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Interoperability in Action Day #2:

Advancing Interoperable Social Determinants of Health #SDOH

The Case for Interoperable Social


Determinants of Health Data
#Interoperability #SDOH #standards

Daniel J. Vreeman, PT, DPT, MS


Regenstrief-McDonald Scholar in Data Standards
Indiana University School of Medicine

Director, LOINC and Health Data Standards


@djvreeman Regenstrief Center for Biomedical Informatics

2017
Disclosure
Im the author of the book LOINC Essentials published
by Blue Sky Premise, LLC where I serve as President.

Not a NYT Best Seller. Net profit going to a special


charitable project: danielvreeman.com/build-a-school

PI on a contract from bioMrieux for LOINC content


Overview

Interoperability:
What we mean by it and what it matters
How we can get it
What it enables
Some low hanging fruit

photo via Vernio77


Interoperability
The ability of health IT to communicate, exchange data,
and use the information that has been exchanged.

Foundational Structural Semantic

HIMSS Definition. Available at: http://www.himss.org/library/interoperability-standards/what-is-interoperability


Why
interoperability
matters
photo via proimos
Connecting Many Data Sources
Social and community determinants

Lifestyle and behavioral

Health history

Patient-generated
EHR
Genetics
Basic science
photo via Heather | cc-by-sa
The rain forest canopy is a
seamless web through which
arboreal creatures efficiently
move to reach the edible
fruits without any attention
to the individual trees.
McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329. photo via nosha | cc-by-sa
photo via Vernio77
A Unified Patient Record

http://www.ihie.org/careweb/
41%
of ED visits are for patients with
data at another institution

Finnell JT, Overhage JM, Grannis SJ. All Health Care is Not Local: An Evaluation of the Distribution of Emergency Department Care Delivered in Indiana. AMIA Annu
Symp Proc. 2011;:409-416. PMID: 22195094
Finnell JT, Overhage JM, Grannis SJ. All Health Care is Not Local: An Evaluation of the Distribution of Emergency Department Care Delivered in Indiana. AMIA Annu
Symp Proc. 2011;:409-416. PMID: 22195094
Nearly every ED in
Indiana shares
patients with every
other ED in the
state
People move faster
and further than their
health information
Interoperability and the free flow of data
are absolutely crucial, absolutely crucial,
to making the benefits as big as possible
for our system and making sure we're
helping as many patients as we can.

Tom Price, MD
HHS Secretary
Speaking at Health Datapalooza April 27, 2017

photo via Mark Taylor | cc-by


Precision Medicine
accounting for individual differences in
peoples genes, environments, and lifestyles

photo via jamescridland | cc-by


Objective 1.
Enable interoperability among
institutions and individuals that
support care delivery across the
cancer continuum, from prevention
through treatment, survivorship,
and end-of-life care.

Presidents Cancer Panel. Improving Cancer-related Outcomes with Connected Health. November 2016. Available online.
To achieve connected/
precision (or just better)
health, we need to
incorporate many different
types of data that are
generated and stored in many
different places and formats.
photo via nasamarshall | cc-by-nc
MO DATA MO PROBLEMS
Problems

Health IT systems often


lack standard mechanisms
for exchanging data.

Even when they do, they


use different ways of
identifying the same
concept.

Only way to overcome is


with standards.
Variation Abounds
CODE NAME
34626D Arterial BP Diastolic
39312D ABP Diastolic
ARTDIASBP Arterial Diastolic BP
nvArtBPS Arterial Blood Pressure Systolic
DBP DBP
25284D BP (NIBP)
2737317 Diastolic Blood Pressure #1
6881D BP Diastolic
6881D BP
77934D BP Manual Diastolic
919109 Diastolic Blood Pressure
DiastBP DiastolicBP
PBPD PRE BLOOD PRESSURE DIASTOLIC
POBPD POST BLOOD PRESSURE DIASTOLIC
Taming this
wicked problem

photo via tgerus | cc-by-sa


Syntax Standards
Messages, Documents, APIs
HL7v2, C-CDA, FHIR

Semantic Standards
Vocabulary/code systems
LOINC, SNOMED CT, RxNorm, CPT, ICD
Similar name, different meaning

meerkat meerkat mere cat meerkat


photo via CaptionTime
LOINC is a rich trove of 84,000+ standardized variables
Genetics Lifestyle

21654-9 CFTR gene targeted mutation analysis


24475-6 F2 gene c.20210G>A [Presence] 41950-7 Number of steps in 24 hour Measured

75547-0 Noninvasive prenatal fetal aneuploidy 75296-4 Carbohydrate intake 24 hour Estimated
and microdeletion panel based on Plasma cell- 82289-0 Rating of perceived exertion [Score]
free+WBC DNA by Dosage of chromosome-specific
circulating cell free (ccf) DNA 72166-2 Tobacco smoking status NHIS

82245-2 Chromosome region 22q11.2 deletion in 64098-7 Distance walked in 6 minutes


Amniotic fluid or CVS by FISH

Lab and clinical Environmental


82464-9 Mosquito count [#] in Environmental
specimen
4548-4 Hgb A1c MFr Bld
67784-9 Individuals below poverty line Neighborhood
8462-4 Diastolic blood pressure 63736-3 Materials to which you were exposed in your
24725-4 Head CT work or daily life
63805-6 How long did you handle paints or solvents
57021-8 CBC W Auto Differential panel - Blood
yourself?
8633-0 QRS duration 67640-3 My teachers believe that I can do well in
my school work
Numeric Results

NM (numeric) means the


answer will be a numeric value Result Value
OBX||NM|41950-7^# steps 24h nRate Measured^LN||10000|{#}/(24.h)|

Units
Same thing, different format
Coded Result Values
CE (coded element)
means the answer
Observation Identifier:
will be coded this is a overall financial resource strain question

OBX||CE|76513-1^How hard is it for you to pay for the very


basics like food, housing, medical care, and heating
[CARDIA]^LN||LA15832-1^Very hard^LN

LN means this code Answer Identifier:


is from LOINC
very hard! (trouble!)
Standards make
health data more
portable and
understandable to
different computer
systems.
Interoperability is ultimately
about people who want
(their health IT systems) to
work together and
understand each other

photo via scarlatti2004_images | cc-by-sa


Strategies for
Wicked Problems
Authoritative
Competitive
Collaborative

Building a community of interest


Roberts N. Wicked problems and network approaches to resolution. International Public Management Review. 2000;1(1):1-19.
Collect once. Use many.
Clinical care, public health reporting, quality
management, clinical and epidemiological research, etc

photo via pagedooley | cc-by


Social Isolation Assessment
from NHANES, as recommended in 2015 EHR Cert Criteria

1. Are you married or living with someone in


a partnership?
2. In a typical week, how many times do you
talk on the phone with family, friends or
neighbors?
3. How often do you get together with
friends or relatives?
4. How often do you attend church or
religious services?
5. How often do you attend meetings of the
clubs or organizations you belong to?
Social Isolation
from NHANES representation in LOINC

76506-5 Social connection and isolation panel

63503-7 Are you now married, widowed, divorced, separated, never married
or living with a partner?

76508-1 In a typical week, how many times do you talk on the telephone
with family, friends, or neighbors? {#}/wk

76509-9 How often do you get together with friends or relatives? /wk

6510-7 How often do you attend church or religious services? /a

76511-5 Do you belong to any clubs or organizations such as church


groups unions, fraternal or athletic groups, or school groups?

76512-3 Social isolation score [NHANES] {score}

Use these to compute Social Isolation Score (76512-3)


(has mortality hazard ratio similar to smoking)

Pantell M et al. Social isolation: a predictor of mortality comparable to traditional clinical risk factors. Am J Public Health. 2013 Nov;103(11):2056-62. Epub 2013 Sep
12. PubMed PMID: 24028260.
If this, then that

If

{Social Isolation Score} < 2

Then

initiate {social isolation care plan}


Same data for

Informing clinical care


Population health analytics / registry
Electronic quality measure analysis
Observational/epidemiological research
Electronic Quality Assessment
% Patients for whom cognitive assessment performed
71492-3 Total score [SLUMS]
54614-3 Brief Interview for Mental Status - summary score [BIMS]
71493-1 Total score [IQCODE]
71722-3 Total score [AD8]
72106-8 Total score [MMSE]
72172-0 Total score [MoCA]
72173-8 Total score [BOMC]
72233-0 Total score [Mini-Cog]

% Patients for whom social isolation screening performed


62933-7 PhenX - social isolation protocol
77800-1 PROMIS short form - social isolation 4a - version 2.0 raw score
77799-5 PROMIS short form - social isolation 6a - version 2.0 raw score
77798-7 PROMIS short form - social isolation 8a - version 2.0 raw score
77849-8 PROMIS social isolation - version 2.0 Tscore
28212-9 Social isolation [CCC]

76512-3 Social isolation score [NHANES]

The same thing is possible for key metrics on food


insecurity, housing, stress, physical activity, etc
Not all juice is worth
the squeeze
In standards, Pareto principle > Long Tail

photo via elwillo | cc-by


Some fruit is lower
than others.
Start here:
professional consensus, saves time, actionable, business value,
people are already doing it!

photo via iancarroll


Vocabulary
standards grow
because USERS ask
(no need to reinvent the wheel)
Take home lesson:
Once represented in data standards,
SDH data elements can be shared
and understood by diverse IT
applications for the benefit of
many in the health ecosystem.

photo via IMLS DCC | cc-by


More on incorporating standardizing measures of SDOH in EHRs at:

danielvreeman.com/sdoh