HL7 Child Health Update

CHCA Evidence-Based Order Set ProjectPediatric Rheumatology Network: CARRANet

American College of Rheumatology (ACR) Concept Mapping

Robert W. Warren, MD, PhD, MPHChief Medical Information OfficerTexas Childrens Hospital January 18, 2010

Copyright 2008, Child Health Corporation of America – All Rights Reserved

CHCA Evidence-Based Order Set Project

Copyright 2008, Child Health Corporation of America – All Rights Reserved

Order Sets Project Executive Team

Robert Warren, Houston Charles Macias, Houston Patrick Barrera, Houston Mark Del Beccaro, Seattle Michael Leu, Seattle Andrew Spooner, Cincinnati Sherrie Graham, CHCA Gary Anthony, CSC

Slide 3

Copyright 2008, Child Health Corporation of America – All Rights Reserved

Order Sets Project Goals

By sharing evidence-based order sets (EBOS) among member hospitals

Improve child health care by decreasing unfounded variability of practice

Increase speed and decrease cost of implementation of evidence-based orders sets in EHRs

Slide 4

Copyright 2008, Child Health Corporation of America – All Rights Reserved

o Establish Project governance to define, implement, and evaluate project goals.

o Establish an evidence-based order set (EBOS) Library, with basic rules for submission, from pilot hospitals.

o Define basic rules for EBOS submissions, including statement of order set development at the submitting institution. EBOS should include (1) set descriptors; (2) inclusion/exclusion criteria; (3) care process with associated evidence; (4) outcome measures

o Create a standard format for EBOS in the Library.o Populate and evaluate initial candidate EBOS, using

the standard format.o Validate effort with CHCA Governance and member

hospitalso Expand effort as appropriate

Milestones and Activities

Copyright 2008, Child Health Corporation of America – All Rights Reserved Slide 6

Order Sets Library Examples

Asthma Acute Gastroenteritis Bronchiolitis Diabetes Acute Chest in Sickle Cell

Patient Status Epilepticus

Femur Fracture Fever-Neonate Pneumonia UTI CAP Fever & Neutropenia in

Oncology Patient DVT

Pediatric Rheumatology Network

CARRANet

$8+M GO grant ; PIs: Sandborg, Schanberg, Ilowite, Wallace

Sustainable, informatics infrastructure for pediatric rheumatology

To enroll 60 sitesTo enroll 20,000 children with rheumatic diseaseRegistry with common and disease-specific data elements

Informatics Infrastructure CARRANet

Centralized, web-based data captureData management, visualization, and cleaning tools to facilitate site-

based and pooled data validationCentralized, ontology-based, centralized,database environment

(i2b2/SHRINE) with site-specific PHI encryption and data ownership, designed for secure, selective sharing and federated query of research data

Means to correlate data from samples housed in the CARRA biorepository with subject-level phenotypic data stored in the distributed database.

From draft CARRANet Clinical Registry Form

Concepts and Definitions …

Medication Inclusion: Pulse steroids? GA BA-directed? Opioids?Use for rheumatologic disease, or any purpose ?Prescribed only ?Current – actually taken today; prescribed for today; if oral, taken

today without emesis; taken anytime in last x days; majority or all of doses taken in last x days ? Is a PRN medication (e.g. ibuprofen for fever) a “current” medication ?

Unknown – to whom? Not in record ?

Be Careful What You Ask. You May Get Another Answer.

Ambiguity Threatens ValueCHIPRA and Meaningful Use Quality Measure:

ImmunizationsIs the question: educate, recommend and/or give an immunization ?Are all immunization data available at the time of care to make the

appropriate decision ? Transient populations ? Vaccine guidelines change. Is quality determined by action based on

guidelines applicable at the time of the encounter ?Is appropriateness dependent on circumstance ? If a child is admitted

to hospital, and rapidly transferred elsewhere for intensive care, should vaccination have been done ?

What if provider practices in a religious community refusing vaccinations?

What if patient is “immunosuppressed” by condition or medication ?

What’s the Source of Truth ?Each provider and patient ? Then nobody else is really sure

what the truth is … Existing and evolving standard terminologies: e.g. LOINC,

RxNorm, ICD, SNOMED … (but they only describe “elements,” not relationships)

Institutional ontologiesCollaborative ontologiesInternal EHR ontologies – Centricity, Epic …“Meta”-EHR ontology – openEHR ?

American College of Rheumatology (ACR)

Concept Mapping

Goals(my take)

Build a Rheumatology functional profile, with rigorously defined data elements: begin with identification of data elements, within constructs such

as “musculoskeletal exam” and “drug monitoring”Utilize UML (Unified Modeling Language) based mind mapping

software and openEHR, so that specifics can be “rapidly” translated to multiple commercial systems

Provide the basis for a “universal translator” (a multifaceted rosetta stone) of critical rheumatology data from multiple different systems and sites, into common terminology for collaborative QI and research efforts

OpenEHR (ISO 18308)Archetype:

Re-usable, versioned, formal model of a clinical domainStandardized formatMaximal datasetConsider using archetypes as basis for CDA entries, with

SNOMED identifiers for each archetypeTemplate:

Structured compilation of archetypes for specific purpose – e.g. basis of documents, forms, reports, messages

OpenEHROntological Separation

Ontologies of information:Domain content models – formal definitions of clinical concepts

(archetypes)Information representation model – basis for domain content

model, designed to be stableOntologies of reality:

“Classifications” like WHO’s ICPC (International Classification of Primary Care)

“Process descriptions” such as clinical guidelines“Descriptive” terminologies” like SNOMED-CT, RxNorm, ICD

© Ocean Informatics 2008

What openEHRprovides

openEHR Semantic architecture

1:N

Templates

1:N

Reference Model

Archetypes

1:N

Terminologyinterface

Messages

Querying

Screen Forms

1:N

Reports

Data conversionschemas Terminologies

Sn

omed

CT

ICD

x

ICP

C

Back to the FutureNational pediatric data lexicon and conceptsShared evidence-based guidelines and order sets with

defined eligibility criteria and outcomes, e.g. CHCA and EpicNational, broad scope, pediatric clinical (research) data

network(s) that really work, are sustainableGoals:

Support clinical research and care, dynamically refining care parameters cross institutions

Identify “new” pediatric diseases: a human phenome project

Questions?