Nationwide Management of Laboratory Information with NPU Terminology

1. Nationwide management of laboratory information with the NPU terminology Ulla Magdal, MI National Board of Health, Denmark

2. What the NPU terminology is • Coding system for identification of medical laboratory results • Developed jointly by IFCC and IUPAC via the • (Sub)Committeeon Nomenclature for Properties and Units • IFCC – International Federation of Clinical Chemistry and Laboratory Medicine • IUPAC - International Union of Pure and Applied Chemistry • In nationwide use in Denmark and Sweden

3. Who I am and what I do • Manager of the Danish version of the NPU terminology for the Board of Health • Titular member for IFCC of the international ’NPU committee’ • Laboratory technologist – clinical biochemistry • Degree in Health Informatics • Work on • laboratory informatics • concept analysis • translation of SNOMED CT Ulla Magdal Petersen Denmark ump@sst.dk

4. Why a terminology for laboratory results? ensure that examination results are • fully defined in the clinical context • transferable between systems • comparable to others of same kind • reuseable – for decision support, calculations, research, statistics For this you need • (common IDs) • clear and stable definitions of result types

5. Describe the property examined • Use structured definitions - describing • what part of the universe you are observing • what component you observe in that part • what property of that component you estimate(add SI unit and more detail where relevant) • Use standard scientific concepts and terms Patient—Body; mass = ? kilogram Blood—Erythrocytes; volume fraction = ? Blood—Hemoglobin(Fe); substance concentration = ? millimole per litre

6. System System Component Component Kind Kind of of property property Unit Unit term term term term term term term term Translation of structured NPU definitions • Keep the structure as a carrier of meaning • Translate each term of the definition • Assume that the translated definition describes the same concept NPU03431 Urine—Sodium ion; substance concentration = ? millimole per litre Urine—Ion sodium; concentration en matière = ? millimole/litre Urin—Natrium-ion; stofkoncentration = ? millimol per liter

7. Health care in Denmark • The National Health Service serves all 5,5 mill. citizens • 27 hospitals owned by 5 Regions (no major private hospitals) • 15 600 hospital beds • 3600 general practitioners have 90% of all patient contacts • GPs are largely publicly funded

8. NPU in Denmark • 1998 – 2001 Danish Board of Health supports development of the NPU coding system and of its Danish version • 2001 NPU coding system recommended for national use in Denmark. Most biochemistry labs implement it • 2003 Biochemistry labs with EDI - 95 % NPU coded • 2006 20 million NPU coded results from labs to GPs • 2007 Web applications for GPs to order and access results from labs nationwide – NPU is main coding system • 2009 NPU use slowly spreading into immunology, microbiology and genetics. A few local and proprietary coding systems remain in use

9. The Danish NPU Release Center • 2 specialists (with a laboratory and informatics background) • translate the NPU terminology into Danish • manage and publish the Danish NPU version via a national website • publish a Users’ Guide • support and advise users (laboratories and system developers) • manage a (small) non-standard extension for specific Danish use • analyse ’coding needs’ of Danish users for communication to the international NPU committee

10. EHR in Danish health care 2009 • About 35% of hospital beds are served by Electronic Health Records (EHR), usually combined with direct access to local lab systems (LIS) • All general practitioners use EHR - about 20 different systems! • All GP’s receive laboratory data messages directly into the EHR

11. MedCom - the Danish Health Data Network • Co-operative venture between authorities, organisations and private firms linked to the Danish healthcare sector • Nationwide transmission of messages between GPs and hospitals and health authorities • discharge reports • referrals • laboratory requests • laboratory reports • drug prescriptions • reimbursement www.medcom.dk

12. Prescriptions Prescriptions 1039105 = 73% 1389023 = 84% Disch Disch . Letters . Letters 1131750 = 94 % 682923 = 85 % Lab. Lab. reports reports 988151 = 99 % 543040 = 82 % Lab Requests 349840 = 85 % Referrals Referrals Referrals Referrals 177525 = 65 % Reimbursement 21049 = 99 % Messages to/from GPs (1992 – 2008) Source: www.medcom.dk July 2009

13. Web based ordering of laboratory tests • on-line laboratory requesting from GP to laboratory of choice

14. Web based access to laboratory information • GP may search for laboratories that hold recent results for a certain patient • look up the results right away - dependant on proper permissions, secure software and digital signature!

15. It was not that easy – some challenges • Conceptual - a new medical language • using standard terminology and SI units • naming the information produced, not the process • describing properties of the patient, not of the sample • Technical • long names vs. screen sizes and field lengths • primitive information models • Organizational and cultural • distrust of ’codes and numbers’ in parts of the medical environment • it-setback caused by a total makeover of public administration in 2007

16. Tradition for naming results ’by process’ 50 years ago Red cell microscopy was a good name for Blood—Erythrocytes, number concentration – but the process has changed • Definitions by ’patient property estimated’ last longer • And are clinically more relevant • But they make unwieldy names, especially on screens • Local names and and abbreviations are often used • NPU information can be available ’behind the screen’

17. Tradition for naming results ’by process’ 50 years ago Red cell microscopy was a good name for – but the process has changed • Definitions by ’patient property estimated’ last longer • And are clinically more relevant • But they make unwieldy names, especially on screens • Local names and and abbreviations are often used • NPU information can be available ’behind the screen’ NPU01960 Blood—Erythrocytes; number concentration 1012/litre

18. Complexity of lab data is underestimated • Clinical, administrative and technical data often needed • Not ’slots’ in systems or messages • There is always a ’test code’ slot • But there are no NPU definitions with ’extra info’  • Local ’test codes’ replace NPU codes in order to convey e.g.: • New, more sensitive method • POCT result • Patient is in pregnancy care program • Bill the sports clinic for this • The information models need revision If you only have a hammer, all your problems must be nails

19. Harmonization is a long process The Danish release center • does almost all the initial coding work for ’first time’ laboratories • publishes a national ’User’s Guide’ • sends out a monthly NPU newsletter • regularly offers all regions to send in their coding tables for checking and updating • helps create Danish ’shortcut names’ for use in EHR result overviews

20. Visible gains • Reusable information in EHRs • calculation of clinical indexes • graphical representation of results • Security when transmitting lab results nationwide • result values end up in the right row every time • A national reference • laboratories gradually achieve a common language • NPU codes are used in laboratory documentation, e.g. in certification or accreditation processes

21. Useful links • Short description of the terminology - with links http://www.sst.dk/English/NPULaboratoryTerminology.aspx • Latest version of the NPU terminology for download(abbreviated definitions, .csv files)http://www.labterm.dk/Enterprise%20Portal/NPU_download.aspx • All the background litteraturehttp://old.iupac.org/divisions/VII/labinfo/English/IFCC_Documents.html

22. Please ask questions