2015 User Conference Care Plan SQL April 25, 2015 Presented by: Greg Anderson CEO EHR Workshop 491.

2015 User Conference

Care Plan SQL April 25, 2015

Presented by:

Greg AndersonCEO

EHR Workshop 491

2015 Office Practicum User Conference

Agenda

▪ SQL database structure (reference before workshop)

▪ Item Types and Items

▪ CQM Lists

▪ Trigger SQL in Items

▪ Putting it all together:Appointment Reasons

▪ Homework: Appointment Types

▪ Q&A


SQL Database Structure

▪ In simplest terms, an SQL database contains entities and relationships

▪ Entities model real world objects▪ Patient (REGISTER)▪ Encounter (ENC_NOTE, PHYSICAL)▪ Appointment (SCHEDULE)▪ Problem (CHARTNOTES)

▪ Each entity is stored in one or more tables, each of which has properties stored in fields▪ Last name (LNAME)▪ Gender (SEX)▪ Birth date (BIRTHDAT)


SQL Database Tables and Fields

▪ Patient REGISTER (first 30 field definitions)


SQL Database Relationships

▪ Relationships define how the tables work together to form an entire picture of the real world problems modeled in the database

▪ Frequently referenced relationships are defined in indexes to facilitate rapid access

▪ Well designed databases use the power of relationships to minimize or eliminate duplicate data and maximize reuse


SQL Entity/Relationship Diagram

▪ SCHEDULE with related entities


SQL Table Data

▪ Table contains multiple rows of data, one for each instance of the entity type it contains


SQL SELECT Statements

▪ SELECT statements are sentences with a specific vocabulary and grammar that define the rules to fetch a subset of available data, according to the following parameters:

▪ Which fields SELECT▪ Which tables FROM, JOIN▪ Which rows within tables WHERE▪ Which order ORDER BY▪ Which groups GROUP BY

▪ Complete SELECT syntax contains additional parameters, but those listed above are the most commonly used for care plans


SQL SELECT Statement Example

The following SQL SELECT statement fetches a list of the last name, first name, sex, and birth date for all active female patients who were born since January 1, 2010:

SELECT LNAME, FNAME, SEX, BIRTHDATFROM REGISTERWHERE (STATUS_PAT = ‘ACTIVE’)AND (SEX = ‘F’)AND (BIRTHDAT >= ‘01/01/2010’)ORDER BY LNAME, FNAME

The results are sorted by last and first name


SQL SELECT Parameters

A parameter is a variable whose value is determined when the SELECT statement is run. (Either the user can provide the values, or the system can provide them programmatically.) Parameters always begin with a “:”.

SELECT PATNO, INVOICENO, CPTCODEFROM ARCHIVE_TRANSACTIONSWHERE (DATE1 BETWEEN :SDATE AND :EDATE)

In this example, :SDATE and :EDATE represent start and end dates for a range of transactions. By not hard-coding the dates into the query, it can be reused for any desired period of time.


Creating Action SQL in Item Types

▪ Item Types are the elemental atoms of data mining - one type of thing found on one section of a patient chart

▪ Very easy when the content of all records is similar except for the patient they apply to

▪ Encourages reuse when only one property of a record varies between use cases▪ Diagnostic tests - only difference between

HGB and LEAD is the name or LOINC

▪ Medication - only difference between Adderall and amoxicillin is the name or RxNorm or NDC


Standard Care Plan Item Types

Section

Chart Elements


Action Item Data Mining Fields

▪ All data mining related to actions must return a specific collection of fields - converts heterogeneous data to a single standard▪ Item_ID - the unique identifier for this record in

the table it comes from

▪ Item_Date - the effective date as of which this record exists for the purpose of recall intervals

▪ Item_Value - freeform text in “Most Recent Info”

▪ Item_Flag - (optional) text indicating whether the record is classified as normal or abnormal

▪ Item_Dx - (optional) text for records that have a diagnosis element


Action Item Data Mining: Vaccines

▪ Let’s look at a simple example:▪ How do you find the most recent

administration of a vaccine or antigen for a specific patient, to see if they need or are due for another?

▪ Step 1: Determine which primary table contains the required data (VACCINE1)

▪ Step 2: Decide if any additional tables need to be joined for a complete dataset

▪ Step 3: Identify which field(s) within the table(s) are required to answer the question



▪ PATNO = patient ID

▪ VACNAME = vaccine name

▪ VACDATE = admin date

▪ CVXCODE = CVX code

▪ ID = unique ID

Question: which field is best for identifying the vaccine (VACNAME or CVXCODE)?



▪ VACNAME = “FLU-LAIV4 2-49yrs”, “FLU-IIV4 3yrs+ pf”, “FLU-IIV4 6-35m pf”, etc.

▪ CVXCODE = “149”, “150”, “153”, etc.

▪ In both cases, there are lists of qualifying items (even if just trying to find nasal flu)▪ Almost all clinical data value sets are lists

▪ Subject to year-over-year variability


Creating a Vaccine Action Item Type

▪ General form for an action Item Type to find the most recent administration of a specific vaccine or antigen for a specific patient:

SELECT FIRST 1 only need 1 record ID as Item_ID, as creates an alias VACDATE as Item_Date, reference date VACNAME as Item_Value “Most Recent Info”FROM VACCINE1 primary tableWHERE (PATNO = :patno)PATNO required! AND (CVXCODE [???]) varying propertyORDER BY VACDATE DESC sort by most recent


Vaccine Action Item - Flu Criteria

▪ To find most recent flu immunization, what goes here?

AND (CVXCODE [???])

Can’t use “=” because a list of CVX codes maps to some formulation of flu vaccine

▪ Might have considered a different rule: AND (VACNAME LIKE ‘%FLU%’)

But what about IPV vs. OPV? Can’t say AND (VACNAME LIKE ‘%PV%’)

(why not?)


▪ Best practice: IN list management operator with the most unambiguous coded valueAND (CVXCODE IN ("15","16","88","111", "125","126","127","128","135","140", "141","144","149","150","153","155", "158","161"))

(yes, the list really is that long as of 2015!)

▪ So now that we know the search condition, where does it go?

Action Item Data Mining: Flu


▪ Option 1: Create an Item Type specifically for flu vaccines

SELECT FIRST 1 ID as Item_ID, VACDATE as Item_Date, VACNAME as Item_ValueFROM VACCINE1WHERE (PATNO = :patno) AND (CVXCODE IN ("15","16","88","111",

"125","126","127","128","135","140","141","144","149","150","153","155", "158","161"))

ORDER BY VACDATE DESC

Action Item Type Data Mining: Flu



▪ Option 1 advantages:▪ Everything is in one place

▪ Has a single purpose, easily understood

▪ Option 1 disadvantages: ▪ Core logic must be replicated for each

antigen, even though method is always the same

▪ Difficult to find and maintain the items on the list when they (inevitably) change

▪ Probably not the only time flu vaccines will be the subject of data mining (CQMs, QI, etc.)



▪ Option 2: Create an Item Type specifically for flu vaccines, but standardize and substitute the coded list

SELECT FIRST 1 ID as Item_ID, VACDATE as Item_Date, VACNAME as Item_ValueFROM VACCINE1WHERE (PATNO = :patno) AND (CVXCODE IN (:CQM_LIST_CVX_FLU))ORDER BY VACDATE DESC


CQM Lists

▪ CQM Lists benefit all data mining, both Care Plans and QIC measures


Defining CQM Lists

▪ List Name is user-assigned, follows a simple formula: CODESET_PURPOSE

CODESET is CVX, LOINC, PROC, RXNORM, etc. So CVX_FLU means a list of CVX codes that define the value set for flu vaccines.

▪ List Contents is a comma-delimited list of items in double-quotes:"15","16","88","111","125","126","127","128","135","140","141","144","149","150","153","155","158","161"


Using CQM Lists: Flu

Think of a CQM List as a variable whose value is substituted at runtime. You can put it anywhere in your SQL as :CQM_LIST_ + the List Name whose contents should be substituted: AND (CVXCODE IN (:CQM_LIST_CVX_FLU))

Which at runtime will expand to:AND (CVXCODE IN ("15","16","88","111","125","126","127","128","135","140","141","144","149","150","153","155","158","161"))


Benefits of CQM Lists

▪ Reusable across Items and Item Types

▪ Used by both care plans and CQMs - keeps the rules consistent

▪ Maintainable as lists change - don’t need to understand everything about how to build care plans or CQMs in order to manage the lists that drive them

▪ Best practice: unless data mining is driven by a single value (and you know it always will be), make a list


Action Item Data Mining: Flu

▪ Option 3: Create an Item Type that works for all vaccines, then create specific Care Plan Items for different antigens

SELECT FIRST 1 ID as Item_ID, VACDATE as Item_Date, VACNAME as Item_ValueFROM VACCINE1WHERE (PATNO = :patno) AND (CVXCODE :ITEM_SQL)ORDER BY VACDATE DESC


Action SQL in Items

▪ Just as CQM Lists can be substituted at runtime, so can the specific condition that distinguishes one use of an Item Type

▪ :ITEM_SQL is a special parameter that tells the care plan engine to find the answer in the Item itself


Action SQL in Items

So … AND (CVXCODE :ITEM_SQL)

in “Flu Vaccine” care plan Item becomes AND (CVXCODE IN (:CQM_LIST_CVX_FLU))

in “Vaccine” care plan Item Type, which becomes AND (CVXCODE IN ("15","16","88","111", "125","126","127","128","135","140", "141","144","149","150","153","155", "158","161"))when CQM List is expanded. Neat, eh?


Trigger SQL in Items

▪ Triggers are conditions that determine whether data exists of a certain type

▪ All triggers take the form:Item Name Condition Value

▪ Care plan engine builds a WHERE clause in which Trigger SQL text replaces Item Name

▪ Helpful hint: All patient demographics are always available by referencing r.field_name



Bright Futures has this set of triggers:

which substitutes Patient Status:

and then Age in Years:



Which turns into this SQL:

WHERE ((r.status_pat = ‘ACTIVE’)

AND ((current_timestamp-r.birthdat)/365.25 <= 21))

Remember, all triggers ultimately resolve to a True or False response


Freestanding Trigger SQL in Items

Sometimes the Trigger SQL contains everything needed to return a True/False response

In this case, simply leave the Condition and Value blank when you use the Item in a trigger.


Let’s Try It!

Ready to Roll Your Own?


Hands-On: Appointment Reasons

▪ Let’s build the data mining for this problem:▪ How do you find the most recent appointment for

a specific patient related to asthma care?

▪ Step 1: Determine which table contains the required data (SCHEDULE)

▪ Step 2: Decide if any additional tables need to be joined for a complete dataset (no, but need list of qualifying template names)

▪ Step 3: Identify which field(s) within the table(s) are required to answer the question


Action Item Data Mining: Appt Reasons

▪ PATNO = patient ID

▪ APPT_DATE = visit date

▪ ENC_TEMPLATE = reason

▪ CODE1 = appt type

▪ VISIT_STATUS = status

▪ UNIQKEY = unique ID


Creating an Appt Reason Item Type

▪ General form for an action item type to find the most recent checked-in visit from a list of specific templates for a specific patient:

SELECT FIRST 1 only need 1 record

UNIQKEY as Item_ID, as creates an alias APPT_DATE as Item_Date, reference date ENC_TEMPLATE as Item_Value “Most Recent Info”FROM SCHEDULE primary tableWHERE (PATNO = :patno) PATNO required! AND (VISIT_STATUS IN ignore cancel/

(‘Complete’, ‘Superbill Exist’)) no show AND (ENC_TEMPLATE :ITEM_SQL) be flexible!ORDER BY APPT_DATE DESC sort by most recent


Creating an Appt Reason Item Type

▪ Plug this into the Care Plan Item Types grid:


Creating an Appt Reason CQM List

Next figure out which template names satisfy the requirement for asthma care or follow up:


Creating an Appt Reason Item List

Then carefully transcribe the names to a new CQM List:

Since there is no specific codeset, just use an obvious prefix and name. You may make numerous template name sets for different conditions, so be consistent.


Creating a Care Plan Item for Asthma

Go to Care Plan Items tab, define a new item:

▪Item Name can be anything but should be very obvious, because it appears everywhere

▪Note that Action SQL takes advantage of maximum reusability


Adding a Care Plan Item to a Care Plan

Finally, go to the Care Plans/Registries tab and add new Item to the Asthma - Moderate plan:

We’re done! The most recent asthma-related appointment for all patients enrolled in the Asthma - Moderate plan will now appear in their personal care plan.


Homework: Appointment Types

▪ Your homework assignment (if you choose to accept it :) is to create a similar collection of Item Type, CQM List, and Item for the Appointment Type field on the schedule (remember, it is illogically named CODE1)

▪ Possible uses:▪ Most recent scheduled well visit (based on

your list of well visit appointment types)

▪ Group or prenatal counseling


Questions?


We want your feedback!

2015 User Conference Care Plan SQL April 25, 2015 Presented by: Greg Anderson CEO EHR Workshop 491.

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Transcript of 2015 User Conference Care Plan SQL April 25, 2015 Presented by: Greg Anderson CEO EHR Workshop 491.