CDC	
  Vocabulary	
  Team	
  Meeting	
  	
  




LOINC®	
  and	
  RELMA®	
  
                                  Introductio...
Overview	
  
•  Origins	
  of	
  LOINC	
  
    –  Background,	
  Growth,	
  and	
  Participation	
  
•  Successes	
  
    ...
Origins	
  of	
  LOINC	
  
The	
  Lingua	
  Franca	
  of	
  Clinical	
  
   Observation	
  Exchange           	
  
Introduction	
  
   •  Regenstrief’s	
  35-­‐year	
  history	
  
   •  The	
  Indiana	
  Network	
  for	
  Patient	
  Care...
From	
  whence	
  comes	
  LOINC?	
  
      • LOINC®	
  
                  –  Logical	
  Observation	
  Identihiers	
  Nam...
Indiana Network for Patient Care
   HL7 v.2.X Message
MSH|^~&|HOSPITAL_A|SAMPLE_HOSPITAL_A|||$YearMonthDay|||||||||||||||
...
Indiana Network for Patient Care
   HL7 v.2.X Message
MSH|^~&|HOSPITAL_A|SAMPLE_HOSPITAL_A|||$YearMonthDay|||||||||||||||
...
LOINC	
  Purpose	
  
        To	
  facilitate	
  the	
  exchange	
  and	
  pooling	
  of	
  results	
  for	
  clinical	
  ...
LOINC’s	
  General	
  Role	
  
•  If	
  an	
  observation	
  is	
  a	
  question,	
  and	
  the	
  observation	
  
   valu...
LOINC	
  Background	
  
•  Organized	
  by	
  Regenstrief	
  Institute	
  in	
  1994	
  
    –  Ongoing	
  support	
  from...
LOINC	
  Submissions	
  2003-­2008	
  




        67	
  Organizations,	
  13	
  Countries	
  
Laboratory	
  LOINC	
  
 Chemistry	
                           Allergy	
  Testing	
  
 Urinalysis	
                       ...
Clinical	
  LOINC	
  
 Vital	
  Signs	
                                EKG	
  
 Hemodynamic	
  Measurements	
             ...
Slope = 2200



Slope = 600
http://loinc.org	
  
Downloads:	
     	
  875/month	
  
~	
  80	
  Organizations	
  Listed	
  
Current	
  Initiatives/
    Successes     	
  
 International	
  and	
  US	
  Adoption	
  
International	
  Adoption	
  
International	
  Adoption	
  
•  Brazil	
  –	
  SIGA	
  Saúde	
  lab	
  integration	
  project	
  in	
  São	
  Paulo	
  ci...
International	
  Adoption	
  
•  Spain	
  –	
  Extensive	
  use	
  in	
  HIE	
  efforts	
  by	
  BiTAC	
  and	
  others,	
...
Translations
                           	
  
•  Spanish,	
  French,	
  Simplihied	
  Chinese,	
  
   German,	
  Korean,	
 ...
Active	
  Translation	
  Efforts	
  




            16	
  Countries	
  
US	
  Adoption                      	
  
                               	
  
a	
  few	
  recent	
  highlights
Consolidated	
  Health	
  Informatics	
  Initiative	
  

•  CHI	
  Goal:	
  
    –  Adopting	
  interoperability	
  standa...
US	
  Federal	
  Agencies
                                     	
  
•  NLM	
  
   –  Source	
  vocabulary	
  in	
  UMLS	
 ...
US	
  Federal	
  Agencies
                                        	
  
•  DoD	
  
    –  Incorporated	
  into	
  Composite...
US	
  Federal	
  Agencies
                                       	
  
•  CDC	
  (why	
  we’re	
  talking!)	
  –	
  Many	
 ...
Other	
  Key	
  US	
  Adoptions
                                         	
  
•  ARRA	
  “Meaningful	
  Use”	
  
•  HITSP	...
Other	
  Key	
  US	
  Adoptions
                                       	
  
•  HL7	
  –	
  many	
  implementation	
  guide...
LOINC	
  101	
  
The	
  LOINC	
  Distribution	
  
•  Free	
  worldwide!	
  
   –  Copyrighted,	
  but	
  open	
  terms	
  of	
  use	
  
   ...
Anatomy	
  of	
  a	
  LOINC	
  Term	
  
        5193-­‐8:Hepatitis	
  B	
  virus	
  surface	
  Ab:ACnc:Pt:Ser:Qn:EIA	
  

...
What	
  is	
  NOT	
  part	
  of	
  a	
  LOINC	
  Name?	
  
  •  The	
  instrument	
  used	
  in	
  testing	
  
  •  Specih...
Component/Analyte	
  
The substance or entity that is measured,
         evaluated, or observed
     -­‐ 	
  Sodium	
  
  ...
Component/Analyte	
  Structure	
  
Analyte Name^Challenge^Adjustments
•  Formal	
  name	
  of	
  Analyte	
  (e.g.	
  Calci...
Property	
  
                             the most difficult LOINC axis


The characteristic or attribute of the analyte t...
Timing*	
  
    The interval of time over which the
  observation or measurement was made
•  Pt	
  -­‐	
  at	
  a	
  point...
System	
  
     The system (context) or specimen type upon
           which the observation was made.
•    Ser	
  -­‐	
  S...
Scale	
  
•  Qn	
  -­‐	
  quantitative	
  	
  
     •  Continuous	
  numeric	
  (real,	
  integer,	
  ratio)	
  
     •  O...
Method	
  
•  Methods	
  only	
  needed	
  if	
  interpretation	
  
   affected	
  
   •  Different	
  normal	
  ranges	
 ...
LOINC	
  “Parts”
                                 	
  
•  Pieces	
  of	
  a	
  LOINC	
  term	
  name	
  are	
  called	
  
...
Hierarchies	
  
•  LOINC	
  ‘class’	
  attribute	
  
•  Trees	
  constructed	
  for	
  the	
  parts	
  that	
  
   make	
 ...
Microbiology	
  Basics
                          	
  
             An	
  inherently	
  complex	
  result	
  structure	
  
...
LOINC’s	
  General	
  Approach	
  
•  Result	
  Status	
  
   –  Not	
  a	
  separate	
  observation	
  or	
  part	
  of	
...
LOINC’s	
  General	
  Approach	
  
•  Culture	
  growth	
  descriptions	
  and	
  
   measurement	
  
   –  Sent	
  as	
  ...
Organisms	
  Identihied	
  in	
  a	
  Culture	
  
•  Sent	
  as	
  results	
  in	
  OBX	
  segments	
  
    –  Coding	
  o...
Organisms	
  Identihied	
  in	
  a	
  Culture	
  
•  Names	
  for	
  results	
  of	
  staining	
  procedures	
  on	
  
   ...
Other	
  Notes	
  on	
  LOINC	
  Property	
  
•  Presence	
  or	
  Identity	
  (Prid)	
  with	
  
   Nominal	
  (Nom)	
  S...
Antimicrobial	
  Susceptibilities 	
  
                              	
  
          Class	
  =	
  ABXBACT

•  Named	
  wit...
Panels,	
  Forms,	
  and	
  Patient	
  
 Assessment	
  Instruments        	
  
Standard	
  Panels	
  in	
  
      LOINC   	
  
Panels	
  (Batteries)	
  in	
  LOINC	
  
•  Panel	
  term	
  linked	
  to	
  enumerated	
  child	
  elements	
  
    –  Ch...
Example	
  Panel
               	
  
Clinical	
  Panels
                 	
  
Example	
  Panel
               	
  
Patient	
  Assessment	
  
       Instruments   	
  
Iterative	
  Enhancement	
  of	
  the	
  Panel	
  Model
              ...
Introduction	
  
•  Survey	
  instruments	
  have	
  psychometric	
  properties	
  
•  Question	
  meaning	
  tightly	
  c...
What’s	
  in	
  the	
  Master	
  Question	
  File?
                                                      	
  
•  Question	...
Future:	
  URL	
  for	
  value	
  set	
  where	
  
 appropriate…e.g.	
  PHIN	
  VADS           	
  
Advantages	
  of	
  the	
  Master	
  Catalog	
  
•  Single	
  database	
  (LOINC)	
  contains	
  the	
  details	
  about	
...
Rules	
  for	
  Display	
  of	
  Items
                                           	
  
1.    SURVEY_QUEST_TEXT	
  (if	
  p...
Currently	
  in	
  LOINC	
  
•  US	
  Government	
  Forms	
  
   –  CARE,	
  MDSv2,	
  MDSv3,	
  OASIS,	
  RFC	
  
   –  U...
Many	
  Other	
  Potential	
  Opportunities
                                          	
  
 •  Mental	
  health	
  instrum...
Intellectual	
  Property	
  Issues
                                      	
  
•  Must	
  negotiate	
  separate	
  agreemen...
RELMA®	
  
         Regenstrief	
  LOINC	
  Mapping	
  Assistant
                                                    	
  
...
RELMA	
  
•  Browse	
  LOINC	
  
   – Restrict	
  based	
  on	
  hierarchies	
  
   – Flexible	
  searching	
  
•  Map	
  ...
Welcome	
  Screen	
  
Simple	
  Search	
  Screen	
  
 
Panels,	
  Forms,	
  and	
  Surveys	
  Browser
                  Clinical	
  Panels
                                   	...
Mapping	
  Screen	
  
                  View	
  or	
  edit	
  local	
  term	
  




Quick	
  select	
  button	
  list
    ...
Standard	
  Mapping	
  Screen	
  




        Navigate	
  through	
  
         the	
  local	
  terms
                     ...
Standard	
  Mapping	
  Screen	
  




          Clear	
  all	
  input	
  
              hields       	
  
Tabbed	
  Access	
  to	
  Functions
                                  	
  




              Navigate	
  to	
  Functions	
...
Tree	
  View	
  
Common	
  Grid	
  Result	
  Functions	
  




Right	
  clicking	
  on	
  a	
  LOINC	
  term	
  
    brings	
  up	
  a	
  T...
LOINC	
  Term	
  Details	
  




Change	
  to	
  expanded	
  or	
  
 custom	
  details	
  view	
  
                       ...
Customizing	
  the	
  Details	
  View	
  
Details	
  View	
  for	
  a	
  Panel	
  -­‐	
  Hierarchy	
  
Details	
  View	
  for	
  a	
  Panel	
  –	
  Summary	
  for	
  Child	
  Elements	
  
Conhigure	
  Export	
  Options	
  for	
  Grid	
  




                 Output	
  Options
                                 ...
Excel	
  Export	
  Format
                        	
  
Setting	
  Search	
  Limits	
  in	
  RELMA	
  
•  Narrows	
  search	
  to	
  subsets	
  of	
  LOINC	
  terms	
  
   –  Red...
Setting	
  Search	
  Limits	
  




Click	
  Hierarchy	
  &	
  Search	
  
           Limits	
  Tab	
  
Setting	
  Search	
  limits	
  
Can	
  also	
  set	
  most	
  of	
  them	
  by	
  toggling	
  
  buttons	
  at	
  the	
  b...
Search	
  Constraints	
  
                                                      Attribute	
  trees
                       ...
Component	
  Hierarchy	
  




         Show	
  the	
  LOINC	
  Codes	
  
          associated	
  with	
  these	
  
      ...
Show	
  Associated	
  LOINCs	
  




            Click	
  on	
  details	
  for	
  more	
  
             information	
  abo...
Details	
  Screen	
  –	
  LOINC	
  Part	
  
Discussion	
  
Context-­‐Specihic	
  Hierarchies
                                	
  
 a	
  generic	
  model	
  for	
  user-­‐dehined	
  ...
Context	
  Specihic	
  Hierarchies	
  
•  Generic	
  data	
  model	
  to	
  allow	
  local	
  dehinition	
  of	
  
   LOIN...
 
Access	
  Context-­‐Specihic	
  Hierarchies




                     Select	
  Context	
  Specihic	
  
                 ...
Context	
  Specihic	
  Hierarchies
                                 	
  
2009 12 17 - LOINC and RELMA Introduction - CDC Vocab Team
2009 12 17 - LOINC and RELMA Introduction - CDC Vocab Team
2009 12 17 - LOINC and RELMA Introduction - CDC Vocab Team
2009 12 17 - LOINC and RELMA Introduction - CDC Vocab Team
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2009 12 17 - LOINC and RELMA Introduction - CDC Vocab Team

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  • The Regenstrief Institute has over 30 years of experience aggregating, storing, and processing electronic health information. The original Regenstrief Medical Record system developed in the early 70’s now forms the core of a community and state-wide health information exchange called the INPC. Currently, more than 100 different source systems contribute data to the INPC, including data from all 5 major health systems in Indianapolis. A fundamental challenge for us and others who integrate data within and among systems is that local systems have idiosyncratic ways of identifying similar concepts. In response to this challenge, Regenstrief investigators pioneered the development of LOINC, a universal code system for laboratory and other clinical observations. When local system terms are mapped to a common vocabulary like LOINC, LOINC can serve as the lingua franca for information exchange, as it does in our network. As we continue integrating sources into the INPC and distributing their content throughout the network, we hope to combat the common problem of important clinical results like lab tests and radiology being unavailable when and where they are needed.
  • In response to this challenge, Regenstrief investigators pioneered the development of LOINC, a universal code system for laboratory and other clinical observations. When local system terms are mapped to LOINC, LOINC can serve as the lingua franca for information exchange, as it does in our network. As these sources are integrated and their content distributed throughout the network, we hope to combat the common problem that clinical data are often unavailable when and where they are needed.
  • Total PHQ-9 Score of 11 = Moderate Depression
  • Total PHQ-9 Score of 11 = Moderate Depression
  • Highlight Code from rest of name Normal results vary, but in general are: Male: 13.8 to 17.2 gm/dL Female: 12.1 to 15.1 gm/dL
  • 2001-2004:Slope = 600 2004-2007:Slope = 2200
  • LOINC Axes What a Challenge Is.
  • co
  • Example properties: mass rate (MRAT) – g/24h, substance rate (SRAT) – mol/24h
  • SPM (specimen) segment of HL7
  • 2009 12 17 - LOINC and RELMA Introduction - CDC Vocab Team

    1. 1. CDC  Vocabulary  Team  Meeting     LOINC®  and  RELMA®   Introduction  and  Tutorial   12.17.2009   Daniel  J.  Vreeman,  PT,  DPT,  MSc   Assistant  Research  Professor   Indiana  University  School  of  Medicine   Associate  Director  of  Terminology  Services  and  Research  Scientist     Regenstrief  Institute,  Inc   http://loinc.org/slideshows   Copyright  ©  2009  
    2. 2. Overview   •  Origins  of  LOINC   –  Background,  Growth,  and  Participation   •  Successes   –  International   –  US   •  LOINC  101   –  Naming  conventions   –  Microbiology   –  Panels,  Forms,  Surveys   •  RELMA   –  Basic  searching  and  mapping   –  Hierarchies   •  Discussion  
    3. 3. Origins  of  LOINC   The  Lingua  Franca  of  Clinical   Observation  Exchange  
    4. 4. Introduction   •  Regenstrief’s  35-­‐year  history   •  The  Indiana  Network  for  Patient  Care     –  A  working  HIE  for  ~15  years   –  More  than  100  sources   –  Regenstrief:  3rd  party  convener   •  Local  systems  use  idiosyncratic  codes   •  Vocabulary  standards   –  LOINC  ®    -­‐  universal  code  system  for  clinical  observations   –  The  lingua  franca  of  information  exchange   •  Laboratory  and  Radiology  results*     –  Often  unavailable  at  the  time  of  a  clinical  visit  (6%,  4%)   –  Often  located  outside  of  their  clinical  system   *Smith  CP,  Araya-­‐Guerra  R,  Bublitz  C,  et  al.  Missing  clinical  information  during  primary  care  visits.  JAMA.  2005;293(5):565-­‐571  
    5. 5. From  whence  comes  LOINC?   • LOINC®   –  Logical  Observation  Identihiers  Names  and  Codes   –  A  universal  code  system  for  laboratory  and  other   clinical  observations   –  The  lingua  franca  of  information  exchange  for   clinical  observations   McDonald  CJ,  Huff  SM,  Suico  JG,  et  al.  LOINC,  a  universal  standard  for  identifying  laboratory  observations:  a  5-­‐year  update.  Clin  Chem.  2003;49(4):624-­‐633.  
    6. 6. Indiana Network for Patient Care HL7 v.2.X Message MSH|^~&|HOSPITAL_A|SAMPLE_HOSPITAL_A|||$YearMonthDay||||||||||||||| PID|||$patientId$||$patientName$|||||||||||||||||||| PV1|||||||$attendingDoctor$||$consultingDoctor$|||||||| OBR|1|||CBC^CBC/Auto Diff^HSPA^57021-8^CBC W Auto Diff^LN||$reqDate||||||||| OBX|2|ST|WBC^WBC^HSP_A^26464-8^Leukocytes [#/volume] in Blood^LN||10.8|K/MM3|||||F| OBX|3|ST|RBC^RBC^HSP_A^26453-1^Erythrocytes [#/volume] in Blood^LN||4.82|MIL/MM3|||||F| OBX|4|ST|HGB^HGB^HSP_A^718-7^Hemoglobin [Mass/volume] in Blood^LN||15.7|GM/DL|||||F| OBX|5|CE|HCT^HCT^HSP_A^20570-8^Hematocrit [Volume Fraction] of Blood^LN||45|%|||||||F| A A
    7. 7. Indiana Network for Patient Care HL7 v.2.X Message MSH|^~&|HOSPITAL_A|SAMPLE_HOSPITAL_A|||$YearMonthDay||||||||||||||| PID|||$patientId$||$patientName$|||||||||||||||||||| PV1|||||||$attendingDoctor$||$consultingDoctor$|||||||| OBR|1|||44249-1^PHQ-9 Quick Depression Assessment Pnl^LN||$requestDate||||||||| OBX|1|ST|44250-9^Little interest or pleasure in doing things:Find:Pt:^Patient:Ord:Reported.PHQ-9^LN| 1|3^More than half the days^Pfizer^LA6570-1^More than half the days^LN||||||||||||| OBX|2|ST|44255-8^Feeling down, depressed, or hopeless^LN|1|2^Several days^Pfizer^LA6569-3^Several days^LN||||||||||||| … OBX|10|ST|44261-6^PHQ-9 Total Score^LN|1|11||||||||||||| A A
    8. 8. LOINC  Purpose   To  facilitate  the  exchange  and  pooling  of  results  for  clinical   care,  outcomes  management,  and  research   •  Specihically,  to  provide  a  universal  ID  for   the  OBX-­‐3  hield  in  HL7  ORU  messages   •  LOINC  codes  “questions”,  not  answers   – Orders/Panels  (OBR-­‐4)   – Questions  (OBX-­‐3)   – NOT  Values  (OBX-­‐5)   • Numbers,  organisms  (E.  coli)   McDonald  CJ,  Huff  SM,  Suico  JG,  et  al.  LOINC,  a  universal  standard  for  identifying  laboratory  observations:  a  5-­‐year  update.  Clin  Chem.  2003;49(4):624-­‐633.  
    9. 9. LOINC’s  General  Role   •  If  an  observation  is  a  question,  and  the  observation   value  an  answer:   –  LOINC  provides  codes  for  the  questions  {OBR-­4,  OBX-­3}   –  Other  systems  (eg  SNOMED)  provide  codes  for  the  answers   What  is  my  patient’s  hemoglobin  level?   718-­‐7:Hemoglobin:MCnc:Pt:Bld:Qn   How  fast  does  my  patient  usually  walk?   41959-­‐8:Walking  speed:Vel:1W^mean:^Patient:Qn:Calculated  
    10. 10. LOINC  Background   •  Organized  by  Regenstrief  Institute  in  1994   –  Ongoing  support  from  NLM  and  Regenstrief   –  Guided  by  the  LOINC  Committee  (Lab  +  Clinical)   •  Covers  domain  of  Clinical  Observations   –  Laboratory  observations  (since  1995)   –  Clinical  observations  (since  1996)   •  LOINC  development  is  a  highly  ‘open  source’  model   –  Open,  nimble,  pragmatic   –  LOINC  and  RELMA  program  are  freely  available   –  Much  work  is  done  by  volunteers   –  Additions  to  the  database  are  end-­‐user  driven  
    11. 11. LOINC  Submissions  2003-­2008   67  Organizations,  13  Countries  
    12. 12. Laboratory  LOINC    Chemistry    Allergy  Testing    Urinalysis    Blood  Bank    Toxicology    Cell  Markers    Hematology    Skin  Tests    Microbiology    Coagulation    Antibiotic  Susceptibilities    Cytology    Immunology/Serology    HLA  Antigens    Molecular  Genetics    Surgical  Pathology    Cell  Counts  
    13. 13. Clinical  LOINC    Vital  Signs    EKG    Hemodynamic  Measurements    Cardiac  Ultrasound    Fluid  Intake/Output    Obstetrical  Ultrasound    Body  Measurements    Discharge  Summary    Emergency  Department  Variables      History  and  Physical    Respiratory  Therapy    Pathology  Findings    Tumor  Registry    Colonoscopy/Endoscopy    Patient  Assessment  Instruments    Clinical  Documents    Ophthalmology  Measurements    Document  Sections    Radiology  Reports    Patient  Assessment  Instruments  
    14. 14. Slope = 2200 Slope = 600
    15. 15. http://loinc.org  
    16. 16. Downloads:    875/month  
    17. 17. ~  80  Organizations  Listed  
    18. 18. Current  Initiatives/ Successes   International  and  US  Adoption  
    19. 19. International  Adoption  
    20. 20. International  Adoption   •  Brazil  –  SIGA  Saúde  lab  integration  project  in  São  Paulo  city   •  Canada  –  Adopted  by  Canada  Health  Infoway,  incorporated   into  many  efforts,  e.g.  the  eCHN  network  (province-­‐wide)   •  China  –Lab  interoperability  prohile  with  gov’t,  academic,   hospital,  and  vendor  participation   •  France  -­‐  Assistance  Publique-­‐Paris  Hospitals  (AP-­‐HP)   •  Germany  –  DIMI  produces  a  companion  LOINC  website   •  Korea  –  Support  from  Korean  Ministry  for  Health,  Welfare,   and  Family  Affairs   •  The  Netherlands  –  Dutch  National  Institute  for  ICT  in   Healthcare  has  2  mapping  efforts  underway  
    21. 21. International  Adoption   •  Spain  –  Extensive  use  in  HIE  efforts  by  BiTAC  and  others,   Red  Agrolab  network  (49  labs)  for  food  safety/animal  health   •  Mexico  –  Mexican  Institute  of  Social  Security  uses  in  more   than  850  medical  services   •  Taiwan  –  Adoption  supported  by  Department  of  Health   since  2004,  large  mapping  project  between  National  Health   Insurance  (NHI)  codes  and  LOINC   •  Europe-­wide  –  being  used  in  European  Patients  Smart  Open   Services  (epSOS)  project    
    22. 22. Translations   •  Spanish,  French,  Simplihied  Chinese,   German,  Korean,  Estonian,  Portuguese,   Italian   •  More  coming:  Catalan,  Dutch,  Russian,   Ukrainian   •  See  http://loinc.org/international  
    23. 23. Active  Translation  Efforts   16  Countries  
    24. 24. US  Adoption     a  few  recent  highlights
    25. 25. Consolidated  Health  Informatics  Initiative   •  CHI  Goal:   –  Adopting  interoperability  standards  to  enable  all  agencies   in  the  federal  health  enterprise  to  “speak  the  same   language”   •  Adopted  LOINC  as  standard   –  Laboratory  results  names  (2003)   –  Laboratory  test  order  names  (2006)   –  Medications:  Structured  Product  Labeling  Sections  (2006)   –  Federally-­‐required  assessments  with  functioning  and   disability  content  (2007)  
    26. 26. US  Federal  Agencies   •  NLM   –  Source  vocabulary  in  UMLS   –  Principal  funder  of  LOINC  development   •  VA  (Standards  and  Terminology  Service)   –  VistA  Lab  interfaces  to/from:   •  VA,  DoD,  Commercial  References  labs   •  Clinical  laboratory  automated  instruments   •  Clinical  decision  support  systems   •  Health  data  repositories/data  warehouse   – Document  Title  Ontology  
    27. 27. US  Federal  Agencies   •  DoD   –  Incorporated  into  Composite  Health  Care  System,  used  by   100+  systems  supporting  500+  hospitals  and  clinics   –  Mappings  to  LOINC  support  the  Global  Laboratory   Information  Transfer  Project  for  lab  orders/results   between  DoD,  VA,  and  commercial  labs   •  IHS   –  After  pilot  project,  now  embarking  on  ~250  facility   mapping  process   •  NCI  –  caBIG   –  Lab  portion  of  LOINC  adopted  as  caBIG  vocab  standard  
    28. 28. US  Federal  Agencies   •  CDC  (why  we’re  talking!)  –  Many  projects  underway   in  various  stages   –  Notihiable  condition  mapping   –  NHANES   –  Data  elements  in  CTSE  position  statements   –  National  immunization  program   –  CDA  IG  for  Case  Reporting   –  Inhluenza  program   –  Lab  response  network-­‐C,  -­‐B   –  NHSN   –  DEEDs  –  Release  1.0  and  1.1  
    29. 29. Other  Key  US  Adoptions   •  ARRA  “Meaningful  Use”   •  HITSP   –  C80:  vital  signs,  lab  results,  lab  orders,  genetic  results,  other  results   –  IS92:  newborn  screening   •  eLINCS   –  Standard  for  results  delivery  from  LIS  to  an  EHR   •  NAACCR   –  Volumes  II    (Data  Standards/Dictionary)  and  V  (Path  Lab  e-­‐Reporting)   •  CDISC   –  Pharmaceutical  research  specs   •  NCQA/HEDIS   –  Used  90%  of  health  plans  to  measure  quality  
    30. 30. Other  Key  US  Adoptions   •  HL7  –  many  implementation  guides,  CDA,  etc   •  HIPAA  Claims  Attachments   •  Many  Regional  HIEs   –  Indiana  Network  for  Patient  Care   –  Maine  Health  InfoNet   –  Florida  Health  Information  Network   –  Vermont  Information  Technology  Leaders   •  Many  large  care  delivery  organizations   –  Intermountain  Healthcare   –  Kaiser  Permanente  
    31. 31. LOINC  101  
    32. 32. The  LOINC  Distribution   •  Free  worldwide!   –  Copyrighted,  but  open  terms  of  use   –  Releases  ~2x/year  (June  and  December)   •  LOINC,  RELMA,  or  LOINC+RELMA   –  LOINC  Table  as  ascii  text  or  .mdb   –  RELMA   •  Easy  searching  of  LOINC   •  Helps  map  local  terms  to  LOINC   •  LOINC  Accessory  Files   –  LOINC  Panels  and  Forms   –  LOINC  Multiaxial  Hierarchy   –  LOINC  Context-­‐specihic  Hierarchy  Template  
    33. 33. Anatomy  of  a  LOINC  Term   5193-­‐8:Hepatitis  B  virus  surface  Ab:ACnc:Pt:Ser:Qn:EIA   5193-8 LOINC Code Hepatitis B virus surface Ab Component ACnc Property Measured Pt Timing Ser System Qn Scale EIA Method There  are  six  major  LOINC  axes  
    34. 34. What  is  NOT  part  of  a  LOINC  Name?   •  The  instrument  used  in  testing   •  Specihic  details  about  the  specimen   •  Priority  (e.g.  STAT)   •  Where  testing  was  done   •  Who  did  the  test   •  Test  interpretation   •  Anything  that  is  not  an  intrinsic  part  of  the  name   of  the  result   •  Other  things  that  are  carried  in;   •  The  OBR  or  OBX  segment   •  An  HL7  Version  3  Observation  Object  
    35. 35. Component/Analyte   The substance or entity that is measured, evaluated, or observed -­‐  Sodium   -­‐  Glucose   -­‐  Brucella  sp.  organism   -­‐  Inhluenza  A  Virus  antigen   -­‐  Cytomegalovirus  Virus  antibody   -­‐  Lipids.Total   5193-­‐8:Hepatitis  B  virus  surface  Ab:ACnc:Pt:Ser:Qn:EIA  
    36. 36. Component/Analyte  Structure   Analyte Name^Challenge^Adjustments •  Formal  name  of  Analyte  (e.g.  Calcium)   •  Must  specify  any  “subanalyte”   • e.g.    Coronavirus  Ag   •  May  have  a  subclass  –  separated  by  “.”   • e.g.  Calcium.ionized   •  Challenge  -­‐  e.g,  1H  post  100  gm  Glucose  PO   •  Two  subparts  separated  by  “post”   •  <time  delay>  post  <challenge  type>   •  Adjustments/corrections   •  E.g.  Adjusted  to  pH  7.4  
    37. 37. Property   the most difficult LOINC axis The characteristic or attribute of the analyte that is measured, evaluated, or observed •  MCnc  –  mass  concentration  (mass/unit  vol)   •  MCnt  –  mass  content  (mass/unit  mass)   •  NCnc  –  number  concentration  (number/unit  vol)   •  TmStp  –  time   •  CCnc  –  catalytic  concentration  (activity)   •  Prid  –  presence  or  identity   •  Imp  –  impression/interpretation   •  Find  –  subjective  or  objective  observation   •  Type  –  “Kind-­‐of”   5193-­‐8:Hepatitis  B  virus  surface  Ab:ACnc:Pt:Ser:Qn:EIA  
    38. 38. Timing*   The interval of time over which the observation or measurement was made •  Pt  -­‐  at  a  point  in  time   •  12H  -­‐  a  twelve  hour  collection   •  24H  -­‐  a  twenty  four  hour  collection   *non-Pt timings are usually associated with Ratio Property
    39. 39. System   The system (context) or specimen type upon which the observation was made. •  Ser  -­‐  Serum   •  Gast  –  Gastric  hluid/contents   •  Bld  -­‐  Whole  blood  (RBC)   •  Food  –  Food  or  feedstuff   •  Ur-­‐  Urine   •  Tiss  –  Tissue   •  BldA  -­‐  Arterial  blood   •  XXX  –  To  be  specihied  in   •  Liver  -­‐  Liver   another  part  of  the  message     •  Flu  –  Body  Fluid,  unspecihied   Super  System   Second  subpart  (^).  When  not  included,  “patient”  is  the   default.  Used  to  indicated  blood  product  unit  (BPU),  a   bone  marrow  donor,  or  a  fetus.  
    40. 40. Scale   •  Qn  -­‐  quantitative     •  Continuous  numeric  (real,  integer,  ratio)   •  Optional  operator  (>,  ≥,  ≤,  <)   •  When  assay  detection  limits  are  exceeded   •  Ord  -­‐  ordinal     •  a  ranked  set  of  possible  values  (1+,  2+,  3+)   •  Nom  -­‐  nominal     •  an  unranked  collection  of  possible  values   •  a    taxonomy  (e.g  list  of  bacteria)   •  Nar  -­‐  narrative     •  free  text  narrative  (e.g.,  visit  note)  
    41. 41. Method   •  Methods  only  needed  if  interpretation   affected   •  Different  normal  ranges   •  Test  Sensitivity   •  Listed  only  at  the  generic  level   •  Agglutination   •  Immunoassay   •  Probe  with  target  amplihication  
    42. 42. LOINC  “Parts”   •  Pieces  of  a  LOINC  term  name  are  called   “parts”  and  are  given  an  “LP*”  code   – E.g  “LP14635-­‐4”  is  Glucose   •  LOINC  parts  are  used  for  synonymy,   building  hierarchies,  algorithmically   creating  alternate  names,  and  attaching   descriptions  
    43. 43. Hierarchies   •  LOINC  ‘class’  attribute   •  Trees  constructed  for  the  parts  that   make  up  the  system,  component,   method  axes  (in  RELMA)   •  Multi-­‐axial  hierarchy   – Component  |  System   – Available  as  separate  download  
    44. 44. Microbiology  Basics   An  inherently  complex  result  structure   Local  HIE  experience:  very  challenging,  systems  don’t  follow  HL7  guidelines  
    45. 45. LOINC’s  General  Approach   •  Result  Status   –  Not  a  separate  observation  or  part  of  name   –  Send  in  HL7  hield  OBR-­‐25   •  Specimen  Type   –  Send  in  HL7  hield  OBR-­‐15   –  May  also  be  part  of  name   •  Details  of  Specimen  Collection   –  Usually  sent  as  OBX  segments  or  comments   under  culture  results  
    46. 46. LOINC’s  General  Approach   •  Culture  growth  descriptions  and   measurement   –  Sent  as  separate  OBX  segments   –  E.g  a  qn  test  of  bacteria  in  a  specimen:   •  564-­‐5:Colony  count:Num:Pt:XXX:Qn:VC   •  Gram  stain  hindings   –  Sent  as  separate  OBX  segments   –  664-­‐3:Microscopic  observation:Prid:Pt:   XXX:Nom:Gram  stain    
    47. 47. Organisms  Identihied  in  a  Culture   •  Sent  as  results  in  OBX  segments   –  Coding  organisms  with  SNOMED  is  good   •  Example  name  of  culture  results   –  6463-­‐4:Bacteria  identihied:Prid:Pt:  XXX  Nom:Culture     •  Example  names  of  methods  of  staining   directly  on  a  sample/material   –  664-­‐3:Microscopic  observation:Prid:Pt:   XXX:Nom:Gram  stain    
    48. 48. Organisms  Identihied  in  a  Culture   •  Names  for  results  of  staining  procedures  on   organisms  growing  in  culture  –  use  Isolate   as  system   –  613-­‐0:Fungus  identihied:Prid:Pt    Isolate:Nom:Fungal  subtyping     •  Names  for  organism-­‐specihic  cultures   –  557-­‐9:Chlamydia  sp  identihied:Prid:Pt:  Genital:Nom:Organism  specihic  culture  
    49. 49. Other  Notes  on  LOINC  Property   •  Presence  or  Identity  (Prid)  with   Nominal  (Nom)  Scale   –  Should  be  used  when  the  value  of  a  test  can   come  from  a  taxonomy  or  spectrum  of  possible   species/subspecies   •  Arbitrary  Concentration  (Acnc)  with   Ordinal  (Ord)  Scale   –  For  when  the  answer  is  positive/negative  or   yes/no  
    50. 50. Antimicrobial  Susceptibilities     Class  =  ABXBACT •  Named  with  generic  name  of  drug,  Property  of   susceptibility  (Susc),  and  appropriate  method,  scale   •  Example  E-­‐tests:   •  Special  Scale:  OrdQn   •  Observations  reported  as  resistant,  intermediate,   susceptible,  or  as  mm  diameter  of  inhibition  zone   •  Difhicult  for  some  systems  to  implement  OBX  sub   IDs  and  links  back  to  parent  culture  battery    
    51. 51. Panels,  Forms,  and  Patient   Assessment  Instruments  
    52. 52. Standard  Panels  in   LOINC  
    53. 53. Panels  (Batteries)  in  LOINC   •  Panel  term  linked  to  enumerated  child  elements   –  Child  elements  can  be  panels  themselves  (nesting)   •  Panel  term  names  (under  discussion)   –  Component    often  have  “panel”,  include  authoritative  source   –  Property    typically  “-­‐”  because  child  elements  will  vary   –  Scale    typically  “-­‐”  because  child  elements  will  vary   –  Class    PANEL.*   •  Child  elements  linked  and  identihied  as:   –  Required  (R)    Element  always  reported  with  panel   –  Optional  (O)    Element  may  not  be  reported  depending  on        institutional  policies  or  capabilities   –  Conditional  (C)  Element  is  a  key  hinding  and  thus  should  be        assumed  to  be  negative,  absent,  or  not  present  if        panel  result  does  not  include  data  for  this  element.  
    54. 54. Example  Panel  
    55. 55. Clinical  Panels  
    56. 56. Example  Panel  
    57. 57. Patient  Assessment   Instruments   Iterative  Enhancement  of  the  Panel  Model  
    58. 58. Introduction   •  Survey  instruments  have  psychometric  properties   •  Question  meaning  tightly  coupled  with  answers   •  With  experience  in  modeling  instruments  from   various  domains,  we  uncovered  additional   relevant  attributes  to  store   General Aim: LOINC could serve as the “master question file” in this domain
    59. 59. What’s  in  the  Master  Question  File?   •  Question  (item)  name/text   –  Exact  question  text,  form-­‐specihic  display  name   •  Data  type   •  Description  and/or  help  text   •  For  numeric  values:  units  of  measure,  range  checks     •  For  categorical  results:  answers  in  an  answer  list   •  Required  item  (Y/N)   •  Cardinality  (more  than  one  answer  allowed)   •  Copyright  and  terms-­‐of-­‐use  notices   •  Skip  logic   •  Consistency/data  integrity  logic   •  …  and  more    
    60. 60. Future:  URL  for  value  set  where   appropriate…e.g.  PHIN  VADS  
    61. 61. Advantages  of  the  Master  Catalog   •  Single  database  (LOINC)  contains  the  details  about   individual  observations  and  sets   –  In  the  database,  all  forms  (sets)  look  the  same   –  Automatic  standardization   –  Data  collection  and  other  programs  can  be  built  upon  a   common  data  model   •  Can  easily  reuse  observations  (and  attributes)  in   different  forms/sets  
    62. 62. Rules  for  Display  of  Items   1.  SURVEY_QUEST_TEXT  (if  populated).  Used  when  item  is  asked  as  a   question.  Sometimes  the  item  has  a  label  and  a  question,  so  we   store  both  as  [label].[question  text]   Pain Presence. Ask resident: “Have you had pain or hurting at any time in the last 7 days?” 2.  DISPLAY_NAME_FOR_FORM  (if  populated).  Provides  an  override   display  linked  to  the  instance  of  the  LOINC  in  a  particular  form.   Allows  for  presentation  variation  that  doesn’t  affect  meaning  and   for  where  the  LOINC  naming  conventions  require  some  difference   b/w  the  item  and  the  LOINC  Component.   Item label = “Body Mass Index (BMI)” LOINC Component = “Body mass index” 3.  COMPONENT.  This  is  the  default  display  
    63. 63. Currently  in  LOINC   •  US  Government  Forms   –  CARE,  MDSv2,  MDSv3,  OASIS,  RFC   –  US  Surgeon  General’s  Family  Health  Portrait   •  Geriatric  Depression  Scale   •  HIV  Signs  and  Symptoms  Checklist   •  Home  Health  Care  Classihication   •  howRU   •  OMAHA   •  PHQ  (9  and  2)  
    64. 64. Many  Other  Potential  Opportunities   •  Mental  health  instruments   •  Lots  of  other  commonly-­‐used   instruments  (SF-­‐36,  etc)   •  AHRQ  Common  Framework  forms   •  CDC  case  report  forms   •  PhenX  protocols  for  clinical  research   trials  
    65. 65. Intellectual  Property  Issues   •  Must  negotiate  separate  agreements  with  each   copyright/IP  holder   •  Many  instruments  are  hiercely  protected   –  Protection  against  change  and  attribution  are   understandable   –  Some  want  royalties   –  Commercial  use  in  LOINC’s  context  is  tricky   •  Even  more  complicated  when  several   instruments  included  in  larger  CMS  ones  (MDS,   CARE,  etc)  
    66. 66. RELMA®   Regenstrief  LOINC  Mapping  Assistant   (some  screen  shots  from  v4.2  that  will  be  out  soon)  
    67. 67. RELMA   •  Browse  LOINC   – Restrict  based  on  hierarchies   – Flexible  searching   •  Map  local  codes  to  LOINC   – Start  with  local  codes  from  master  hile  or   HL7  messages   • Include  sample  data,  units,  categories   • Mass  translations   • Propose  new  LOINC  codes  based  on  old  ones   • Export  mapped  terms  
    68. 68. Welcome  Screen  
    69. 69. Simple  Search  Screen  
    70. 70.   Panels,  Forms,  and  Surveys  Browser Clinical  Panels  
    71. 71. Mapping  Screen   View  or  edit  local  term   Quick  select  button  list   Custom  Grid  Conhiguration  
    72. 72. Standard  Mapping  Screen   Navigate  through   the  local  terms  
    73. 73. Standard  Mapping  Screen   Clear  all  input   hields  
    74. 74. Tabbed  Access  to  Functions   Navigate  to  Functions  from   Mapping  Page   Switch  between  Grid  and   Tree  Views  
    75. 75. Tree  View  
    76. 76. Common  Grid  Result  Functions   Right  clicking  on  a  LOINC  term   brings  up  a  Task  Menu  
    77. 77. LOINC  Term  Details   Change  to  expanded  or   custom  details  view    
    78. 78. Customizing  the  Details  View  
    79. 79. Details  View  for  a  Panel  -­‐  Hierarchy  
    80. 80. Details  View  for  a  Panel  –  Summary  for  Child  Elements  
    81. 81. Conhigure  Export  Options  for  Grid   Output  Options   Include     column  headers   Save  Conhiguration/Export  
    82. 82. Excel  Export  Format  
    83. 83. Setting  Search  Limits  in  RELMA   •  Narrows  search  to  subsets  of  LOINC  terms   –  Reduces  number  of  candidate  terms   •  Component  attribute  can  be  further  restricted   by  number  of  words   •  Tree  structure  allows  for  hierarchical   constraints  
    84. 84. Setting  Search  Limits   Click  Hierarchy  &  Search   Limits  Tab  
    85. 85. Setting  Search  limits   Can  also  set  most  of  them  by  toggling   buttons  at  the  bottom  of  the  screen     Toggle  Buttons  
    86. 86. Search  Constraints   Attribute  trees   Local  Unit  Constraint:   Now  defaults  to  “ON”   Predehined,  general  search   constraints  
    87. 87. Component  Hierarchy   Show  the  LOINC  Codes   associated  with  these   Components  
    88. 88. Show  Associated  LOINCs   Click  on  details  for  more   information  about  the   selection  
    89. 89. Details  Screen  –  LOINC  Part  
    90. 90. Discussion  
    91. 91. Context-­‐Specihic  Hierarchies   a  generic  model  for  user-­‐dehined  hierarchies  
    92. 92. Context  Specihic  Hierarchies   •  Generic  data  model  to  allow  local  dehinition  of   LOINC  code  hierarchies   •  Template  data  base  is  provided  with  RELMA   •  CONTEXT_SPECIFIC_HIERARCHY_TEMPLATE.mdb   •  Or  download  from  LOINC  website   •  Described  in  detail  in  RELMA  User’s  Manual   •  Hierarchies  can  be  displayed  (only)  in  RELMA   •  Codes  may  come  from  multiple  code  systems   •  May  share  community  contributed  hierarchies   on  LOINC  website  and/or  incorporate  into   main  LOINC  distribution  
    93. 93.   Access  Context-­‐Specihic  Hierarchies Select  Context  Specihic   Hierarchies  
    94. 94. Context  Specihic  Hierarchies  

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