Medical(Informatics405:(HIT(Integration,(Interoperability...

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Medical Informatics 405: HIT Integration, Interoperability and Standards Winter 2010 WEEK 1 What components make up information architecture? Systematic, planned approach. Databases, applications standards, procedures, information use and confidentiality policies, hardware, software, networks for a given public health enterprise. What are the benefits of having information architecture?

A guiding plan component orientation (easier development, “functional decomposition, easier upgrades, easier incorp of

new infm tech) simplification (dec. redundancy of data entry/storage standards (^ efficiency/interoperability) promotes planning, clarifies business processes Control/decision-‐making returned to executive level, not IT

What are the steps involved in information resource management planning?

1. Understand the business 2. Simplify 3. Integrate (data, software, technology can be shared across the enterprise, and so one fact is stored in one

place) What are the advantages of using local vocabulary codes?

1. Familiar to local staff 2. More easily updated/changed 3. Easier to compare old data to new

What are the disadvantages of using universal vocabulary codes? 1. May be unfamiliar to local staff, req. training 2. Not as flexible or easily updated 3. May not be representative of local organizations info needs

What is the sequence of steps typically involved in the standards setting process? 1. Identify areas req. standardization 2. Determine if any pre-‐existing standards 3. Submit a proposal to appropriate SDO 4. Discussion/debate (first at technical level, then if appropriate, on to central governing board of SDO) 5. Review Process/Incorporate changes 6. Consensus/Final Vote

How was the MOHSAIC Information Strategy Plan developed? Problems assessed Goals decided Adopted Information Engineering (C. Finkelstein) Users involved in design

o Assessed all information systems o Identified all functions performed, all data needed o Two identical ISP’s developed (state and local), then converged to one ISP to cover all inform.

needs of PH in MO What requirements were identified for the integrated MOHSAIC system?

Same standards used to capture all data All data included in one integrated system

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One technical platform Records client-‐centeredholistic view of client Supported data sharing among public agencies/staff One-‐time capture of client information (demographic, etc.) dec. redundant info entry/storage One system designed for MDOH and local indep. PHA’s Tailored to specific needs as developedGood fit. Assessment, policy devel., assurance

What types of architectures were included in the MOHSAIC Information Strategy Plan?

1. Information 2. Business systems 3. Technical

What factors add risk of failure when developing integrated systems? The larger the system the more likely to fail Coordinating across many programs Need support from many programs Lack of funding Difficulty converting lots of existing systems with different formats, data systems, data definitions into one

database Differing confidentiality rules Politics Lack of serious support from upper management

What problems were encountered when converting legacy data? Different data formats Lack of uniform standards for data entry Design flaw in Legacycritical data entered via work around Insufficient data entry rules or edits to prevent incorrect data entry Insufficient ID data

May a system need to be redone if users do not actively participate in the system design? YES WEEK 2 Integration: process that allows different info systems to exchange dataseamless to end user Interface: program that tells 2 different systems how to exchange data Benefits of integration:

Instant access to apps/data Data integrity: shared dataless data entryless errors Less labor cost Client record more accurate/complete Improved info tracking more accurate cost assessment

Interface engine: software app that allows users of different information systems to exchange info without having to build direct customized interfaces. Benefits of an interface engine?

Transfers info from sending system to 1 or many receiving systems Users of diff systems can send/access info Allows seamless integration Allows diff systems with unlike terminology to exchange info without expensive point-‐to-‐point

interfacesDecreases integration cost

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o Translation tables o Clinical data repository/warehouse (CDW)

Mapping: major benefit is mapping for multiple receiving systems can be built for ea. sending system

Improves timeliness/availability of critical admin/clinical data Improves data quality Lets clients pick best system for their needs Preserves existing systems, institutional investment Simplifies admin of healthcare data processing Simplifies/speeds up integration Improves management of care, financial tracking, efficacy

Mapping: terms in one system matched to terms in another Interoperability: ability of two entities to exchange/use data while retaining original meaning What does HL7 rely upon for the storage and movement of clinical documents between systems? XML markup language Syntactic/functional interoperability: ability to exchange the structure of the data, not necessarily the meaning (e.g. HTML web page) Semantic interoperability: ensures meaning is the same (crucial for clinical data) Archetype: high quality, reusable clinical models of content and process, defined by clinicians (header + definition + ontology) SOA: service-‐oriented architecture-‐ places key functions into reusable modules (similar to object-‐oriented programming. (Defines service as self-‐contained unit; function of, step of, or entire process.)

Doesn’t require re-‐engineering of existing system Vendor/technology neutral Supports info exchange between diff program languages Streamlined HIE Quality, security (authentication, authorization, reliable mess. policies

What factors slow integration?

Unrealistic vendor promises Unrealistic institutional timetables Changing user specifications Lack of vendor support Insuff. documentation Lack of agreement between merged institutions All of vendor’s products might not work together

What are the estimated implementation and operating costs for the national healthcare information network? Total capital: $103 billion + Annual operating cost: $27 billion Data dictionary: ensures consistent understanding; includes synonyms Master patient index: lists all identifiers assigned to one client in all systems across the enterprise

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What do HL7 standards address? Provides standards for management/integration of healthcare data. Definitions of data to be exchanged, timing of the exchanges, communication of certain errors between apps. What is DICOM used for? Production, display, storage, retrieval, printing of medical images and derived structured documents Management of related workflow Integration of information from specialty imaging apps into HER-‐ defining network and media interchange

services for storage and access of DICOM objects for EHR How does standardization affect the economy? Well-‐ designed standards can slow down production/innovation but provides a stable base, which helps to minimize undesirable outcomes, thus enables innovation in the long run. (Swann, p. iv) How do companies benefit from participating in the standards development process?

Head start on rivals in adapting to market demands and new technology Reduce cost. Increase quality Reduce risk (technological and market) Reduce research risk, development costs Can steer the process in ways that benefit own interests (Swann, p. iv)

How does standardization affect the marketplace?

Benefits the economy as a whole, but does not necessarily increase profits for individual companies Opens up markets/enables competition Increases volume of trade (exports and imports). Important contribution to macroeconomic growth

(Swann, p. iv) How is the pace of traditional public standards setting procedures perceived?

Perceived as being too slow, given the fast pace of innovation, intense global competition, and ever-‐shorter product life cycles. (Swann, p. v)

What impact does the rate of technological change have on the pace of standardization? Puts pressure on standards developers to increase the pace, but there is also pressure to develop quality standards (Swann, p. v) What impact does involving customers directly in the standardization process have? Better quality standards that may have better longevity, given there is meaningful input from the customer. Standards more inline with the trajectory or long-‐range intent of the innovators. Lessens risk of standards being short-‐sighted. (Swann, p. v) What is the role of the government in the standardization process?

Ensure the balance of participation (inclusive of customers, as well as producers) (Government may be a customer.)

Represent excluded interests Alter the shape of the standards infrastructure Protect the customers’ interests Stabilize/protect the long-‐term health of standards infrastructure (Swann, p. vi)

WEEK 3 What organization developed CPT?

AMA (p. 203 ch 6) CPT serves as what level of the HCPCS?

Level 1 (p. 203 ch 6)

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What organization maintains Level 2 HCPCS codes? CMS (p. 203 ch 6)

What standard is considered the most comprehensive international and multilingual clinical reference terminology in the world?

SNOMED (p. 205 ch 6) What standards have been cross-‐mapped with SNOMED CT? ICD-‐9-‐CM, ICD-‐03, LOINC, NIC, NOC, NANDA, and PNDS (p. 208 ch 6) What are the desirable characteristics that make clinical terminologies more useful?

Content, concept orientation, concept permanence, nonsemantic concept identifier, polyhierarchy, formal definitions, reject “not elsewhere classified”, multiple granularities, multiple consistent views, context representation, graceful evolution, and recognized redundancy (p. 208-‐211, ch 6) Six additional characteristics added: (p. 211, ch 6) Copyrighted and licensed CIS (Commercial Information System) vendor-‐neutral Scientifically valid Well-‐maintained Self-‐sustaining Scalable infrastructure and process control

What are the federal data sets? DEEDS Data Elements for Emergency Department Systems MDS Minimum Data Set for Long-‐Term Care OASIS Outcome and Assessment Information Set UACDS Uniform Ambulatory Care Data Set UHDDS Uniform Hospital Discharge Data Set (p. 99, ch 4) What are the Joint Commission (JCAHO) standards relating to the acquisition, analysis, and reporting of information?

• Institution wide planning and design of information management processes • Confidentiality, security, and integrity of information • Uniform data definitions and methods of data capture • Education and training in principles of information management by decision makers as well as

those who generate, collect, and analyze data and information • Timely, accurate transmission of data in standardized formats when possible • Integration and reporting of data with linkages of patient care and on-‐patient-‐care data across

departments and care modes over time • Detailed list of patient-‐specific data • Aggregate data from the entire institution • Incorporation of knowledge-‐based information, including the library, formulary, and poison

control information, in the information management systems plan • Contributions to and use of external reference databases

(p. 129, ch 4) What items are included in the Uniform Hospital Discharge Data Set?

01. Personal identification 02. Date of birth (month, day, and year) 03. Sex 04. Race and ethnicity 05. Residence (usual residence, full address, and zip code I nine-‐digit zip code, if available) 06. Hospital identification number (Three options are given for this institutional number, with the Medicare provider number as the recommended choice. The federal tax identification number or the AHA number is preferred to creating a new number.)

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07. Admission date (month, day, and year) 08. Type of admission (scheduled or unscheduled) 09. Discharge date (month, day, and year) 10. Attending physician identification (UPIN) 11. Operating physician identification (UPIN) 12. Principal diagnosis (The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.) 13. Other diagnoses (All conditions that coexist at the time of admission or that develop subsequently that affect the treatment received or the length of stay. Diagnoses that relate to an earlier episode and have no bearing on the current hospital stay are excluded.) 14. Qualifier for other diagnoses (A qualifier is given for each diagnosis coded under “other diagnoses” to indicate whether the onset of the diagnosis preceded or followed admission to the hospital. The option “uncertain” is permitted.) 15. External cause-‐of-‐injury code (Hospitals should complete this item whenever there is a diagnosis of an injury, poisoning, or adverse effect.) 16. Birth weight of neonate 17. Procedures and dates a. All significant procedures are to be reported. A significant procedure is one that (1) is surgical in nature, (2) carries a procedural risk, (3) carries an anesthetic risk, or (4) requires specialized training. b. The date of each significant procedure must be reported. c. When multiple procedures are reported, the principal procedure is designated. The principal procedure is one that was performed for definitive treatment rather than one performed for diagnostic or exploratory purposes or was necessary to take care of a complication. If two procedures appear to be principal, then the one most related to the principal diagnosis is selected as the principal procedure. d. The UPIN of the person performing the principal procedure must he reported. 18. Disposition of the patient a. Discharged home (not to home health service) b. Discharged to acute care hospital c. Discharged to nursing facility d. Discharged to home to be under the care of a home health service e. Discharged to other health care facility f. Left AMA g. Alive, other, or alive, not stated h. Died 19. Patient’s expected source of payment a. Primary source b. Other source 20. Total charges (List all charges billed by the hospital fbi this hospitalization. Professional charges for individual patient care by physicians are excluded.)

(p. 130, ch 4) What segments make up the Uniform Ambulatory Care Data Set? Patient data items, provider data items, encounter data items (p. 131-‐132, ch 4) What are the characteristics of data quality?

Accuracy: Data are the correct values and are valid. Accessibility: Data items should be easily obtainable and legal to collect. Comprehensiveness: All required data items are included. Ensure that the entire scope of the data is collected and document intentional limitations. Consistency: The value of the data should be reliable and the same across applications.

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Currency: The data should be up to date. A datum value is up to date if it is current for a specific point in time. It is outdated if it was current at some preceding time yet incorrect at a later time. Definition: Clear definitions should be provided so that current and future data users will know what the data mean. Each data element should have clear meaning and acceptable values. Granularity: The attributes and values of data should be defined at the correct level of detail. Integrity: Data are true to the source and have not been altered or destroyed. Precision: Data values should be just large enough to support the application or process. Relevancy: The data are meaningful to the performance of the process or application for which they are collected. Timeliness: Timeliness is determined by how the data are being used and their context. (p. 144, ch 4)

What are the major segments in the ASTM E1384 standard? Administrative Data I Demographics II Legal agreements III Financial information IV Provider/practitioner Clinical Data: Problem / Diagnosis V Problem list Clinical Data: History VI Immunization VII Hazardous stressor exposure VIII Health history Clinical Data: Assessments/Examinations IX Assessments / Patient-‐reported data Clinical Data: Care/Treatment Plans X Clinical orders Clinical Data: Services XI Diagnostic tests XII Medications XIII Scheduled appointments/events Administrative Data: Encounter XIV Administrative data / Encounter disposition Clinical Data: Encounters Chief complaint/diagnoses Clinical course Therapy procedures

(p. 147, ch 4) What are the main parts of an encounter record?

1. Administrative and diagnostic summaries 2. History of current illness 3. Progress notes and clinical course 4. Therapies 5. Procedures 6. Charges

(p. 149, ch 4) Under what conditions does semantic heterogeneity occur?

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Semantic heterogeneity occurs when there is disagreement about the meaning, interpretation or intended use of the same or related data [3]. It occurs in different contexts, like database schema integration, ontology mapping, or integration of different terminologies. (p. 1, article)

What areas of integration can semantic heterogeneity occur in? Data integration (ontology and vocabulary) Functional integration (application framework) Desktop/presentation integration (Lenz, et al, p. 386-‐387)

What is the goal of data integration? The goal of data integration is to create a unique semantic reference for commonly used data and to ensure data consistency. As a basic categorization for such a semantic reference we roughly distinguish three different facets: (1) The instance level, referring to the semantics of individual data objects, which corresponds to the meaning of entries in a database. (2) The type level, designating the semantic classification of data objects, which roughly corresponds to the database schema. (3) The context, which refers to the semantic relationships that associate an object with other objects. (p. 2, article)

What does insufficient functional integration result in? Functional integration refers to the meaningful cooperation of functions. Uncontrolled

data redundancy is often the result of an insufficient functional integration. (p. 3, article)

What category of integration is concerned with the consolidation of procedural knowledge? Functional integration (p. 3, article)

What category of integration is single sign-‐on? Desktop integration or presentation integration (p. 3, article)

What category of integration do syntactic framework standards fall in? Technical/data integration (p. 3, article) What category of integration do ontology and vocabulary standards fall in?

Semantic/data integration (p. 3, article)

What are examples of a syntactic framework? XML and RDF are examples for syntactic frameworks supporting data integration. (p. 3, article) What do middleware standards provide?

Middleware standards typically provide a common infrastructure for interconnecting distributed software components. (p. 3, article)

What does an application framework provide? Functional integration. A reference for programmers to create functionally compatible software components Clear specifications of interfaces and interaction protocols which are needed for embedding a

software component into a system of cooperating components. (p. 3, article)

WEEK 4 Medical Informatics 405: HIT Integration, Interoperability and Standards Winter 2010 Study Questions- Session 4

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1. What groups will receive the largest annual dollar savings from Level 4 interoperability? a. Executive Summary, p. 134 b. Labs, radiology centers, public health departments, and payers (maybe pharmacies)

2. How will clinical care be improved by improving interoperability between providers and laboratories? a. Executive Summary, p. 2 b. Give clinicians better access to patients’ longitudinal test results c. Eliminate errors associated with verbally reporting results d. Optimize ordering patterns by making test cost information readily available to clinicians e. Make testing more convenient for patients

3. What is a benefit of improved interoperability between outpatient providers and radiology centers? a. Executive Summary, p. 2 b. Improves ordering by Giving radiologists access to relevant clinical information Enabling them to

recommend optimal testing and reduce errors of commission on the part of the ordering physician c. Improves patient safety by alerting both the provider and the radiologist to test contraindictions d. Improves coordination of care for both providers and patients e. Helps prevent errors of omission by enabling automated reminders to both clinicians and patients

when follow up studies are indicated f. Helps environment by reducing the use of chemicals and paper used in film processing g. Reduces redundant tests and saves time and costs associated with paper and film based processes

4. What is a benefit of improved interoperability between outpatient providers and pharmacies? a. Executive Summary, p. 3 b. Improve care through Formation of complete medication lists

i. Reducing duplicate therapy ii. Reducing drug interactions iii. Reducing other adverse drug events iv. Reducing medication abuse

c. Generate automated refill alerts d. Give clinicians easy access to information about whether patients fill prescription e. Complete insurance forms required for some medications f. Identify patients in a drug recall, or discovery of new side affects g. Improve formulary management and promote adherence to formulary guidelines h. Promote adherence to formulary guidelines i. Saves phone time for clinicians and pharmacists

5. Why are implementation costs for Level 3 higher than for Level 4? a. Executive Summary, p. 5 b. Level 3 requires more interfaces

6. How many providers do patients see annually? a. Executive Summary, p. 7 b. 1.3-‐13.8 unique providers annually, with the average medicare beneficiary seeing 6.4

7. What is a potential benefit of health care information exchange and interoperability? a. Executive Summary, p. 9 b. Patient safety and Clinical quality are improved as we Intergrate health information from multi

sources and providers and Intergrate decision support tools with guidelines and research results c. Patients can gain access to their own personal health information which empowers them to better

manae their health

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d. Public health system benefits from improved reporting of communicable diseases and Real time aggregation of data for biosurveillance and detection of emerging disease patterns

e. Aggregating electronic billing and payment data will facilitate better understanding of healthcare costs

f. Potential financial benefit may accrue from decreasing human involvement in information exchange and reducing redundant procedures

8. What differentiates Level 3 interoperability from Level 4? a. Executive Summary, p. 14 b. 4 is differentiated from 3 by the use of standard, controlled vocabularies that enable systems to

understand incoming data, such as LOINC, SNOMED, DSM, ICD, and CPT codes. Level 4 semantic interoperability while level 3 is only structured interoperability.

c. Executive Summary, p. 1 d. Level 3 is Machine organizable data, level 4 is machine interpretable data with standardized

message formats and content

9. How much money can Level 4 interoperability save the United States annually? a. Executive Summary, p. 133 b. $77.8 billion annually, or 5% of U.S. Healthcare expenditure

10. How much money can Level 4 interoperability save payers? a. Executive Summary, p. 134 b. $21.6 billion

11. What are the components of the CITL Healthcare IT Value Framework? a. Executive Summary, p. 137 b. Financial Value, Clinical Value, Organization Value

12. What must be in place to achieve health information exchange? a. Ch. 13, RHIO’s, p. 317 -‐ 318 b. Patient Identifier c. Technology infrastructure d. A model e. Participants f. Funding g. Policies h. Consent management i. Community buy-‐in j. Scalability

13. What information is typically available to participants of a health information exchange? a. Ch. 13, RHIO’s, p. 319 b. E-‐prescribing c. Lab results d. Pathology results e. Radiology results f. Diagnostic images g. Physician’s dictation, including history and physical, progress notes, and discharge summaries h. Inpatient medication treatments i. Nursing care documentation j. Client demographic information

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k. Client healthcare insurance information l. Names of primary and consulting physicians m. Long-‐term health records n. Ambulatory care / clinic visits o. Public health records p. Home health information q. Decision support r. Quality measurement and reporting services s. Telehealth consults t. Immunization records u. Prescribed medications, vitamins and supplements, and homeopathic remedies

14. What benefits are associated with a health information exchange? a. Ch. 13, RHIO’s, p. 320 b. Saves money c. Improves outcomes d. Improves provider-‐patient relationships e. Streamlines workflow f. Provides a positive perception

15. What are the different models for a health information exchange? a. Ch. 13, RHIO’s, p. 320 b. Community-‐based c. Proprietary d. Federation e. Co-‐op f. Hybrid

16. What are the primary features of a community health information network? ? a. Ch. 13, RHIO’s, p. 321 b. Open communications c. Clinical data repository d. Mechanisms for cost, outcome, and utilization analysis

17. What are the obstacles to the long-‐term success of a health information exchange? a. Ch. 13, RHIO’s, p. 323 b. Governance c. Funding d. Competition e. Internal policies f. Consumer privacy concerns g. Trust h. Legal and regulatory issues i. Technology j. Scarce human resources

18. What are the purposes of a clinical data repository? a. Ch. 5, CDR’s, p. 169 b. Provides easy access to patient information for providers and demonstrates time saved over

paper record use

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c. Expedites results reporting through customizable displays d. Provides quick and easy access to longitudinal patient data e. Supports a common user interface for accessing patient information, usually through a

workstation f. Provides information in a comprehensive, integrated manner rather than by departmental

orientation g. Provides an easy vehicle for applying population management for the prospective clinical

planning needed today h. Supports monitoring and analysis of patient care outcomes

19. What types of information is present on a data flow application diagram? a. Couldn’t find this b. Process – An activity or a function that is performed for some specific reason; can be manual or

computerized; ultimately each process should perform only one activity c. Data Flow – single piece of data or logical collection of information like a bill d. Data Store – collection of data that is permanently stored e. External Entity – A person, organization, or system that is external to the system but interacts

with it

20. What are the managerial-‐related aspects of an interface engine that should be considered? a. Healthcare IT Talk, slide 12 b. Cost / Control / Skills / Productivity / growth / connectivity / speed / manageability c. Easy access to the information d. Quick resolution e. Proactive, 1st to know, 1st to respond / reduce frequent calls from users

21. What elements of an interface engine support a proactive approach? a. Healthcare IT Talk, slide 13 b. Monitoring c. Alerting

22. Is the HL7 version 3.0 standard backwards compatible? a. What does HL7 Compliance Really mean? Slide 2 b. no

23. Does the HL7 standard allow for customization? a. What does HL7 Compliance Really mean? Slide 2 b. yes

24. What is implied by stating that an interface is compliant with the HL7 standard? a. What does HL7 Compliance Really mean? Slide b. They have followed base standard and have made no customizations

25. Is 100% compliance with the HL7 standard likely? a. What does HL7 Compliance Really mean? Slide b. no

26. What are the general approaches to interfacing? How is conformance achieved with each approach? a. What does HL7 Compliance Really mean? Slide b. Point to Point

i. One or both vendors change their software to conform to the other

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c. Interface engine i. Conformance happens in the interface engine, not software

WEEK 5 What harmonization issues do implementation guides help address? (Didi,Slide 9)

Reduction/elimination of optionality in current standards Reduction/elimination of need for point-‐to-‐point Improved consistency of information/terminologies Improved security and privacy of information

Who is involved in IHE? (Didi,slide 12)

Users-‐clinicians, staff, administrators, CIOs, Gov’t agentcies(e.g. NIST, VA, DoD, CDC, CMS) Prof. Societies representing 270.00 indiv. Mmbrs: (HIMSS,RSNA,ACC, ACP, AAO, ACCE, ASTRO, etc) Standards Dev. Orgs (SDOs):HL7,DICOM,ISO,CDISC,ASTM,W3C,IEEE,IETF,etc) Vendors & consultants (e.g.imaging,EHRs,cardiology,medical devices)

Who benefits from IHE’s work?(Didi,slide 13)

Patients-‐enhanced care’s qual., safety, effic. & effect. Clinicians-‐imp. Workflow and info reporting Fewer error opportunities, less repeated work Vendors/consultants-‐satisfy customer’s interop. Demands, decrease cost &complex. of installation and

better ROI SDOs-‐rapid feedback to address real-‐world issues, establishment of crit. Mass and widespread adoption Govt-‐dec. cost of implementing HER systems, incr. pt info interoperability

What are the IHE domains? (Didi, slide14)

Radiology IT infrastructure for Healthcare Cardiology Laboratory Eye care Radiation oncology Patient care coord. Patient care devices Pathology Quality, research and public health

What federal organization is IHE aligned with? (Didi, slide 20) Office of the National Coordinator for HIT What year was AHIC established? (FHA, slide 7) 2005 Who do health IT standards impact? (FHA, slide 8)

Policy decision makers Investment planning decisions

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Health IT implementations Health IT system architects Health IT developers

What organizations does AHIC work closely with? (FHA, slide 11) CCHIT-‐ Certification Commission for Health Information Technology HISPC-‐ Health Information Security and Privacy Collaboration HITSP-‐ Health Information Technology Standards Panel NHIN-‐National Health Information Network architecture projects

What types of issues do standards generally have? (FHA, slide19) Gaps Overlap Adoption Specificity

What is the sequence of steps in the in the HITSP harmonization process? (FHA, slide 32) I. harmonization request II. requirements analysis III. identification of candidate standards IV. gaps, duplications, & overlaps resolution V. standards selection VI. construction of interoperability specifications VII. inspection test VIII. interoperability Spec IX. program management

What federal organizations are members of HITSP? (FHA, slide 75) • Agency for Healthcare Research Center for Mental Health Services/SAMHSA • Centers for Disease Control & Prevention • Centers for Medicare & Medicaid Services • Department of Defense • Department of Health & Human Services • Department of Veterans Affairs • Food & Drug Administration • General Services Administration • HHS/NIH/ National Library of Medicine • National Committee for Vital Health Statistics • National Library of Medicine • NIST -‐ US Department of Commerce • Office of Management & Budget • Social Security Administration What technical committees does HITSP have? (FHA, slide 76) 1. Care Delivery 2. Consumer Empowerment 3. Population Health 4. Cross-‐Technical Committee Coordination 5. Security and Privacy 6. Emergency Responder – EHR Coordination What can Extensible Markup Language be used for? (Ferranti, p. 246) Use by CDA and CCR to facilitate the exchange of structured medical data

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What can CDA be used for? (Ferranti, p. 246) The HL7 CDA is based on a formal information model and can be used for a number of document types, including radiology reports, progress notes, clinical summaries, and discharge summaries. What organization joined together with the ASTM-‐I to create the CCR? (Ferranti, p. 246)

Several high-‐profile medical organizations, including the American Academy of Pediatrics, the Massachusetts Medical Society, the American Academy of Family Physicians (AAFP), the Health Information Management and Systems Society (HIMSS), and the American Health Care Association, have joined forces with ASTM International to create what is now known as the CCR.

What types of patient information does CCR include? (Ferraniti, p. 246) ASTM International defines the CCR as a ‘‘summary of the patient’s health status (e.g., problems, medications, allergies) and basic information about insurance, advance directives, care documentation, and care plan recommendations.’’

What types of information formats can CDA include? (Ferraniti, p. 248) HL7 RIM (Reference Information Model) MIME-‐encoded payload within an HL7 message HL7 R-‐MIM (Refined Message Information Model) LOINC SNOMEDCT The CDA derives its content directly from the HL7 Reference Information Model (RIM) and therefore is specifically designed to integrate with current HL7 technologies. A CDA document ‘‘can exist outside of a messaging context and/or can be a MIME-‐encoded payload within an HL7 message. Thus the CDA complements HL7 messaging.’’17 In essence, each CDA instantiation represents a distinct clinical document, whether a progress note, discharge summary, or radiology report. The CDA is basically a constrained version of the HL7 RIM, in which RIM object classes have been assigned specific data types and vocabularies.18 In HL7 terms, this constraint of the RIM is called a Refined Message Information Model (R-‐ MIM). The CDA document type and Universal Observation Identifier Names are defined with LOINC19 document codes. Like the CCR, the CDA allows for controlled terminologies such as SNOMED CT to enhance semantic interoperability between medical information systems. Although some contend that a single CDA document could in itself represent a complete EHR, others have envisioned the EHR consisting of a structured collection of multiple CDA documents. The defining characteristics of all CDA documents are persistence, stewardship, wholeness, human readability, and potential for authentication.16 Like the CCR, the CDA is implemented using XML. What are the defining characteristics of a CDA document? (Ferranti. P. 248)

Persistence Stewardship Wholeness Human readability Potential for authentication

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How do the CDA levels differ from one another? (Ferranti. P. 249) In essence, each increasing level allows for additional machine readability, but the clinical content of the notes should be identical in all three levels. What benefits do each of the CDA levels provide? (Ferranti. P. 249) Level 1: “unconstrained” CDA; allows for free text to facilitate transfer of unstructured clinical notes. Provides max. compatibility with older systems; simplifies implementation process from technical standpoint Level 2: adds specification for section constraints w/in CDA to provide structure but also allows for unconstrained elements w/in headings Level 3: provides fully structured “entry level templates”; most granular; allows max. machine readability. Does the CCR standard provide for user-‐configurable fields? (Ferranti. P. 250) CCR makes a point of not allowing any user-configurable fields and thus does not allow for local differences in implementation. WEEK 6 Pg 1-‐abstrast What are the components of a framework used to assess the informational value of data? Data dimensions, aligning data quality with business practices, identifying authoritative sources and integration key, merging models, uniting updates of varying frequency and overlapping or gapped data sets What type of source contains the most reliable value for a specific data element? Pg 2 Authoritative sources What do defined data dimensions help do with regards to the data model? Pg 3 Once defined, the dimensions help to build, communicate and validate models and to identify potential errors. What happens to data during the Extract-‐Transfer-‐Load process? Pg 5 Non-‐redundant, cleansed and validated data are load in a code DB from the ODS through the Extract-‐Transfer Load process. What does the conceptual data model identify and define? Pg 6-‐fig 5 A CDM defines the main concepts included into and excluded from the study. What layers does integration occur at? Pg 7 – four layers: data souces, Des, data sets, and data values What is the most important characteristic of a data source? Pg 7 – The purpose What are the characteristics of a focal data element? Pg 7 – Mandatory and have the highest quality

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Can peripheral data elements be integrated effectively? Pg 7 – Yes-‐optional What does a controlled vocabulary provide to a project? Pg 9 – quality and consistency in data collection, processing and interpretation within a project. What categories can data elements be split into for the purposes of integration? Pg 10 -‐ integration keys, informative DEs and auxiliary DEs What type of data elements can integration keys and informative data elements be chosen from? Pg 10 -‐ focal DEs. What is an integration key? Pg 10-‐ is a combination of DEs that identifies exactly the same entity in two sources and is chosen from the overlapping focal DEs. What is the most crucial part of an integration project? Pg 10-‐ Choosing integration keys What are the most common ways of acquiring data from a source? Pg 12 -‐ Data gathering agents, data pulls, and flat file updates What is challenging when performing the semantic integration of models? Pg 14-‐ Semantic integration [59] of models is challenged by multiple ways to interpret relationships between entities [60] and by different levels of granularity in presentation of models. What does schema matching involve? Pg 14-‐ involves database re-‐engineering, schema transformations [61] and middleware data models [62] What type of mapping of data elements is the most frequently used method for data exchange? Pg 15-‐ direct system-‐to-‐system mapping of data elements What are the components of the information pipeline architecture? Pg 5 – Data source, ODS, ETL, Core DB, data mart (reporting, visualization, anlaysis, data mining) What is the process to identify authoritative data sources and integration keys?

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Pg 9 -‐ WEEK 7 Study Questions- Session 7 Explain the simple idea of the data warehouse concept. P.7 – A single data repository to support decision making, reporting and analysis. A quality copy of all data that is cleansed, standardized, and integrated. Data is consistent with respect to format, semantics, etc. What are examples of advanced analytical tools used in conjunction with a healthcare data warehouse? P.8 – Data Mining Tool, Surveillence and Utilization Review System (SURS), ACGCGG Groupers, Provider Profiling, Disease Management What benefits are sought through healthcare data warehousing? P.9 – Improved access to clinical information at the point of care, Evidence based clinical decision making, Evidence based clinical policy decision making, Management of chronic diseases (better quality life, healthcare cost savings), More consistent patient behavior, More effective costs management, Better risk management (quantify risks), Elimination of redundant testing and reporting, Waste/fraud control What initiatives is data warehousing supporting in the Veterans Health Administration? P.13 – Enterprise Performance measurements, Pharmacy Datamart (best medication for a patient, savings in purchasing), Chronic diseases telemedicine, Resource Management.

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What are the critical success factors in healthcare data warehousing? P.16 – P.24 -‐ Enterprise Approach, Support for complex data structures, Support for complex queries, Large Data Volumes, Concurrent and timely use, Flexibility, High Performance, High Availability, Privacy and Security, Support and Education, Data Quality and Standards The big benefits of data warehousing are dependent on which two aspects of an enterprise approach? P.16 – Enterprise level data integration, and Support for multiple different views and uses of the data. What does high performance mean in data warehousing today? P.20 – Complete simple queries quickly, Complete large, complex queries efficiently and scalability, and Load new data into the data warehouse in a timely way. What does every successful data warehouse program include in terms of data quality and standards? P.22 – Strong commitment to data quality, data standards, data semantics, and data definition. What are the performance objectives for the healthcare industry? P.2 – Effective treatment of patients, reimbursement for treatments, reduct. Of admin costs, effectively record and track patient med history, efficient mgmt of health care delivery schedules for practitioners as well as patients. What are some sample key performance indicators for the healthcare industry? P.3 – Avg. length of stay, maintained bed occupancy, FTEs per adjusted occupied bed, Case-‐mix index, monthly surgical cases (inpat. & outpat.), inpatient & outpatient revenues, costs per adj. patient day (inp&outp), % of revenue from charitable sources, revenue and expense per physician, margin per department, admitting-‐process performance. What are some performance metrics for the emergency room? P.3 – Door to provider time, Admission to provider time, Length of stay, Wait time for ambulances, throughput (urgent/non-‐urg), triage to initial assessment, bed turnover, staff applied to each type of patient, type of cases What are some performance metrics for the customer satisfaction? P.3 – Wait times, quality of physician, cleanliness, food taste What data should be tracked to populate trending reports related to the relationships of the different parties involved in healthcare? P.4 – People and Orgs: Patients, health care provider orgs, indiv. Practitioners, insurance companies. Relationships Between: patient/practitioners, provider / health care networks, practitioners / health care provider organizations. Services and Products provided by the healthcare providers. Agreements: patient / practitioner, provider / network, provider / supplier. Records of health care services performed as it relates to various health care incidents, visits and episodes. Claims submitted and the status of claims. Other data needed to track financial statement and personnel data. What individual phases can a healthcare episode be broken down into? P.6 – Episode, Health care delivery, delivery outcome, episode’s outcome What dimensions can be included in a star schema for an episode? P.7 – Diagnosis type, episode type, incident type, individual healthcare practitioner, outcome type, provider organization, time by week What does a data model show? P.7 – A data model shows the various relationships between each bit of data within the data warehouse.

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Describe the data flow diagram for an approach to healthcare conceptual business intelligence architecture. P.9 – Source applications (HR, GL, etc) feed into the staging area, which handles the raw data. The data goes through ETL process and populates Operational Data Warehouse. Data is extracted from ODW for Management Data Warehouse to provide reports for management and operations. Describe a general project methodology to initiate a data warehouse. P.9 – The phases consist of: 1) Current state assessment. 2) Future state requirements. 3) Gap analysis & roadmap development. 4) Detailed project plan. 5) Release Phase I. 6) Release Phase 2. 7) Release Phase 3. What steps should be included in each release phase when initiating a data warehouse? P.12 – Requirements / Scoping, Development, Testing, Implementation What benefits result from including management and stakeholders on the implementation team? P12. – decisions can be made quickly without having to bring decision-‐makers into the loop with each crucial step needing resolution. WEEK 8 What are the top data integration issues according to the TDWI report on data integration by Colin White? data quality and security, lack of a business case and inadequate funding, and a poor data integration infrastructure, metadata management issues, lack of IT data integration skills (p.3) What levels in an information technology system can enterprise business integration occur at? data, application, business process, and user interaction (p.6) What are the main techniques used for integrating data? consolidated (physical), federated (virtual), propagated (p.6) What are the advantages of using the data consolidation technique? allows large volumes of data to be transformed (restructured, reconciled, cleansed, and/or aggregated) as it flows from source systems to the target data (p.10) What are the disadvantages of using the data consolidation technique? the computing resources required to support the data consolidation process and the amount of disk space required to support the target data store.(p. 10) What is the main data integration technique used to build and maintain an enterprise data warehouse? Data consolidation (p.10) What technologies support the data consolidation technique? ETL (extract, transform, load) is one of the more common; ECM(enterprise content managemant). Most ECM’s focus on consolidating and managing unstructured data (e.g. documents, reports, web pages) (p. 10) What is an example of a technology that supports a federated approach to data integration? EII (Enterprise information integration) (p. 10) What may be used to document semantic relationships between data elements when using a federated approach? Business metadata (p.10) What are the advantages of using a federated approach? It provides access to current data and removes the need to consolidate source data into another data store. (p.10) What are the disadvantages of using a federated approach? Not well suited for retrieving and reconciling large amounts of data, or for applications where there are significant data quality problems in the source data. Another consideration is the potential performance impact

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and overhead of accessing multiple data sources at run time. (p.11) What technologies support the data propagation technique? Data propagation- guarantees delivery of data to target

applications copy data from one location to another o usually online o push- event driven

sync (updates to source/target at same time) async

Enterprise application integration (EAI) message- or transaction-centric Enterprise data replication (EDR) data-centric architecture (p.11) What are the advantages of using the data propagation technique?

real-‐time or near-‐real-‐time movement of data guaranteed data delivery two-‐way data propagation can also be used for workload balancing, backup and recovery, and disaster recovery (p.11)

What two aspects of data quality need to be considered in a data integration project?

1. analysis of the source data stores for contents and quality 2. cleansing of poor quality data; often done by inserting data transformation process in the data integration

workflow area; data trans. includes data restructuring, cleansing, reconciliation, and aggregation.. (p.13) What is the objective of enterprise information integration? -‐to enable applications to see dispersed data as though it resided in a single database What are distinguishing features to look for when evaluating enterprise information integration products? the data sources and targets supported (including Web services and unstructured data), transformation capabilities, metadata management, source data update capabilities, authentication and security options, performance, and caching (p.16) What circumstances make it more appropriate to using extract, transfer, and load technology as opposed to enterprise information integration technology?

When only read-‐only access to reasonably stable data is required When users need historical or trend data When data access performance and availability are key requirements. When user needs are repeatable and can be predicted in advance When data transformation is complex (p.18)

What is one of the more significant differences between enterprise data replication and enterprise application integration? data replication is designed for the transfer of data between databases, whereas EAI is designed for the movement of messages and transactions between applications. EDR typically involves considerably more data than EAI (p.21) What are the main types of source data used in integration projects according to the TDWI report on data integration by Colin White?

structured data (75 percent of respondents) spreadsheets (21%) unstructured datat files (14%) (p.22)

What is the sequence of the phases that make up the master data management lifecycle?

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1. Data assessment 2. Data harmonization 3. Loading the MDM systems (product information management, customer data integration, for example) 4. Creating operational processes that deliver data integrity 5. Putting in place data governance for ongoing assessment and evaluation (p.24) What are the data integration application variables that affect the choice of techniques and technologies for doing data integration? • Source data type – Structured – Semi-‐structured (e.g., XML) – Unstructured – Packaged application – EAI – Web service – Metadata • Source data organization – Homogeneous or heterogeneous – Centralized or distributed (integrated data and metadata) – Federated (integrated metadata) or dispersed (no integrated metadata) • Source data transformation requirements – Data restructuring – Data cleansing – Data reconciliation – Data aggregation • Target data currency (latency) and access – Real time – Near real time – Point in time – Read-‐only or read-‐write • Data integration technique and mode – consolidation, federation, propagation, changed data capture – event push or on-‐demand pull – synchronous or asynchronous • Data integration technology – ETL, EII, EAI, EDR, ECM • Data scale – Number of data sources – Data store size – Data store volatility (p.30) WEEK 9 Study Questions- Session 9 What are the major levels that states are encouraged to undertake action on to develop overall interoperability by the SemanticHEALTH project in the January 2009 report? political, organizational technical

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semantic with educational and awareness raising mechanisms to underpin initiatives in those main Which application fields and domain have been analyzed to achieve semantic interoperability by the SemanticHEALTH project in the January 2009 report? (1) electronic health records (2) ontologies and terminologies (3) public health (4) socio-‐economic issues. Which priority areas and related challenges have been identified to benefit most from the recommendations outlined in the SemanticHEALTH January 2009 report? Patient Care Public Health Research and translational medicine Support for diverse markets What are the semantic interoperability facets relevant to individual patients? Assisted clinical data capture Quick access to the patient record and pertinent background knowledge Quality assurance Clinical decision support Monitoring and alerts Feedback re. quality and costs What are the semantic interoperability facets relevant to aggregated population data? Reporting Health economics Surveillance Quality assurance Epidemiology Bio and tissue banking What are major desiderata for semantically interoperable systems? Consistency Understandability Reproducibility Is full semantic interoperability part of the future vision in the SemanticHEALTH January 2009 report? NO What three layers do current attempts to standardize the capture, representation, and communication of clinical data rely on? Generic reference models for representing clinical data (EHR) ISO/EN, HL7CDA Agreed clinical data structure definitions Open EHR archetypes, ISO/EN, HL7 Clinical terminology systems

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LOINC, SNOMED CT What is the SemanticHEALTH roadmap for electronic health record systems in the January 2009 report? Reference

model Archetypes Terminology

SNOMED-CT Applications Socio-economic

issues 2008 Generic model

for EHR communication

Clinical data structure

Key use cases

EHR/terminology

2009 Standardized representation

Policies on SN term coordination (TC)

User training

2010 Best practice A. design

SNOMED-CT Improve internationaii-zation

2011 Authoring/validation tools

Term Browsers

Agree on SIOP goals for PHR

2012 QA & certification Termnology servers

2013 Repositories Busisness rules for TC term info

EHR visualization apps

Link EHR to educational material

2014 Term binding Consistency test HL7

Adaptable clinical applications

Acceptance evaluation

2015 Care pathways Global experience test

What is the SemanticHEALTH roadmap for terminologies and ontologies in the January 2009 report?

SNOMED CT ICD. LOINC DICOM

Terminologies and EHRs

Ontologies Ontologies Transl. Medicine

Socio-econ. issues

2008

Feasibility study & reformulation of a subset

Joint feasibility studies on convergence/ harmonization

Toolkit/

2009

Multilingual-cultural subsets

Tools for Terminfo test

Environment for feasibility study

European centers f excellence

2010

Statistical extension of QA

Large scale service for convergence using

Toolkit for HL7 messages & archetypes binding

Formulations & multiculturalism

Collaboraton wit EBI & NBCO

Sustainable framework wth EU industry for effective

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einvironment

2011

Formal QA of SNOMED as a whole

Integration with large scale social computing environment

Large scale social computing environment for terminologies/ontologies

Standards development

2012

Central Reference

Services Intern. Biobanking collaboration

2013 Sustainable Centers for Selected Ontologies/Terminologies/references Resources What is the SemanticHEALTH roadmap for public health in the January 2009 report? WEEK 10 Study Questions- Session 10 What order do the five stages of the telehealth technology innovation continuum occur in? (Spivack, p2)

1. Need identified 2. Applications developed

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3. Devices developed 4. Integration with clinical protocols 5. Programs developed

What are examples of telehealth technology? (Spivack, p2)

remote monitoring diagnostics video conferencing digital imaging, information technologies (IT)

networking/interfaces robotics/remote controls store-‐and-‐forward simulation and training

What part of the federal government operates the largest civilian telehealth program in the United States? (Spivack, p6) VA

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What level of interoperability is needed to improve productivity, increase quality, and reduce costs? (Spivack, p10)

o Interactions among stations or applications developed by independent vendors; o Connectivity among medical devices and other “peripherals” developed by independent vendors; and o “Plug and play” components developed by multiple vendors for independent vendors.

What does the National Institute of Standards and Technology work towards regarding emerging telehealth technologies? (Spivack, p11)

The National Institute of Standards and Technology (NIST) works with industry, research, and government organizations to make emerging information technologies, including telehealth technologies, more usable, more secure, more scalable, and more interoperable.

On the patient-‐end side of the problem of telehealth device interoperability, what problem needs to be solved on the lower layers of the OSI stack? (Schmitt, p. 259)

A standardized transport technology enabling basic connectivity has to be developed.

On the patient-‐end side of the problem of telehealth device interoperability, what problem needs to be solved on the upper layers of the OSI stack? ? (Schmitt, p. 259)

Profiles have to be developed, which define what capabilities of the transport technology have to be used to best support the application requirements.

On the patient-‐end side of the problem of telehealth device interoperability, what problem needs to be solved on the application layer of the OSI stack?? (Schmitt, p. 259)

Standardized data models and formats have to be developed, which represent an abstract unique mapping of the real world entities.

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