150 Navigating the Maze Shelley Weems, RHIA, CCS

150 Navigating the Maze

Shelley Weems, RHIA, CCSSTS Standardization Analyst

Holli MurphySTS Terminology Analyst

Standards & Terminology Services (STS)

Objectives

• What is terminology standardization and how does it benefit our veterans?

• How are VHA standards established and implemented?

• To map or not to map?• How are standards maintained after

implementation?• How has standardization improved

veteran care thus far?

Standards & Terminology Services

• Who are we?• What do we do?• Why do we do it?• How do we do it?• What are the impacts to you?

Standardization is the identification, adoption, implementation, verification, maintenance, and compliance monitoring of data standards

What is Standardization?

Improve quality, safety, and cost effectiveness of patient care for

veterans

Goals of Standardization

Business Drivers for Standardization

• To support development of an integrated, longitudinal patient record

• To enable decision support on patient’s complete medical record

• To enable exchange of clinically relevant health data between VA, other agencies, and other health partners

• To support data exchange, comparison, aggregation, and reporting among VHA sites

• To readily support clinical research efforts• To reduce costs by eliminating redundant

expenses

• Domain: a content area with related files, fields, and code sets– e.g., Demographics, Allergies,

Pharmacy, Laboratory• HDR defines a domain within VistA

Standardization Approach

ImmunizationHome BasedPrimary

HealthFactors

EventCapture

Laboratory MentalHealth

Nursing

PatientEducation

OrdersNutrition &Food

Service

Pharmacy Problems Prosthetics Radiology

Allergies/Adverse

Reactions

ClinicalProcedures& Medicine

Comp & Pension Exam

ClinicalDecisionSupport

Consults Demographics

(partial)

Dental

EncountersAudiology &Speech Path

SurgeryRAI / MDS TIU Visual Impairment / Blind Rehab

Vitals Women’sHealth

Registry Data

Enterprise Domains

• Domain: a content area with related files, fields, and code sets– e.g., Demographics, Allergies,

Pharmacy, Laboratory• HDR defines a domain within VistA• Enterprise sequence plan for domains

Standardization Approach

• Review HDR content requirements based on patient data files

Domain Analysis

Patient Data File

How can a patient data file be recognized?• Stores data associated with a patient

#70RAD/NUC MED PATIENT

Patient Name

Exam Date

Procedure

Category of Exam

• Identify associated reference files

Domain Analysis

Reference File

#70RAD/NUC MED PATIENT

Patient Name Pointer to #2

Exam Date Date/Time

Procedure Pointer to #71

Category of Exam Set of Codes

#71RAD/NUC MED PROCEDURE

Procedure Name Free Text

Type of Procedure Set of Codes

Modality Pointer to #73.1

How can a reference file be recognized?• It is pointed to from a patient data file.• It contains terminology, not patient data.

• Identify associated reference files• Request reference file data from HDR• Research existing Standards

Development Organization (SDO) standards based on Healthcare Information Technology Standards Panel (HITSP) recommendation

Initial Domain Analysis

Domain Action Team (DAT)

• Responsibilities:– Review reference file data from sites– Research existing standards– Recommend a standard for adoption

• Goal:– Approved VHA standard

DAT Members

• Standardization Analysts – Lead• STS Project Manager• Program Office Representatives• Site Clinical Application Coordinators• Subject Matter Experts• Terminology Experts• HDR Content Analysts• STS Developers• Package Developers• Architects• Implementation Managers• Enterprise Product Support

DAT Members

• Standardization Analysts – Lead• STS Project Manager• Program Office Representatives• Site Clinical Application Coordinators• Subject Matter Experts• Terminology Experts• HDR Content Analysts• STS Developers• Package Developers• Architects• Implementation Managers• Enterprise Product Support

Options for Implementing the Standard

in VistA

Standardization in VistA

Option 1Standard introduced into the existing reference file

Option 1 - Standardize Existing File

• Any entries in the file that are not exact text matches to the VHA standard are automatically inactivated and cannot be entered anymore

• Non-standard (inactivated) entries remain in the file to support historical patient data

• The file is maintained by STS and can no longer be edited by the site

EXISTING REFERENCE FILE

IEN NAME

1 HONDA

2 ACCORD

4 Toyota

5 MAZERATI

6 JEEP

AUTOMAKERSTANDARD

MASERATI

TOYOTA

VOLKSWAGEN

IEN NAME

1 HONDA

2 ACCORD

4 Toyota

5 MAZERATI

6 JEEP

AUTOMAKERSTANDARD

MASERATI

TOYOTA

VOLKSWAGEN

IEN NAME STATUS

1 HONDA

2 ACCORD

4 Toyota

5 MAZERATI

6 JEEP

A new field for status is added to the existing reference file by installing a patch.

AUTOMAKERSTANDARD

MASERATI

TOYOTA

VOLKSWAGEN

IEN NAME STATUS

1 HONDA A

2 ACCORD I

3 VW I

4 TOYOTA A

5 MAZERATI I

6 JEEP I

The standardization process assigns an active (A) or inactive (I) status to each existing entry.

AUTOMAKERSTANDARD

MASERATI

TOYOTA

VOLKSWAGEN

IEN NAME STATUS

1 HONDA A

2 ACCORD I

3 VW I

4 TOYOTA A

5 MAZERATI I

6 JEEP I

7 FORD A

8 MASERATI A

9 VOLKSWAGEN A

All standard entries that were not already part of the file are added.

IEN NAME STATUS

1 HONDA A

2 ACCORD I

3 VW I

4 TOYOTA A

5 MAZERATI I

6 JEEP I

7 FORD A

8 MASERATI A

9 VOLKSWAGEN A

Standardization

Complete

Examples• Allergy Domain

– GMR Allergies, 120.82– Sign/Symptom, 120.83

• Vitals Domain – GMRV Vital Type, 120.51 – GMRV Vital Qualifier, 120.52

Standardization in VistA

Option 1Standard introduced into the existing reference file

Option 2Standard introduced as a new file with mappings linking it to the existing reference file

Option 2 - Map to Standardized File

• The existing reference file is unchanged, with continued maintenance by the site

• Sites must map all of the actively used reference file entries to entries in the new standard file

• The standard file cannot be edited by the site

IEN NAME

1 HONDA

2 ACCORD

4 Toyota

5 MAZERATI

6 JEEP

AUTOMAKERSTANDARD

MASERATI

TOYOTA

VOLKSWAGEN

NEW STANDARD FILEIEN NAME

1 FORD

2 HONDA

3 MASERATI

4 TOYOTA

5 VOLKSWAGEN

AUTOMAKERSTANDARD

MASERATI

TOYOTA

VOLKSWAGEN

A patch installation creates a new standard file.

1 FORD

2 HONDA

3 MASERATI

4 TOYOTA

5 VOLKSWAGEN

IEN NAME

1 HONDA

2 ACCORD

4 Toyota

5 MAZERATI

6 JEEP

1 FORD

2 HONDA

3 MASERATI

4 TOYOTA

5 VOLKSWAGEN

IEN NAME MAPPING

1 HONDA

2 ACCORD

4 Toyota

5 MAZERATI

6 JEEP

1 FORD

2 HONDA

3 MASERATI

4 TOYOTA

5 VOLKSWAGEN

A new field to be used for mapping is added to the existing reference file by patch installation.

IEN NAME MAPPING

1 HONDA 2

2 ACCORD 2

3 VW 5

4 Toyota 4

5 MAZERATI 3

6 JEEP

1 FORD

2 HONDA

3 MASERATI

4 TOYOTA

5 VOLKSWAGEN

The site maps their existing reference file to the standard file.

IEN NAME MAPPING

1 HONDA 2

2 ACCORD 2

3 VW 5

4 Toyota 4

5 MAZERATI 3

6 JEEP

1 FORD

2 HONDA

3 MASERATI

4 TOYOTA

5 VOLKSWAGEN

If the site has an existing entry that does not have an appropriate map to a standard entry, they should request that it be added to the standard.

IEN NAME MAPPING

1 HONDA 2

2 ACCORD 2

3 VW 5

4 Toyota 4

5 MAZERATI 3

6 JEEP

1 FORD

2 HONDA

3 MASERATI

4 TOYOTA

5 VOLKSWAGEN

Standardization

Complete

Examples• Clinical Document Titles

Existing reference file– TIU Document Definition, #8925.1Mapped to the new standard file– TIU VHA Enterprise Standard Title, #8926.1

• LaboratoryExisting reference file– Laboratory Test File, #60Mapped to a standard file– Laboratory LOINC File, #95.3

Comparing Option 1

to Option 2

Site Impacts - Option 1

Option 1 - Standardize Existing File• Entries may be missing from the

standard and must be requested by site staff for addition by STS

• Processing requests and deployment of new standard terminology takes time

Site Impacts - Option 2

Option 2 – Map to Standardized File• Site staff map all actively used entries in

the existing reference file to the standard• Site staff must add new entries with their

appropriate mappings• Entries may be missing from the standard

file and must be requested by site staff from STS in order to complete their mapping

Application Impacts

Option 1 - Standardize Existing File Templates, clinical reminders, reports, etc., may have to be revised if they relied upon entries inactivated by standardization

Option 2 - Map to Standardized File• New standard file must be created• Tools must be created to support mapping

Data Quality Impacts

Option 1 - Standardize Existing File• Data quality is ensured because all

sites are using the exact same standard

Option 2 - Map to Standardized File• Data quality is dependent upon the

quality and maintenance of the mapping

STS Impacts

Option 1 - Standardize Existing File• STS responds to site requests for

new standard terms

Option 2 - Map to Standardized File• STS responds to site requests for

new standard terms• STS must monitor and continually

evaluate the quality of the mapping

Domain Implementation Team (DIT)

• Responsibilities:– Determine and document implementation plan – Create software change requirements– Implement software changes

• Complete unit, integration, and system testing – Support installation of software– Support any data clean-up activities– Establish a mechanism for maintenance and

compliance

• Responsibilities:– Determine and document implementation plan – Create software change requirements– Implement software changes– Complete unit, integration, and system testing – Support installation of software– Support any data clean-up activities– Establish a mechanism for maintenance and

compliance

Domain Implementation Team (DIT)

• Software Package Project Manager – Lead• Package Developers • Standardization Analysts• STS Project Manager• Program Office Representatives• Clinical Application Coordinators• Terminology Experts• STS Developers• Architects• Implementation Managers

DIT Members

• Software Package Project Manager – Lead• Package Developers • Standardization Analysts• STS Project Manager• Program Office Representatives• Clinical Application Coordinators• Terminology Experts• STS Developers• Architects• Implementation Managers

DIT Members

Implementation

1. Site installs required standardization patches

2. Site receives initial terminology deployment from STS

• Production Account ONLY3. STS verifies that the initial

deployment was correctly instantiated in the file

Deployment Process

Master File Server ( )

TerminologyDeployment

Server(TDS)

VitriaInterfaceEngine(VIE)

HL7 Package

MFSTargeted

Reference File

HL7 MessageVistA Site

Deployment Process

Server(TDS)

HL7 Package

Master File Server (MFS)

TargetedReference File

VistA SiteHL7 Message

Deployment Process

Server(TDS)

HL7 Package

VistA Site

HL7 Message

Deployment Process

Server(TDS)

HL7 Package

VistA Site

Write toGlobal

What is HL7?

• Health Level 7• A standard interface for exchanging

and translating data between computer systems

• A non-profit organization accredited by the American National Standards Institute (ANSI) that develops standards for data transfer

www.payorid.com/glossary.asp

Deployment Process

Server(TDS)

HL7 Package

VistA Site

Terminology Deployment Server

• STS software developed in-house• Detects updates to the terminology

server• Converts the updates to HL7 messages• Deploys HL7 messages to all VistA

sites• Verifies that VistA was updated

correctly

Deployment Process

Server(TDS)

HL7 Package

VistA Site

Vitria Interface Engine (VIE)

• Routes HL7 messages across the enterprise

• Returns confirmation back to the sending server that the message was received– Commit Acknowledgement (CA)

Deployment Process

Server(TDS)

HL7 Package

VistA Site

• MUMPS software• Unpacks the HL7 message• Writes the terminology update to the

VistA global• Sends response back to TDS

– Application Acknowledgement (AA)– Application Error (AE)

We’re Standardized . . . Now What?

• Healthcare is not static…neither are standards

• Centralized maintenance process for standard files is called

New Term Rapid Turnaround (NTRT)

NTRT Web Portal

http://vista.med.va.gov/ntrt/

Web portal contains links to:• NTRT request application• NTRT notifications• New term deployment logs

NTRT Review Team Process

• Each request is evaluated to determine if it is an appropriate addition to the standard.

• The team makes sure that the request is not a duplicate and follows established rules for terminology creation.

• The requester receives direct feedback on their request via e-mail.

NTRT Review Team

Members:• STS Terminology Analyst - Lead• Clinicians• Site Representatives• Package Developers and Analysts • Subject Matter Experts• Terminology Experts• Enterprise Product Support

NTRT Review Team

Members:• STS Terminology Analyst - Lead• Clinicians• Site Representatives• Package Developers and Analysts • Subject Matter Experts• Terminology Experts• Enterprise Product Support

Quality Assurance Testing

3 Phases• STS Internal Testing

– 1 VistA test lab account• Software Quality Assurance (SQA) Testing

– 2 VistA test lab accounts• Beta Test Sites, > 24 hours

– Los Angeles – Martinsburg – Portland– Salt Lake City

Notification

• An Automated Notification Report (ANR) is sent to VHA OI Software Announcement on Wednesdays via Outlook

• Submit a Remedy ticket and ask to be added to VHA OI Software Announcement if you would like to receive the ANR’s

• Listserv e-mail contains same information

NTRT Deployment Process

HL7 Package

HL7 Message

Write toGlobal

Server(TDS)

HL7 MessageHL7 Package

Master File Server MFS

HL7 Message

Write toGlobal

NTRT Process

• Enterprise wide deployments are sent weekly on Thursdays

• Approved new terms are:– Added to the national standard– Deployed to all 128 VistA databases– Updated at all sites virtually

simultaneously• Newly deployed terms are immediately

available to end-users

NTRT Examples

Scenario• Two new terms are requested through

NTRT and approved,– FERRARI– JEEP

• How does NTRT differ for standards implemented with Option 1 and Option 2?

IEN NAME STATUS

1 HONDA A

2 ACCORD I

3 VW I

4 TOYOTA A

5 MAZERATI I

6 JEEP I

7 FORD A

8 MASERATI A

9 VOLKSWAGEN A

New Standard TermsFERRARI

The two new terms are deployed from TDS to the existing reference file.

IEN NAME STATUS

1 HONDA A

2 ACCORD I

3 VW I

4 TOYOTA A

5 MAZERATI I

6 JEEP I

7 FORD A

8 MASERATI A

9 VOLKSWAGEN A

10 FERRARI A

Ferrari does not match any existing inactive entries and is added to the end of the file.

IEN NAME STATUS

1 HONDA A

2 ACCORD I

3 VW I

4 TOYOTA A

5 MAZERATI I

6 JEEP I

7 FORD A

8 MASERATI A

9 VOLKSWAGEN A

10 FERRARI A

Jeep does match an existing inactive entry.

IEN NAME STATUS

1 HONDA A

2 ACCORD I

3 VW I

4 TOYOTA A

5 MAZERATI I

6 JEEP A

7 FORD A

8 MASERATI A

9 VOLKSWAGEN A

10 FERRARI A

The existing entry is activated.

IEN NAME STATUS

1 HONDA A

2 ACCORD I

3 VW I

4 TOYOTA A

5 MAZERATI I

6 JEEP A

7 FORD A

8 MASERATI A

9 VOLKSWAGEN A

10 FERRARI A

NTRT Completed!

IEN NAME MAPPING

1 HONDA 2

2 ACCORD 2

3 VW 5

4 Toyota 4

5 MAZERATI 3

6 JEEP

1 FORD

2 HONDA

3 MASERATI

4 TOYOTA

5 VOLKSWAGEN

IEN NAME MAPPING

1 HONDA 2

2 ACCORD 2

3 VW 5

4 Toyota 4

5 MAZERATI 3

6 JEEP

1 FORD

2 HONDA

3 MASERATI

4 TOYOTA

5 VOLKSWAGEN

6 FERRARI

7 JEEP

The two new terms are deployed from TDS to the new standard file.

IEN NAME MAPPING

1 HONDA 2

2 ACCORD 2

3 VW 5

4 Toyota 4

5 MAZERATI 3

6 JEEP

1 FORD

2 HONDA

3 MASERATI

4 TOYOTA

5 VOLKSWAGEN

6 FERRARI

7 JEEP

The site can now map their existing entry to JEEP.

IEN NAME MAPPING

1 HONDA 2

2 ACCORD 2

3 VW 5

4 Toyota 4

5 MAZERATI 3

6 JEEP 7

1 FORD

2 HONDA

3 MASERATI

4 TOYOTA

5 VOLKSWAGEN

6 FERRARI

7 JEEP

IEN NAME MAPPING

1 HONDA 2

2 ACCORD 2

3 VW 5

4 Toyota 4

5 MAZERATI 3

6 JEEP 7

7 FERRARI 6

1 FORD

2 HONDA

3 MASERATI

4 TOYOTA

5 VOLKSWAGEN

6 FERRARI

7 JEEP

JEEPIn order to use FERRARI, the site must add it to their file and map it to the standard file (not required).

IEN NAME MAPPING

1 HONDA 2

2 ACCORD 2

3 VW 5

4 Toyota 4

5 MAZERATI 3

6 JEEP 7

7 FERRARI 6

1 FORD

2 HONDA

3 MASERATI

4 TOYOTA

5 VOLKSWAGEN

6 FERRARI

7 JEEP

NTRT Completed!New Standard Terms

FERRARIJEEP

NTRT Requests Statistics

• Through April 2007, the NTRT Review Teams had processed the following number of requests:– 37 Vital Qualifier– 380 Allergy Reactant and Signs/Symptoms– 723 Clinical Document Titles

• Resulting in the following number of new terms:– 15 Vital Qualifier– 105 Allergy Reactant and Signs/Symptoms– 298 Clinical Document Titles

Examples ofBenefits of Standardization

to Veterans So Far . . .

Prior to Standardization:

1,000,000 free text allergies

Not computable

Now 825,000 coded standard allergy terms that function in order checks

Clinical Document Titles

• Titles created locally can be difficult to decipher:

AUDIO/REEVAL/HA CHECK (T)(CI)CH-SARP NOTECIH/STAR II CONSULTDME CLINIC (T)IC/ID/VMH-CWT PATIENT CHECKLIST (CH) NURSING PRRTP NOTE SOCIAL WORK BOMH DISPOSITION NOTE (O) (T) UR 67CD (T)(K)

• Standard titles have descriptive names and can be understood across VHA, not just at the site where created

• Clinicians can quickly find relevant content

MAPPING EXAMPLES

LOCAL NOTE TITLE STANDARD NOTE TITLE

AUDIO/REEVAL/HA CHECK (T)(CI) AUDIOLOGY E & M NOTE

UR 67CD (T)(K) NURSING ADMINISTRATIVE NOTE

COX-2 INHIBITOR ASSESSM PHARMACY CONSULT

FOBT LAB FOLLOW-UPPRIMARY CARE TELEPHONE ENCOUNTER NOTE

SATP PATIENT ORIENTATIONADDICTION PSYCHIATRY EDUCATION NOTE

• Clinical Data Repository/Health Data Repository (CHDR)

• Standardization enables the sharing of computable data between VA and Department of Defense (DoD)

• The following data triggers order checking and decision support and can be viewed in VA via Remote Data Views and VistAWeb– Allergy Reactants– Signs/Symptoms– Outpatient Medications

CHDR Medication Example

CHDRHDR

DecisionSupport

Terminology Reference FileIEN = 76ABACAVIR SO4 300MG TABVUID = 4013382

Patient InstanceVUID = 4013382

VUID Rx CUI RxNorm Description

4013382 242679 Abacavir 300 MG Oral Tablet

Departmentof

Defense

CHDR Statistics for May 2007

VA to DoD DoD to VA

Attempt

sSuccess

RateAttempt

sSuccess

RateMedicatio

ns 126,049 94% 61,535 91%

Reactants 1,654 80% 4,904 67%Signs/Symptoms 959 86% 3,521 87%

Next Domains

• Encounters (not Encounter Forms)• Immunizations • Problem List• Radiology

Today we’ve covered . . .

• Establishment of VHA terminology standards

• Impact of standardization implementation strategies

• Maintenance of standards• Benefits of standardization to veterans

Thanks!

Referenceshttp://vaww.vistau.med.va.gov/vistau/hdr/http://vaww.sts.infoshare.va.govhttp://vista.med.va.gov/http://vista.med.va.gov/ntrt/

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150 Navigating the Maze Shelley Weems, RHIA, CCS

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