Jack, I hate to have to disagree with you, but I think you are taking a narrow medical point of view. Of course we would like to use standard vocabularies such as those you mention for those domains which they cover. But even these standard vocabularies overlap, and there is no authority that can control which of them a partner will choose to use. Also, the level of detail appropriate for primary care and specialist care differs, and we can’t expect both to use the same vocabulary. But even more important, these vocabularies don’t address important public health and programmatic needs. There is no standard vocabulary that covers risk factors for HIV/AIDS, that covers the water source used by a family, that covers a patient’s reason for abandoning prophylaxis, that describes a supplemental food package or an insecticide-treated bed net, that describes the type of outreach conducted and the number of condoms distributed through that outreach, and so on and so forth. It is not sufficient that the health record contains doctor observations and orders, the EMR must be useful for measuring and improving quality of care at the facility and for conducting surveillance. Furthermore, in our environment, there are going to be multiple standards of care being employed by our partners, such as MSF and UNICEF. It is simply a fact that are going to be local vocabularies and the HIE has to be able to handle them.
Speaking on behalf of the TS community, I shudder to think about an HIE authority defining, much less maintaining, yet another terminology model (enterprise identifiers). I would suggest that the authority specify which standard Reference Terminologies (SNOMED LOINC, ICD-10, etc.) are to be used for each content domain: lab results, procedures, etc. Then the IL manages the “translation” of incoming messages by extracting coded entries from the message and
querying the TS to either (1) validate incoming Reference Terminology codes, or (2) translate incoming Interface Terminology codes to the authorized enterprise standard Reference Terminology code. Note that step 2 requires that the appropriate interface->reference mappings have previously been developed. This map development is an “off-line”, set-up activity that must be provided (and maintained on an ongoing-basis) by the authority (or designee, sometimes a “commercial” Interface Terminology comes with Reference mappings and HIE authority intervention is not required). Incoming codes without existing maps (which will always occur) should fire “alerts” to a background process for subsequent remediation. One common process question is whether the offending transaction should be passed on without standard codes or queued for future processing when the mappings have been resolved.
Addressing one of the other points, our recommendation is that the IL ADD reference/standardized codes to the incoming message, not REPLACE interface/local codes with reference codes. This maintains clinical integrity.
From: Jack Bowie
Sent: Mar 7, 2014 10:53 AM
Cc: Derek Ritz , Bob Jolliffe , firstname.lastname@example.org, Ryan Crichton , Suranga Kasthurirathne
Subject: Re: The Role of the TR as the source of truth, and syncing against OpenMRS (POC / SHR) concept dictionaries