150 Navigating the Maze

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150 Navigating the Maze

• Shelley Weems, RHIA, CCS
• STS Standardization Analyst
• Holli Murphy
• STS Terminology Analyst
• Standards Terminology Services (STS)

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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?

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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?

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What is Standardization?

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

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Goals of Standardization

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

6
Business Drivers for Standardization

• To support development of an integrated,
  longitudinal patient record
• To enable decision support on patients 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

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Standardization Approach

• Domain a content area with related files,
  fields, and code sets
• e.g., Demographics, Allergies, Pharmacy,
  Laboratory
• HDR defines a domain within VistA

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Enterprise Domains
HDR
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Standardization Approach

• 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

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Domain Analysis

• Review HDR content requirements based on patient
  data files

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Patient Data File
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RAD/NUC MED PATIENT
Patient Name Exam Date Procedure Category of
Exam

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

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Domain Analysis

• Review HDR content requirements based on patient
  data files
• Identify associated reference files

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Reference File
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RAD/NUC MED PATIENT
RAD/NUC MED PROCEDURE
Patient Name Pointer to 2 Exam
Date Date/Time Procedure Pointer to 71 Category
of Exam Set of Codes
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.

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Initial Domain Analysis

• Review HDR content requirements based on patient
  data files
• 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

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Domain Action Team (DAT)

• Responsibilities
• Review reference file data from sites
• Research existing standards
• Recommend a standard for adoption
• Goal
• Approved VHA standard

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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

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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

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Options for Implementing the Standardin VistA
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Standardization in VistA

• Option 1
• Standard introduced into the existing reference
  file

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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

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Option 1 - Standardize Existing File
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Option 1 - Standardize Existing File
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Option 1 - Standardize Existing File
A new field for status is added to the existing
reference file by installing a patch.
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Option 1 - Standardize Existing File
The standardization process assigns an active (A)
or inactive (I) status to each existing entry.
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Option 1 - Standardize Existing File
All standard entries that were not already part
of the file are added.
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Option 1 - Standardize Existing File
Standardization Complete
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Option 1 - Standardize Existing File

• Examples
• Allergy Domain
• GMR Allergies, 120.82
• Sign/Symptom, 120.83
• Vitals Domain
• GMRV Vital Type, 120.51
• GMRV Vital Qualifier, 120.52

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Standardization in VistA

• Option 1
• Standard introduced into the existing reference
  file
• Option 2
• Standard introduced as a new file with mappings
  linking it to the existing reference file

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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

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Option 2 - Map to Standardized File
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Option 2 - Map to Standardized File
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Option 2 - Map to Standardized File
A patch installation creates a new standard file.
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Option 2 - Map to Standardized File
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Option 2 - Map to Standardized File
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Option 2 - Map to Standardized File
A new field to be used for mapping is added to
the existing reference file by patch installation.
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Option 2 - Map to Standardized File
The site maps their existing reference file to
the standard file.
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Option 2 - Map to Standardized File
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.
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Option 2 - Map to Standardized File
Standardization Complete
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Option 2 - Map to Standardized File

• Examples
• Clinical Document Titles
• Existing reference file
• TIU Document Definition, 8925.1
• Mapped to the new standard file
• TIU VHA Enterprise Standard Title, 8926.1
• Laboratory
• Existing reference file
• Laboratory Test File, 60
• Mapped to a standard file
• Laboratory LOINC File, 95.3

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Comparing Option 1 to Option 2
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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

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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

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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

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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

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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

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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

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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

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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

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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

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Implementation

• Site installs required standardization patches
• Site receives initial terminology deployment from
  STS
• Production Account ONLY
• STS verifies that the initial deployment was
  correctly instantiated in the file

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Deployment Process
Master File Server
(
)
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Deployment Process
VistA Site
HL7 Message
HL7 Package
Vitria Interface Engine (VIE)
Terminology Deployment Server (TDS)
Master File Server
Targeted Reference File
(
MFS
)
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Deployment Process
VistA Site
HL7 Package
HL7 Message
Vitria Interface Engine (VIE)
Terminology Deployment Server (TDS)
Master File Server
Targeted Reference File
(
MFS
)
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Deployment Process
VistA Site
HL7 Package
Vitria Interface Engine (VIE)
Terminology Deployment Server (TDS)
Master File Server
Targeted Reference File
(
MFS
)
Write to Global
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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

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Deployment Process
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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

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Deployment Process
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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)

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Deployment Process
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Master File Server (MFS)

• 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)

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Were Standardized . . . Now What?

• Healthcare is not static
• neither are standards
• Centralized maintenance process for standard
  files is called
• New Term Rapid Turnaround (NTRT)

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NTRT Web Portal
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NTRT Web Portal

• http//vista.med.va.gov/ntrt/
• Web portal contains links to
• NTRT request application
• NTRT notifications
• New term deployment logs

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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.

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NTRT Review Team

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

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NTRT Review Team

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

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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

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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 ANRs
• Listserv e-mail contains same information

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NTRT Deployment Process
VistA Site
HL7 Message
HL7 Package
HL7 Message
Master File Server
Targeted Reference File
(
MFS
)
Write to Global
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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

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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?

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Option 1 - Standardize Existing File
New Standard Terms FERRARI JEEP
The two new terms are deployed from TDS to the
existing reference file.
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Option 1 - Standardize Existing File
New Standard Terms FERRARI JEEP
Ferrari does not match any existing inactive
entries and is added to the end of the file.
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Option 1 - Standardize Existing File
New Standard Terms FERRARI JEEP
Jeep does match an existing inactive entry.
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Option 1 - Standardize Existing File
New Standard Terms FERRARI JEEP
The existing entry is activated.
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Option 1 - Standardize Existing File
New Standard Terms FERRARI JEEP
NTRT Completed!
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Option 2 - Map to Standardized File
New Standard Terms FERRARI JEEP
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Option 2 - Map to Standardized File
The two new terms are deployed from TDS to the
new standard file.
New Standard Terms FERRARI JEEP
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Option 2 - Map to Standardized File
The site can now map their existing entry to JEEP.
New Standard Terms FERRARI JEEP
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Option 2 - Map to Standardized File
New Standard Terms FERRARI JEEP
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Option 2 - Map to Standardized File
New Standard Terms FERRARI JEEP
In order to use FERRARI, the site must add it to
their file and map it to the standard file (not
required).
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Option 2 - Map to Standardized File
New Standard Terms FERRARI JEEP
NTRT Completed!
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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

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Examples ofBenefits of Standardization to
Veterans So Far . . .
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Prior to Standardization
Now 825,000 coded standard allergy terms that
function in order checks
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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

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MAPPING EXAMPLES
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CHDR

• 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

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CHDR Medication Example
Terminology Reference File IEN 76 ABACAVIR SO4
300MG TAB VUID 4013382
VistA
Decision Support
Department of Defense
CHDR
HDR
Patient Instance VUID 4013382
STS
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CHDR Statistics for May 2007
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Next Domains

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

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Today weve covered . . .

• Establishment of VHA terminology standards
• Impact of standardization implementation
  strategies
• Maintenance of standards
• Benefits of standardization to veterans

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Thanks!

• References
• http//vaww.vistau.med.va.gov/vistau/hdr/
• http//vaww.sts.infoshare.va.gov
• http//vista.med.va.gov/
• http//vista.med.va.gov/ntrt/
• Questions