Agency for Health Care Administration

Florida Center for Health Information and Policy Analysis

Adding Clinical Data Elements to Administrative Data
Data Challenges in Joining Clinical Laboratory Data to Administrative Inpatient Data
Christopher B. Sullivan, Ph.D.
Florida Agency for Health Care Administration
HCUP Partner's Meeting -November 2009

AHRQ Project Stages

Circular diagram of project stages with project description in center:

Project description:

Adding Clinical Data to Statewide Administrative Data

The AHRQ pilot project's goals are to demonstrate and evaluate the process required to join the clinical laboratory data with the administrative data, to assess the quality of patient care within hospitals and to test the improvement in predicting potential complications by adding the POA indicator and the clinical laboratory data to the administrative data.

Project Steps:

Step 1: Contracts and approvals
Step 2: Hospital recruitment
Step 3: LOINC mapping
Step 4: Data transmission
Step 5: Merging data
Step 6: Data Analysis
Finish: Final Report
The process involves ongoing communications throughout the entire cycle of steps.

End Diagram

What This Talk Will Cover

• Florida inpatient administrative datasets and Present on Admission
• Laboratory data collected from hospitals in AHRQ project
• Need for LOINC coding of lab data
• Challenges of joining laboratory data to administrative data
• Challenge of analyzing the data

Circular diagram of project stages with project description in center:

Project description:

Adding Clinical Data to Statewide Administrative Data

The AHRQ pilot project's goals are to demonstrate and evaluate the process required to join the clinical laboratory data with the administrative data, to assess the quality of patient care within hospitals and to test the improvement in predicting potential complications by adding the POA indicator and the clinical laboratory data to the administrative data.

Project Steps:

Step 1: Contracts and approvals
Step 2: Hospital recruitment
Step 3: LOINC mapping
Step 4: Data transmission
Step 5: Merging data
Step 6: Data Analysis
Finish: Final Report
The process involves ongoing communications throughout the entire cycle of steps.

End Diagram

Hospitals in the AHRQ Project

Pediatric Hospitals

All Children's Hospital (216 Beds)
Miami Children's Hospital (268 Beds)

BayCare Health System

Mease Countryside Hospital (300 Beds)
Mease Dunedin Hospital (143 Beds)
Morton Plant Hospital (687 Beds)
St. Joseph's Women's Hospital (192 Beds)
Morton Plant North Bay Hospital (122 Beds)
St. Joseph's Children's Hospital (164 Beds)
South Florida Baptist Hospital (147 Beds)
St. Anthony's Hospital (365 Beds)
St. Joseph's Hospital (527 Beds)

Broward Health

Broward General Medical Center (716 Beds)
Coral Springs Medical Center (200 Beds)
Imperial Point Medical Center (204 Beds)
North Broward Medical Center (409 Beds)
Chris Evert Children's Hospital (141 Beds)

Memorial Healthcare System

Memorial Hospital Miramar (100 Beds)
Memorial Hospital Pembroke (301 Beds)
Memorial Hospital West (236 Beds)
Memorial Regional Hospital (690 Beds)
Memorial Regional Hospital South (100 Beds)
Joe DiMaggio Children's Hospital (100 Beds)

Statutory Authority to Collect Data

• Since 1988 AHCA has exercised its authority to collect Hospital Inpatient Discharge Data
• Data are released when 75% of the hospitals have certified the accuracy of data reported. 100% certification takes about 180 days
• Rule Change in 2005 allowed AHCA to collect Present on Admission for 31 diagnostic codes
• http://www.floridahealthfinder.gov

21.	Admitting Diagnosis admitdiag	A valid ICD-9-CM or ICD-10-CM diagnosis code provided by the admitting physician at the time of admission which describes the patient's condition upon admission or purpose of admission. The code must be entered with a decimal point that is included in the valid code and without use of a zero(s) that are not included in the valid code. A required field. (NOTE: Admitting diagnosis data is available beginning first quarter 2006.)
22.	Principal Diagnosis Code: prindiag	A valid ICD-9-CM or ICD-10-CM diagnosis code. The principal diagnosis is the code representing the diagnosis established, after study, to be chiefly responsible for occasioning the admission. The code must be entered with a decimal point that is included in the valid code and without use of zero(s) that are not included in the valid code. A required field. (NOTE: Prior to first quarter 2006, principal diagnosis codes did not include decimal points between the third and fourth digit.)
23.	Principal Diagnosis Present on Admission Indicator: poa_prin_diag	A character alpha code differentiating whether the condition represented by the corresponding Principal Diagnosis code was present on admission or whether the condition developed after admission as determined by the physician, medical record, or nature of the condition. Y – Yes – Present at time that the order for inpatient admission occurs. N- No - Not present at the time that the order for inpatient admission occurs. U – Unknown – Documentation is insufficient to determine if condition is present on admission. W- Clinically Undetermined – Provider is unable to clinically determine whether condition was present on admission or not. E or Blank Field – Exempt – The condition is exempt from POA reporting. (NOTE: Present on Admission data for the principal diagnosis is available beginning first quarter 2007.)

Hospital POA for Principle Diagnoses

The chart does not show data labels, so values are reported by the range of percentages within which each bar falls. For all hospitals, percent POA Prin Diag is greater than percent POA Diag 1.

Hospital Name	Percent POA Diag 1	Percent POA Prin Diag
St. Joseph's Hospital Inc.	70% to 80%	70% to 80%
St. Anthony's Hospital	80% to 90%	90% to 100%
South Florida Baptist Hospital	80% to 90%	80% to 90%
North Broward Medical Center	80% to 90%	90% to 100%
Morton Plant North Bay Hospital	90% to 100%	90% to 100%
Morton Plant Hospital	70% to 80%	80% to 90%
Miami Children's Hospital	50% to 60%	70% to 80%
Memorial Regional Hospital	70% to 80%	80% to 90%
Memorial Hospital West	60% to 70%	70% to 80%
Memorial Hospital Pembroke	80% to 90%	90% to 100%
Memorial Hospital Miramar	60% to 70%	70% to 80%
Mease Hospital - Countryside	70% to 80%	80% to 90%
Mease Hospital - Dunedin	80% to 90%	90% to 100%
Imperial Point Medical Center	80% to 90%	90% to 100%
Coral Springs Medical Center	60% to 70%	70% to 80%
Broward General Medical Center	70% to 80%	80% to 90%
All Children's Hospital	70% to 80%	90% to 100%

Clinical Laboratory Data Elements

Albumin
Alkaline phosphatase
Base Excess
Bicarbonate
Blood urea nitrogen
Blood/Lymph Culture - Positive
Calcium (ionized)
Calcium (total)
Chloride
CPK MB
Creatinine
Gamma glutamyl transferase
Glucose
Hematocrit
Mean cell Hemoglobin
Mean Cell volume
Partial thromboplastin time
pCO2
pH
Phosphorous
Platelets
PO2.sat
Potassium
Prothrombin time
SGOT
SGPT
Sodium
Total bilrubin fractions
Total Hemoglobin
Troponin I
White blood cell count
Additional Data Elements
Date of Specimen Run
Time of Specimen Run
Type of test performed
Reference range of test

Lab Result Interface Code Comparisons

Lab Test Name	All Children's	Miami Children's	BayCare Health	Broward Healthcare	Memorial Healthcare
SGPT	ALT	ALT (SGPT)	ALT	55548699	ALT
Albumin	ALB	Albumin	Albumin	55548695	ALB
Alkaline phosphatase	AP	Alkaline Phos	Alk Phos	55548696	ALKP
SGOT	AST	AST (SGOT)	AST	55548697	AST
Blood/Lymph Culture - Positive	BCECMO	Blood Culture	C Blood	C BLD	CXBLD
Glucose	GLU	Glucose	Glucose	55548690	GLUC
Hematocrit	HCT1	HCT	HCT	55542287	HCT
Total Hemoglobin	HGB1	HGB	HGB	55542285	HGB
Potassium	K1	Potassium	Potassium	55548685	K
Sodium	NA	Sodium	Sodium	55548683	NA

Anatomy of a LOINC Term

Component: Property: Timing: Sample: Scale: Method

5193-8 - LOINC code; sequential number plus check digit

Example:

HEPATITIS B SURFACE AB: ACNC: PT: SER: QN: EIA
HEPATITIS B SURFACE AB is the component
ACNC is the property
PT is the timing
SER is the sample
QN is the scale
EIA is the method

Lab Result Interface Code Comparisons

Lab Test Name	LOINC Name
SGPT	Alanine aminotransferase:CCnc:Pt:Ser/Plas:Qn:
Albumin	Albumin:MCnc:Pt:Ser/Plas:Qn:
Alkaline phosphatase	Alkaline phosphatase:CCnc:Pt:Ser/Plas:Qn:
SGOT	Aspartate aminotransferase:CCnc:Pt:Ser/Plas:Qn:
Blood/Lymph Culture - Positive	Bacteria identified:Prid:Pt:Bld:Nom:Culture
Glucose	Glucose:MCnc:Pt:Ser/Plas:Qn:
Hematocrit	Hematocrit:VFr:Pt:Bld:Qn:Automated count
Total Hemoglobin	Hemoglobin:MCnc:Pt:Bld:Qn:
Potassium	Potassium:SCnc:Pt:Ser/Plas:Qn:
Sodium:	Sodium:SCnc:Pt:Ser/Plas:Qn:

Laboratory Dataset Submitted by Hospitals

LOINC Name	LOINC Code	Reference Code	Reference Name	Value	Unit	Value Range	Date	Time
Alanine aminotransferase:CCnc:Pt:Ser/Plas:Qn:	1742-6	41243	ALT	25	units/L	7-56	2007-04-14	07:05
Aspartate aminotransferase:CCnc:Pt:Ser/Plas:Qn:	1920-8	41242	AST	41	units/L	5-40	2007-04-14	07:05
Albumin:MCnc:Pt:Ser/Plas:Qn:	1751-7	41239	Albumin Lvl	3.6	gm/dL	3.9-5.0	2007-04-14	07:05
Alkaline phosphatase:CCnc:Pt:Ser/Plas:Qn:	6768-6	41241	Alk Phos	220	units/L	38-126	2007-04-14	07:05
Urea nitrogen:MCnc:Pt:Ser/Plas:Qn:	3094-0	41220	BUN	7	mg/dL	7-18	2007-04-14	07:05

Blood Culture Laboratory Data

LOINC Name	LOINC Code	Test ID	Isolate Number	Organism Name	Date	Time	Free Text
Blood/Lymph Culture-Positive	600-7	CXBLD	2	Klebsiella pneumoniae	4/4/2007	11:15	!PIMIC RVTK1;04/08/07;08:56;
Blood/Lymph Culture-Positive	600-7	CXBLD	1	Strep. pneumoniae	4/4/2007	12:10	!DIFF1-:53;|ˆ48-@Preliminary ID: Alpha hemolytic Streptococcus. |;
Blood/Lymph Culture-Positive	600-7	CXBLD	1	Corynebacterium, not jeikeium	4/4/2007	16:40	No further work-up.
Blood/Lymph Culture-Positive	600-7	CXBLD	1	Staphylococcus aureus	4/4/2007	17:50	!SDRT EAD;04/06/07;09:38;Dox=R ~&MRSA;
Blood/Lymph Culture-Positive	600-7	CXBLD	1	Klebsiella oxytoca	4/4/2007	11:19	@Preliminary ID: Gram negative bacilli
Blood/Lymph Culture-Positive	600-7	CXBLD	2	Klebsiella pneumoniae	4/4/2007	11:19	!PIMIC RVTK1;04/08/07;08:56;!PIMIC1 RVTK1;04/08/07;08:56;
Blood/Lymph Culture-Positive	600-7	CXBLD	1	Klebsiella oxytoca	4/4/2007	11:15	@Preliminary ID: Gram negative bacilli
Blood/Lymph Culture-Positive	600-7	CXBLD	1	Staphylococcus aureus	4/4/2007	17:50	NOTICE! This is a Methicillin Resistant Staph Aureus (MRSA).

Lab Matches from 3M HIS

Adm	Counts	not in Lab	not in Blood
BayCare\Final 2deit Mease Dunedin admin del 2006	4,793	191	4,793
BayCare\Final 2deit Morton Plant North Bay admin del 2006	4,838	1,359	4,838
BayCare\Final 2deit Morton Plant admin data del 2006	23,662	23,662	23,662
BayCare\Final 2deit St Anthony admin del 2006	8,158	392	8,158
BayCare\Final 2deit St Joseph admin del 2006	37,214	4,914	37,214
BayCare\Final 2deit Mease Countryside admin del 2006	12,929	1,286	12,929
BrowardHealth\Final deit Broward General Medical Center Admi	21,896	1,863	21,896
BrowardHealth\Final deit Coral Springs Medical Center Admin	9,876	1,314	9,876
BrowardHealth\Final deit Imperial Point admin 2006	5,318	272	5,318
BrowardHealth\July 09 final revised admin Broward North	10,120	182	10,120
Memorial\Final deit Memorial Pembroke admin del 2006 Tab	5,185	1,344	5,109
Memorial\Final deit Memorial West admin del 2006 Tab	20,405	7,680	20,206
Memorial\Final deit Miramar admin del 2006 Tab	8,142	3,530	8,094
Memorial\Final deit Regional del 2006 Tab	28,401	12,605	28,139
MiamiChildren\July 09 Final deit Miami admin 2008	12,060	10,815	9,047
AllChildrens\Final july09 deit revised admin All Children de	5,947	1,086	5,702
TOTAL	218,944

Pediatric Blood Cultures in First 24 Hours

Principal Diagnosis = 771.81 – Septicemia of Newborn
Tests	Not Present on Principal Diagnosis	Tests	Not Present on Principal Diagnosis
1	Calcium.ionized:SCnc:Pt:Bld:Qn:	2	Bilirubin:MCnc:Pt:Ser/Plas:Qn:
1	Calcium:MCnc:Pt:Ser/Plas:Qn:	2	Calcium:MCnc:Pt:Ser/Plas:Qn:
1	Chloride:SCnc:Pt:Ser/Plas:Qn	2	Chloride:SCnc:Pt:Ser/Plas:Qn:
1	Creatinine:MCnc:Pt:Ser/Plas:Qn:	2	Creatinine:MCnc:Pt:Ser/Plas:Qn:
1	Erythrocyte mean corpuscular hemoglobin:EntMass:Pt:RBC:Qn:Automated count	2	Erythrocyte mean corpuscular hemoglobin:EntMass:Pt:RBC:Qn:Automated count
1	Glucose:MCnc:Pt:Ser/Plas:Qn:	2	Glucose:MCnc:Pt:Ser/Plas:Qn:
1	Hematocrit:VFr:Pt:Bld:Qn:Automated count:	2	Hematocrit:VFr:Pt:Bld:Qn:Automated count
1	Leukocytes:NCnc:Pt:Bld:Qn:Automated count	2	Leukocytes:NCnc:Pt:Bld:Qn:Automated count
1	Mean corpuscular volume:EntVol:Pt:RBC:Qn:Automated count	2	Mean corpuscular volume:EntVol:Pt:RBC:Qn:Automated count
1	Platelets:NCnc:Pt:Bld:Qn:Automated count	2	Platelets:NCnc:Pt:Bld:Qn:Automated count
1	Potassium:SCnc:Pt:Ser/Plas:Qn:	2	Potassium:SCnc:Pt:Ser/Plas:Qn:
1	Sodium:SCnc:Pt:Ser/Plas:Qn:	2	Sodium:SCnc:Pt:Ser/Plas:Qn:
1	Urea nitrogen:MCnc:Pt:Ser/Plas:Qn:	2	Urea nitrogen:MCnc:Pt:Ser/Plas:Qn:

Patient to Lab Ratios

Hospital	Patient Admissions	Labs	Labs per Patient	Length of Stay - Days
BayCare Health System	91,594	3,636,370	39.7	4.2
Broward Health	47,210	4,677,511	99.1	4.1
Memorial Healthcare	62,130	3,631,655	58.5	3.5
Miami Children's	12,060	10,397	0.9	5.1
All Children's	5,947	316,479	53.2	6.3

Lessons Learned and Lessons to Learn

• Never underestimate the complexity of your data
• Never overestimate the power of your analysis tools
• Computer speed and memory must be sufficient
• Software capacity for creating and managing a large database is vital
• Never think you can "knock off" an analysis in an afternoon
• Always appreciate the database work that has gone on before you and remember to ask for help

Conclusions

• The AHRQ "Adding Clinical Data to Administrative Data" opened up new avenues to data collection and data analysis in Florida that will carry over into other areas, such as health information exchange
• Conducting the LOINC mapping and translation and collecting the laboratory data was the easy part – joining the clinical and laboratory datasets has proven to be the true challenge in working with the data
• The potential for new analytic approaches in working with administrative and laboratory data creates many opportunities for future research and discovery

AHCA logo

Christopher B. Sullivan, Ph.D.

Agency for Health Care Administration
Florida Center for Health Information and Policy Analysis
Office of Health Information Technology
2727 Mahan Drive
Tallahassee, FL 32308
850-414-5421
sullivac@ahca.myflorida.com