150 Navigating the Maze Shelley Weems, RHIA, CCS
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Transcript of 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)
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
Standardization is the identification, adoption, implementation, verification, maintenance, and compliance monitoring of data standards
What is Standardization?
5
Improve quality, safety, and cost effectiveness of patient care for
veterans
Goals of Standardization
6
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
7
• 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
8
ImmunizationHome BasedPrimary
Care
HealthFactors
EventCapture
Laboratory MentalHealth
Nursing
PatientEducation
OrdersNutrition &Food
Service
Pharmacy Problems Prosthetics Radiology
HDR
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
9
• 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
10
• Review HDR content requirements based on patient data files
Domain Analysis
11
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
12
• Review HDR content requirements based on patient data files
• Identify associated reference files
Domain Analysis
13
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.
14
• 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
Initial Domain Analysis
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
Options for Implementing the Standard
in VistA
19
Standardization in VistA
Option 1Standard 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
EXISTING REFERENCE FILE
IEN NAME
1 HONDA
2 ACCORD
3 VW
4 Toyota
5 MAZERATI
6 JEEP
22
Option 1 - Standardize Existing File
AUTOMAKERSTANDARD
FORD
HONDA
MASERATI
TOYOTA
VOLKSWAGEN
EXISTING REFERENCE FILE
IEN NAME
1 HONDA
2 ACCORD
3 VW
4 Toyota
5 MAZERATI
6 JEEP
23
Option 1 - Standardize Existing File
AUTOMAKERSTANDARD
FORD
HONDA
MASERATI
TOYOTA
VOLKSWAGEN
EXISTING REFERENCE FILE
IEN NAME STATUS
1 HONDA
2 ACCORD
3 VW
4 Toyota
5 MAZERATI
6 JEEP
A new field for status is added to the existing reference file by installing a patch.
24
Option 1 - Standardize Existing File
AUTOMAKERSTANDARD
FORD
HONDA
MASERATI
TOYOTA
VOLKSWAGEN
EXISTING REFERENCE FILE
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.
25
Option 1 - Standardize Existing File
AUTOMAKERSTANDARD
FORD
HONDA
MASERATI
TOYOTA
VOLKSWAGEN
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
All standard entries that were not already part of the file are added.
26
Option 1 - Standardize Existing File
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
Standardization
Complete
27
Examples• Allergy Domain
– GMR Allergies, 120.82– Sign/Symptom, 120.83
• Vitals Domain – GMRV Vital Type, 120.51 – GMRV Vital Qualifier, 120.52
Option 1 - Standardize Existing File
28
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
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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
30
Option 2 - Map to Standardized File
EXISTING REFERENCE FILE
IEN NAME
1 HONDA
2 ACCORD
3 VW
4 Toyota
5 MAZERATI
6 JEEP
31
Option 2 - Map to Standardized File
AUTOMAKERSTANDARD
FORD
HONDA
MASERATI
TOYOTA
VOLKSWAGEN
32
Option 2 - Map to Standardized File
NEW STANDARD FILEIEN NAME
1 FORD
2 HONDA
3 MASERATI
4 TOYOTA
5 VOLKSWAGEN
AUTOMAKERSTANDARD
FORD
HONDA
MASERATI
TOYOTA
VOLKSWAGEN
A patch installation creates a new standard file.
33
Option 2 - Map to Standardized File
NEW STANDARD FILEIEN NAME
1 FORD
2 HONDA
3 MASERATI
4 TOYOTA
5 VOLKSWAGEN
34
Option 2 - Map to Standardized File
EXISTING REFERENCE FILE
IEN NAME
1 HONDA
2 ACCORD
3 VW
4 Toyota
5 MAZERATI
6 JEEP
NEW STANDARD FILEIEN NAME
1 FORD
2 HONDA
3 MASERATI
4 TOYOTA
5 VOLKSWAGEN
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Option 2 - Map to Standardized File
EXISTING REFERENCE FILE
IEN NAME MAPPING
1 HONDA
2 ACCORD
3 VW
4 Toyota
5 MAZERATI
6 JEEP
NEW STANDARD FILEIEN NAME
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.
36
Option 2 - Map to Standardized File
EXISTING REFERENCE FILE
IEN NAME MAPPING
1 HONDA 2
2 ACCORD 2
3 VW 5
4 Toyota 4
5 MAZERATI 3
6 JEEP
NEW STANDARD FILEIEN NAME
1 FORD
2 HONDA
3 MASERATI
4 TOYOTA
5 VOLKSWAGEN
The site maps their existing reference file to the standard file.
37
Option 2 - Map to Standardized File
EXISTING REFERENCE FILE
IEN NAME MAPPING
1 HONDA 2
2 ACCORD 2
3 VW 5
4 Toyota 4
5 MAZERATI 3
6 JEEP
NEW STANDARD FILEIEN NAME
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.
38
Option 2 - Map to Standardized File
EXISTING REFERENCE FILE
IEN NAME MAPPING
1 HONDA 2
2 ACCORD 2
3 VW 5
4 Toyota 4
5 MAZERATI 3
6 JEEP
NEW STANDARD FILEIEN NAME
1 FORD
2 HONDA
3 MASERATI
4 TOYOTA
5 VOLKSWAGEN
Standardization
Complete
39
Option 2 - Map to Standardized File
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
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
• 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)
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• 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
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• 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
50
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
51
Deployment Process
Master File Server ( )
TerminologyDeployment
Server(TDS)
VitriaInterfaceEngine(VIE)
HL7 Package
MFSTargeted
Reference File
HL7 MessageVistA Site
52
Deployment Process
TerminologyDeployment
Server(TDS)
VitriaInterfaceEngine(VIE)
HL7 Package
Master File Server (MFS)
TargetedReference File
VistA SiteHL7 Message
53
Deployment Process
TerminologyDeployment
Server(TDS)
VitriaInterfaceEngine(VIE)
HL7 Package
Master File Server (MFS)
TargetedReference File
VistA Site
HL7 Message
54
Deployment Process
TerminologyDeployment
Server(TDS)
VitriaInterfaceEngine(VIE)
HL7 Package
Master File Server (MFS)
TargetedReference File
VistA Site
Write toGlobal
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
TerminologyDeployment
Server(TDS)
VitriaInterfaceEngine(VIE)
HL7 Package
Master File Server (MFS)
TargetedReference File
VistA Site
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
TerminologyDeployment
Server(TDS)
VitriaInterfaceEngine(VIE)
HL7 Package
Master File Server (MFS)
TargetedReference File
VistA Site
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
TerminologyDeployment
Server(TDS)
VitriaInterfaceEngine(VIE)
HL7 Package
Master File Server (MFS)
TargetedReference File
VistA Site
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
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
64
65
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
68
69
70
71
72
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 ANR’s
• Listserv e-mail contains same information
78
NTRT Deployment Process
HL7 Package
Master File Server (MFS)
TargetedReference File
VistA SiteHL7 Message
HL7 Message
Write toGlobal
TerminologyDeployment
Server(TDS)
VitriaInterfaceEngine(VIE)
HL7 MessageHL7 Package
Master File Server MFS
TargetedReference File
VistA SiteHL7 Message
HL7 Message
Write toGlobal
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
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
New Standard TermsFERRARI
JEEP
The two new terms are deployed from TDS to the existing reference file.
82
Option 1 - Standardize Existing File
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
New Standard TermsFERRARI
JEEP
Ferrari does not match any existing inactive entries and is added to the end of the file.
83
Option 1 - Standardize Existing File
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
New Standard TermsFERRARI
JEEP
Jeep does match an existing inactive entry.
84
Option 1 - Standardize Existing File
EXISTING REFERENCE FILE
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
New Standard TermsFERRARI
JEEP
The existing entry is activated.
85
Option 1 - Standardize Existing File
EXISTING REFERENCE FILE
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
New Standard TermsFERRARI
JEEP
NTRT Completed!
86
Option 2 - Map to Standardized File
EXISTING REFERENCE FILE
IEN NAME MAPPING
1 HONDA 2
2 ACCORD 2
3 VW 5
4 Toyota 4
5 MAZERATI 3
6 JEEP
NEW STANDARD FILEIEN NAME
1 FORD
2 HONDA
3 MASERATI
4 TOYOTA
5 VOLKSWAGEN
New Standard TermsFERRARI
JEEP
87
Option 2 - Map to Standardized File
EXISTING REFERENCE FILE
IEN NAME MAPPING
1 HONDA 2
2 ACCORD 2
3 VW 5
4 Toyota 4
5 MAZERATI 3
6 JEEP
NEW STANDARD FILEIEN NAME
1 FORD
2 HONDA
3 MASERATI
4 TOYOTA
5 VOLKSWAGEN
6 FERRARI
7 JEEP
New Standard TermsFERRARI
JEEP
The two new terms are deployed from TDS to the new standard file.
88
Option 2 - Map to Standardized File
EXISTING REFERENCE FILE
IEN NAME MAPPING
1 HONDA 2
2 ACCORD 2
3 VW 5
4 Toyota 4
5 MAZERATI 3
6 JEEP
NEW STANDARD FILEIEN NAME
1 FORD
2 HONDA
3 MASERATI
4 TOYOTA
5 VOLKSWAGEN
6 FERRARI
7 JEEP
New Standard TermsFERRARI
JEEP
The site can now map their existing entry to JEEP.
89
Option 2 - Map to Standardized File
EXISTING REFERENCE FILE
IEN NAME MAPPING
1 HONDA 2
2 ACCORD 2
3 VW 5
4 Toyota 4
5 MAZERATI 3
6 JEEP 7
NEW STANDARD FILEIEN NAME
1 FORD
2 HONDA
3 MASERATI
4 TOYOTA
5 VOLKSWAGEN
6 FERRARI
7 JEEP
New Standard TermsFERRARI
JEEP
90
Option 2 - Map to Standardized File
EXISTING REFERENCE FILE
IEN NAME MAPPING
1 HONDA 2
2 ACCORD 2
3 VW 5
4 Toyota 4
5 MAZERATI 3
6 JEEP 7
7 FERRARI 6
NEW STANDARD FILEIEN NAME
1 FORD
2 HONDA
3 MASERATI
4 TOYOTA
5 VOLKSWAGEN
6 FERRARI
7 JEEP
New Standard TermsFERRARI
JEEPIn 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
EXISTING REFERENCE FILE
IEN NAME MAPPING
1 HONDA 2
2 ACCORD 2
3 VW 5
4 Toyota 4
5 MAZERATI 3
6 JEEP 7
7 FERRARI 6
NEW STANDARD FILEIEN NAME
1 FORD
2 HONDA
3 MASERATI
4 TOYOTA
5 VOLKSWAGEN
6 FERRARI
7 JEEP
NTRT Completed!New Standard Terms
FERRARIJEEP
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
Examples ofBenefits of Standardization
to Veterans So Far . . .
94
Prior to Standardization:
1,000,000 free text allergies
Not computable
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
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
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
CHDRHDR
VistA
STS
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
99
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%
100
Next Domains
• Encounters (not Encounter Forms)• Immunizations • Problem List• Radiology
101
Today we’ve covered . . .
• Establishment of VHA terminology standards
• Impact of standardization implementation strategies
• Maintenance of standards• Benefits of standardization to veterans
102
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/
Questions