this is always done on serum!

Totally generic test names

Miscellaneous serology, PCR, culture

You must know the specifics of what this test

actually measures
Local experts, package inserts can be very
informative.
Units of measure, sample results are critical
Can be hard to address as a downstream recipient
Dont throw away information in local test names
by mapping to more general LOINC terms.

Stay up to date

photo via Arul Irudayam | by-nd

LOINC
New releases published twice yearly
June and December

Regenstrief and LOINC Committee Best

Practice
LOINC recommends that users update to the current version
of LOINC within 90 days of its publication.

Why?
The most recent release is always our best
release ever.
The world moves fast.
Maximize the potential benefit of
standardized data.

How?
Join the mailing list, or
Go Premium
curl -O ftps://[username]:[pwd]@loinc.regenstrief.org:990/currentversion.zip

Then, use your updated RELMA

Identify Replacement Terms

Tools -> Find Local Terms Mapped to Deprecated LOINCs

Identify Replacement Terms

Tools -> Find Local Terms Mapped to Deprecated LOINCs

Review commentary

Identify Replacement Terms

Tools -> Find Local Terms Mapped to Deprecated LOINCs

Review commentary
Check the alternatives

Identify Replacement Terms

Tools -> Find Local Terms Mapped to Deprecated LOINCs

Map when ready

Review commentary
Check the alternatives

SNOMED CT
New releases of International Version / US
Edition published twice yearly
IHTSDO License requires prompt updating
Within one-hundred and eighty (180) days after the Licensor has notified
the Licensee of the release of a new version of the International Release,
the Licensee must upgrade the version of the International Release in its
own systems and in the Licensee Products to that new version

RxNorm
Full full RxNorm data set released
NLM also publishes weekly updates with newly
approved drug info
Weekly updates are meant to be used in conjunction with the most
recent full monthly release and any previous weekly updates for that
same month.

Couldnt find any licensing or best practice guidance

about update frequencybut this space moves fast

ICD-10-CM
Updates released yearly

CPT
Updates released yearly

Try to evolve gracefully.

photo via Dawn Huczek | cc-by

Gracefully handle unmapped test results

Strategies weve used when dealing with
unmapped tests in live message streams
Let them flow to the repository for use in clinical care
Display under misc test results in HIE viewers
Work out a mechanism for updating the mappings after the fact
(for example, applications/queries that interact through
terminology services rather than the raw instance level data in
the database).

Create a robust logging /

history mechanism to
track changes
Allow spaces to record in
narrative why a change in
mapping was made

Be vigilant for changes

in source system coding
Things to watch for:
changed test name, changed units, new
codes with the same name

Sharing is caring

photo via polycola| cc-by

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.

Dixon BE, Hook J, Vreeman DJ. Learning From the Crowd in Terminology Mapping: The LOINC Experience. Lab Med. 2015 Spring;46(2):168-74. PMID: 25918199.

Vreeman DJ, Hook J, Dixon BE. Learning from the crowd while mapping to LOINC. J Am Med Inform Assoc. 2015 Jul 29. pii: ocv098. doi: 10.1093/jamia/ocv098.
PubMed PMID: 26224334.

Mapping Repository
A community resource
Value depends on its representativeness
Easy to contribute, and helps advance
interoperability
Dont have to have everything mapped

danielvreeman.com/speaking

photo via milos milosevic