Head-to-Toe Assessment�Modeling and Mapping�Respiratory Assessment Pilot

Prepared by:

Susan Matney, PhD, RNC-OB, FAAN, FACMI, FHIMSS, FHL7, AL2

Terminology and Modeling WG Co-Chairs

Stephanie Hartleben, MSN, MHA, RN, NI-BC

Tess Settergren, MHA, MA, RN, NI-BC

Mischa Sorensen, MSN, RN, NI-BC

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Acknowledge: Bonnie Adrian, RN, PhD and David Boyd, RN, PhD – Chairs of the Transforming Documentation Workgroup

Agenda

• Nursing Knowledge Big Data Initiative (NKBDI
• H2T Data
• Modeling
• Pre vs. post-coordination
• Body Locations
• WDL
• FHIR Alignment
• SNOMED Observation/Clinical Finding concept model
• Process Review
• Mapping
• Current LOINC Model
• Initial observation and values review
• Revision submission
• Terminology Discussion
• Implementation Implications
• Collaboration Plan

H2T Data

• High level observations
• No definitions
• Within defined limits (WDL) defined for each observation
• Precoordination of body location with assessment item
• Two Observations combined into one (and)

LOINC Physical Assessment Model

• Decided to model the assessment as complete as possible
• Will not create assessments base on context – e.g. Med surg respiratory assessment, Nursing respiratory assessment, ED respiratory assessment
• Panel observations and values can be constrained by context during implementation
• Can possibly be added to United States Core Data for Interoperability (USCDI) since not context specific

Terminology Modeling Process

• Terminology Modeling
• Developed post-coordination model for body location
• Aligned with FHIR
• Evaluated Observation+body location observations
• Established guidelines for body location observations

Body Locations Observations

• Proposed model
• Site-specific observations (e.g. Pain body location) are no longer created/used
• Observations on Body Locations will use the Body Site Identification Observation
• Rationale
• One reusable observation feeds the FHIR bodySite element quality measures, and research
• Value sets scoped per assessment context: wound, pain, lung lobes

Breath Sounds Right Upper Lobe�Body Location Post-Coordination

Respiratory assessment

0730

Breath sounds – RUL

Coarse crackles

▼

WDL

Clear

Diminished

Fine crackles

Coarse crackles

Rhonchi

Wheezes

Stridor

Absent

What the nurse sees

The nurse clicks one value. The decomposition happens beneath the screen.

What the record stores

The question

LOINC 80319-7

Breath sounds by auscultation

The location

Body Site 39111–0

Value: Structure of upper lobe of right lung (SCT 42400003)

The finding

SNOMED CT 47525004

Coarse respiratory crackles

FHIR Assessment Breath Sounds Observation

{ "resourceType": "Observation",

"status": "final",

"code": {

"coding": [ {

"system": "http://loinc.org",

"code": "80319-7",

"display": "Breath sounds by Auscultation" } ] },

"bodySite": {

"coding": [ {

"system": "http://snomed.info/sct",

"code": "42400003",

"display": "Structure of upper lobe of right lung" } ] },

"valueCodeableConcept": {

"coding": [ { "system": "http://snomed.info/sct",

"code": "47525004",

"display": "Coarse respiratory crackles" } ] }}

LOINC 80319-7

Breath sounds by auscultation

Body Site 39111–0

Value: Structure of upper lobe of right lung (SCT 42400003)

SNOMED CT 47525004

Coarse respiratory crackles

Within Defined Limits

• WDL is selected on the front end
• Backend - each normal value as separate observations
• Provides the ability to track and trend
• Provides values for secondary use

Respiratory assessment

0730

Breath sounds – RUL

WDL

▼

WDL

Diminished

Fine crackles

Coarse crackles

Rhonchi

Wheezes

Stridor

Absent

What the record stores

Breath sounds by auscultation

LOINC 80319-7

value SNOMED CT 48348007 Normal breath sounds (finding)

bodySite 39111-0: Structure of upper lobe of right lung (SCT 42400003)

What the nurse sees

Terminology Mapping Process

• Assessment Question Mapping
• Mapped to LOINC
• Mapped to SNOMED
• Assessment question semantic type = Observable entity
• Alignment with FHIR observation
• Determined if more than one observation in assessment question (AND)
• Nursing Assessment value
• Reviewed for semantic consistency
• Evaluated LOINC Answers (LA Codes) in LOINC lists (LL Codes)
• Queried SNOMED for possible missing values
• Clinical finding links to observation using “Interprets” attribute
• Ran ECL query to discover Clinical Finding values “linked” to SNOMED Observable entity
• Compared SNOMED Clinical finding codes to the LOINC Answer (LA) codes
• Expanded the value set with pertinent values

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Respiratory Assessment Observations

Value Mapping

• Reviewed LOINC answers associated with found observations
• Mapped to SNOMED Manually
• Determined “interprets” attribute value
• Ran ECL query to discover Clinical Finding values “linked” to SNOMED Clinical Observables

Example: SNOMED Observable entity�Color of Sputum (primitive)

Example Color of Sputum Clinical Finding

• Clinical findings uses attribute “Interprets” with the value the specific observation

Observable Entity to Clinical Finding

ECL for Color of Sputum Clinical Finding values�

• << 404684003 |Clinical finding (finding)| : << 363714003 |Interprets (attribute)| = << 277896005 |Color of sputum (observable entity)|

Terminology Mapping Coverage

LOINC — Observations

6

of 9 observations

mapped to LOINC

67%

mapped

SNOMED CT — Values

46

of 52 values

mapped to SNOMED CT

88%

mapped

Unmapped: 3 LOINC observations | 6 SNOMED CT values

Breath Sounds

Observation Values

Breath Sounds SCT ECL 42Results� Interprets 52653008 |Respiratory sounds (observable entity)|

Examples

Breath Sounds Discussion

• Constrained to children of << 128254003 |Respiratory auscultation finding (finding)| :
• Breathing phase is precoordinated with some concepts
• Expiratory/Inspiratory
• Breath sounds value set needs SME input and refining

Color values: which semantic type?

ISA guidance

SNOMED CT concepts used as observation values should generally come from the Clinical finding or Situation with explicit context hierarchies.

Two candidate bindings for Color

SNOMED CT 371254008

Brown color

Qualifier value

SNOMED CT 277910004

Brown sputum

Clinical finding

MATCHES ISA GUIDANCE

No recommendation yet. The workgroup needs to decide whether color values are bound as qualifiers or as pre-coordinated findings, and apply the answer consistently across the dataset.

Observable + Value = Clinical Finding

Sputum Characteristics

Observation Values

One additional SNOMED Value - Sputum abnormal - color (finding) 271827002

Sputum Color Discussion

• Standards organizations need to decide on using Clinical Finding or Qualifier value for Colors
• Should we combine sputum color with consistency into one observations (Stan’s suggestion)

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Proposed LOINC Revisions

Revision V2 compared with the LOINC 2.82 export

Respiratory Assessment Panel LOINC 80318-9 · member of Nursing Physiologic Assessment Panel (80346-0)

Respiration rhythm

LOINC 9304-7 — answer list appended

MODIFIED

Respiratory rate

LOINC 9279-1

UNCHANGED

Respiratory effort

LOINC 80341-1 — answer list appended

MODIFIED

Breath sounds by auscultation

LOINC 80319-7 — answer list appended

MODIFIED

Location of breath sounds by auscultation

LOINC 80342-9 — replaced by body-site panel

REMOVED

Body site identification panel

LOINC 72369-2 — reuses list LL3853-0

NEW

Respiratory assessment interpretation

LOINC 80320-5

UNCHANGED

History of Respiratory system disorders

LOINC 8686-8 — keep? pending team

UNDER REVIEW

Chest symmetry

new LOINC needed

NEW

Tracheal position

new LOINC needed

NEW

Cough type

new LOINC needed

NEW

Cough strength

SCT 769210005 — split from Cough

NEW

Sputum volume

new LOINC needed

NEW

Color of sputum

LOINC 86243-3 — existing code added

NEW

Sputum consistency

new LOINC needed

NEW

Color of skin

LOINC 39107-8 — currently in Skin Assessment Pnl

UNDER REVIEW

New addition

Modified (answer list)

Removed

Unchanged

Under review

Baseline: 7 observations, flat → Revision: 15 members, including 8 new, 3 modified, 1 removed, 2 under review, and 2 nested panels

Respiratory Assessment Revision

• Respiratory Assessment Revision Submission

Terminology Discussion

• Semantic consistency
• Two observations in the assessment question
• Values need to be semantically consistent
• Mapping and maintenance
• SNOMED and LOINC concepts will need to be requested
• Who?
• How will requests be tracked and new mappings added?
• Value sets will need to be created and maintained (who, how?)
• Content will need to be evaluated after each terminology release
• Work with LOINC and SNOMED
• Need to determine if Qualifier Values or Clinical Findings should be used for Colors
• How does this align with LOINC ontology work?

Implementation Implications

• WDL – ability store multiple observations
• Post-coordinate question on the front-end with precoordinated observations on the backend
• Breath sounds with body location
• One assessment question with values from 2:* observations
• e.g. Respiratory Rate and Respiratory rhythm
• Store both observations on the back end but have one display on the front end
• Need a consistent consumable content delivery format for vendors
• Discuss with vendors
• Versioning

Clinical LOINC Committee Collaboration

• Compare LOINC Proposed Respiratory Assessment to Yours
• Review each observation and all values together
• Additional observations may be added
• Additional values may be added
• How to address questions?
• Submission process
• Will need definitions and citations for each concept requested

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