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150 Navigating the Maze

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HONDA. 1. STATUS. NAME. IEN. EXISTING REFERENCE FILE ... HONDA. FORD. AUTOMAKER. STANDARD. A patch installation creates a new standard file. 33 ... – PowerPoint PPT presentation

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Title: 150 Navigating the Maze


1
150 Navigating the Maze
  • Shelley Weems, RHIA, CCS
  • STS Standardization Analyst
  • Holli Murphy
  • STS Terminology Analyst
  • Standards Terminology Services (STS)

2
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?

3
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?

4
What is Standardization?
  • Standardization is the identification, adoption,
    implementation, verification, maintenance, and
    compliance monitoring of data standards

5
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

7
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

8
Enterprise Domains
HDR
9
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

10
Domain Analysis
  • Review HDR content requirements based on patient
    data files

11
Patient Data File
70
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

12
Domain Analysis
  • Review HDR content requirements based on patient
    data files
  • Identify associated reference files

13
Reference File
70
71
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.

14
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

15
Domain Action Team (DAT)
  • Responsibilities
  • Review reference file data from sites
  • Research existing standards
  • Recommend a standard for adoption
  • Goal
  • Approved VHA standard

16
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

17
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

18
Options for Implementing the Standardin VistA
19
Standardization in VistA
  • Option 1
  • Standard introduced into the existing reference
    file

20
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

21
Option 1 - Standardize Existing File
22
Option 1 - Standardize Existing File
23
Option 1 - Standardize Existing File
A new field for status is added to the existing
reference file by installing a patch.
24
Option 1 - Standardize Existing File
The standardization process assigns an active (A)
or inactive (I) status to each existing entry.
25
Option 1 - Standardize Existing File
All standard entries that were not already part
of the file are added.
26
Option 1 - Standardize Existing File
Standardization Complete
27
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

28
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

29
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

30
Option 2 - Map to Standardized File
31
Option 2 - Map to Standardized File
32
Option 2 - Map to Standardized File
A patch installation creates a new standard file.
33
Option 2 - Map to Standardized File
34
Option 2 - Map to Standardized File
35
Option 2 - Map to Standardized File
A new field to be used for mapping is added to
the existing reference file by patch installation.
36
Option 2 - Map to Standardized File
The site maps their existing reference file to
the standard file.
37
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.
38
Option 2 - Map to Standardized File
Standardization Complete
39
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

40
Comparing Option 1 to Option 2
41
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

42
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

43
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

44
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

45
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

46
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

47
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

48
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

49
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

50
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

51
Deployment Process
Master File Server
(
)
52
Deployment Process
VistA Site
HL7 Message
HL7 Package
Vitria Interface Engine (VIE)
Terminology Deployment Server (TDS)
Master File Server
Targeted Reference File
(
MFS
)
53
Deployment Process
VistA Site
HL7 Package
HL7 Message
Vitria Interface Engine (VIE)
Terminology Deployment Server (TDS)
Master File Server
Targeted Reference File
(
MFS
)
54
Deployment Process
VistA Site
HL7 Package
Vitria Interface Engine (VIE)
Terminology Deployment Server (TDS)
Master File Server
Targeted Reference File
(
MFS
)
Write to Global
55
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

56
Deployment Process
57
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

58
Deployment Process
59
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)

60
Deployment Process
61
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)

62
Were Standardized . . . Now What?
  • Healthcare is not static
  • neither are standards
  • Centralized maintenance process for standard
    files is called
  • New Term Rapid Turnaround (NTRT)

63
NTRT Web Portal
64
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66
NTRT Web Portal
  • http//vista.med.va.gov/ntrt/
  • Web portal contains links to
  • NTRT request application
  • NTRT notifications
  • New term deployment logs

67
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68
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69
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73
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.

74
NTRT Review Team
  • Members
  • STS Terminology Analyst - Lead
  • Clinicians
  • Site Representatives
  • Package Developers and Analysts
  • Subject Matter Experts
  • Terminology Experts
  • Enterprise Product Support

75
NTRT Review Team
  • Members
  • STS Terminology Analyst - Lead
  • Clinicians
  • Site Representatives
  • Package Developers and Analysts
  • Subject Matter Experts
  • Terminology Experts
  • Enterprise Product Support

76
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

77
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

78
NTRT Deployment Process
VistA Site
HL7 Message
HL7 Package
HL7 Message
Master File Server
Targeted Reference File
(
MFS
)
Write to Global
79
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

80
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?

81
Option 1 - Standardize Existing File
New Standard Terms FERRARI JEEP
The two new terms are deployed from TDS to the
existing reference file.
82
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.
83
Option 1 - Standardize Existing File
New Standard Terms FERRARI JEEP
Jeep does match an existing inactive entry.
84
Option 1 - Standardize Existing File
New Standard Terms FERRARI JEEP
The existing entry is activated.
85
Option 1 - Standardize Existing File
New Standard Terms FERRARI JEEP
NTRT Completed!
86
Option 2 - Map to Standardized File
New Standard Terms FERRARI JEEP
87
Option 2 - Map to Standardized File
The two new terms are deployed from TDS to the
new standard file.
New Standard Terms FERRARI JEEP
88
Option 2 - Map to Standardized File
The site can now map their existing entry to JEEP.
New Standard Terms FERRARI JEEP
89
Option 2 - Map to Standardized File
New Standard Terms FERRARI JEEP
90
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).
91
Option 2 - Map to Standardized File
New Standard Terms FERRARI JEEP
NTRT Completed!
92
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

93
Examples ofBenefits of Standardization to
Veterans So Far . . .
94
Prior to Standardization
Now 825,000 coded standard allergy terms that
function in order checks
95
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

96
MAPPING EXAMPLES
97
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

98
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
99
CHDR Statistics for May 2007
100
Next Domains
  • Encounters (not Encounter Forms)
  • Immunizations
  • Problem List
  • Radiology

101
Today weve covered . . .
  • Establishment of VHA terminology standards
  • Impact of standardization implementation
    strategies
  • Maintenance of standards
  • Benefits of standardization to veterans

102
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
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