An Introduction to  Clinical LOINC Stanley M. Huff, M.D. Intermountain Healthcare [email_address]
Outline for All Tutorials <ul><li>LOINC Introduction and Foundation </li></ul><ul><li>Documents </li></ul><ul><li>Assessme...
Outline <ul><li>LOINC background and goals </li></ul><ul><li>LOINC structure and content </li></ul><ul><ul><li>Clinical LO...
Important facts <ul><li>LOINC 2.27 (June 2009) contains 55,056 codes </li></ul><ul><ul><li>40,302  Lab LOINC codes </li></...
Coverage <ul><li>Laboratory LOINC </li></ul><ul><ul><li>All laboratory categories including genetic testing , veterinary m...
The Messaging Paradigm 07/19/10 System A System B Trigger Event Network Order Result
HL7 Result Message (ORU) 07/19/10 Segment Data Field MSH|^~&|||||19981105131523||ORU^R01| PID|||100928782^9^M11||Smith^Joh...
OBX: a name-value pair approach 07/19/10 A code that identifies the data in OBX-5 (Temp Reading) OBX||NM|11289-6^^LN||38|C...
OBX: with a coded value 07/19/10 OBX||CE|883-9^ Blood Group ^LN||58460004^ Group O ^SCT| The code is from SNOMED The code ...
So we are all using HL7, what is the problem? <ul><li>Site 1: </li></ul><ul><ul><li>OBX|1|CE| SysBP ^ Systolic BP || 132 |...
<ul><li>Site 1: </li></ul><ul><ul><li>OBX|1|CE| 8479-8 ^ SysBP ^ LN || 132 ||mmHg| </li></ul></ul><ul><li>Site 2: </li></u...
How terminologies fit into the model <ul><li>LOINC – attributes/observables </li></ul><ul><li>SNOMED CT – findings/values ...
Focus of LOINC <ul><li>Value for ‘Observation Identifier’ (Seq. #3) of OBX </li></ul><ul><ul><li>Or the name of the observ...
Brief History of LOINC <ul><li>Logical Observation Identifier Names and Codes </li></ul><ul><li>Organized by Clement McDon...
Approach <ul><li>Collect result names and descriptions </li></ul><ul><ul><li>IHC, VA, Regenstrief, Mayo Clinic, 3M, Vendor...
LOINC makes names for things in use  <ul><li>We do not make all possible permutations that the six axes would allow (no bl...
Two LOINC committees <ul><li>Laboratory LOINC </li></ul><ul><ul><li>Clem McDonald, Chair </li></ul></ul><ul><ul><li>All as...
Current and Former Clinical LOINC Members <ul><li>James Barthel , Dean Bidgood, Bruce Bray, Bill Francis, Alan Golichowski...
Clinical LOINC Subject Areas <ul><li>Vital Signs </li></ul><ul><li>Hemodynamics </li></ul><ul><li>Fluid Intake/Output </li...
LOINC Mascot 07/19/10
Outline <ul><li>LOINC background and goals </li></ul><ul><li>LOINC structure and content </li></ul><ul><ul><li>Clinical LO...
<ul><li>LOINC codes are created systematically using a six axis model </li></ul>General Form of Clinical LOINC Names 07/19...
Summary of the six primary axes (clinical) <ul><li>Component </li></ul><ul><ul><li>Ejection fraction, heart beats, cardiac...
Component 07/19/10 <ul><li>The substance or entity that is measured,  </li></ul><ul><li>evaluated, or observed. </li></ul>...
Subtypes – period as a separator <ul><li>CAPACITY.VITAL.FORCED </li></ul><ul><li>GRADIENT.MAX (as across a valve) </li></u...
Challenge/Pre condition - ^ as a separator <ul><li>FLUID OUTPUT.URINE  ^   POST VOID </li></ul><ul><li>FRACTIONAL COLLAPSE...
Adjustments - ^ ^ as a separator <ul><li>DIFFUSION CAPACITY.CARBON MONOXIDE  ^  ^   ADJUSTED FOR HEMOGLOBIN </li></ul><ul>...
Kind of Property <ul><li>TYPE – selection of subtype (nominal items) </li></ul><ul><li>PRID – presence or identified (nomi...
Timing <ul><li>PT - at a point in time </li></ul><ul><li>STDY^MIN – minimum over the period of a study </li></ul><ul><li>2...
System <ul><li>YOLK SAC^FETUS </li></ul><ul><li>UPPER GI TRACT </li></ul><ul><li>TRICUSPID VALVE^PATIENT </li></ul><ul><li...
Patient, Control, or Donor (as part of system) <ul><li>CONTROL </li></ul><ul><li>PATIENT </li></ul><ul><li>DONOR </li></ul...
Scale <ul><li>QN - quantitative </li></ul><ul><ul><li>4, 7.4, 1:8 </li></ul></ul><ul><li>ORD - ordinal, the answers can be...
Method <ul><li>STATED – reported verbally </li></ul><ul><li>MEASURED – actually observed </li></ul><ul><li>CALCULATED – nu...
Putting it all together <ul><li>Code Component Prop TIME System Scale Method </li></ul><ul><li>8302-2 BODY HGHT LEN PT ^PA...
More complex examples <ul><li>9273-4 NEONATAL APGAR^ 2M POST BIRTH FCN PT ^PATIENT ORD </li></ul><ul><li>9192-6 FLUID OUTP...
Outline <ul><li>LOINC background and goals </li></ul><ul><li>LOINC structure and content </li></ul><ul><ul><li>Clinical LO...
HL7 & the Claims Attachment Recommendation <ul><li>HIPAA Legislation was passed in Aug 1996 </li></ul><ul><li>Extended deb...
Unsolicited Attachment 07/19/10
Request for Additional Information 07/19/10
Organizations & Documents 07/19/10 X12 277 Transaction 12748-1 9832-1 X12 275 Transaction HL7 CDA R1 15748-3 7832-8 20118-...
Attachment Types Selected for HIPAA <ul><li>Attachment types ultimately selected for development and HIPAA recommendation:...
CDA: Semi- or fully-structured HIPAA  Claims Attachments 07/19/10 Autoadjudicate Provider Payer Transcription * Scanned Pa...
Outline <ul><li>LOINC background and goals </li></ul><ul><li>LOINC structure and content </li></ul><ul><ul><li>Clinical LO...
Use cases for Context Specific Hierarchies <ul><li>Roll-up in decision support </li></ul><ul><ul><li>Body weight </li></ul...
Consultation Note Example <ul><li>11488-4  Consultation note  Find  Pt  {Setting}   Doc  {Provider} </li></ul><ul><li>3410...
Outline <ul><li>LOINC background and goals </li></ul><ul><li>LOINC structure and content </li></ul><ul><ul><li>Clinical LO...
Issues related to “collections” <ul><li>Two “kinds” of items within LOINC </li></ul><ul><ul><li>Individual measurements/ob...
Proposed stragegy <ul><li>For individual measurements </li></ul><ul><ul><li>Continue to create codes that distinguish betw...
Literature References <ul><li>McDonald CJ, Huff SM, etal. LOINC® a universal standard for identifying laboratory observati...
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2010 07 15 - Clinical LOINC Tutorial - Introduction and Foundations

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  • 07/19/10
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  • 07/19/10 The pig picture was on an old t-shirt that was found stuffed under something when we moved offices. I cut the pig out and put it in an 8 x 10 frame that we had. I took a picture of it with my cell phone and emailed it to myself. Then I inserted the picture into a blank powerpoint and VOILA - The French Pig. (Sandy Poremba) Do we know who the original artist was?  (Stan) I think it was Jill Warvel - a programmer from here. (Sandy Poremba)
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  • 2010 07 15 - Clinical LOINC Tutorial - Introduction and Foundations

    1. 1. An Introduction to Clinical LOINC Stanley M. Huff, M.D. Intermountain Healthcare [email_address]
    2. 2. Outline for All Tutorials <ul><li>LOINC Introduction and Foundation </li></ul><ul><li>Documents </li></ul><ul><li>Assessment Instruments and Survey Instruments </li></ul><ul><li>Radiology and Imaging </li></ul>07/19/10
    3. 3. Outline <ul><li>LOINC background and goals </li></ul><ul><li>LOINC structure and content </li></ul><ul><ul><li>Clinical LOINC </li></ul></ul><ul><ul><li>Examples </li></ul></ul><ul><li>Attachments </li></ul><ul><li>Context specific hierarchies </li></ul><ul><li>Collections </li></ul>07/19/10
    4. 4. Important facts <ul><li>LOINC 2.27 (June 2009) contains 55,056 codes </li></ul><ul><ul><li>40,302 Lab LOINC codes </li></ul></ul><ul><ul><li>10,773 Clinical LOINC codes </li></ul></ul><ul><ul><li>1,354 Claims Attachment codes </li></ul></ul><ul><ul><li>2,629 Survey codes </li></ul></ul><ul><li>LOINC is protected by copyright, but is licensed Free for Use </li></ul><ul><li>Download files and tools from Regenstrief Web Site </li></ul><ul><ul><li>www.regenstrief.org/loinc/loinc.htm </li></ul></ul><ul><ul><li>Reference manual, submission database, RELMA </li></ul></ul><ul><li>RELMA – a tool for mapping local codes to LOINC </li></ul>07/19/10
    5. 5. Coverage <ul><li>Laboratory LOINC </li></ul><ul><ul><li>All laboratory categories including genetic testing , veterinary medicine testing </li></ul></ul><ul><li>Clinical LOINC </li></ul><ul><ul><li>Many routine measures, parts of H+P, EKG, Cardiac echoes, OB ultrasound, Nursing survey instruments, Much more </li></ul></ul><ul><li>HIPAA attachments </li></ul><ul><ul><li>(Content managed by HL7) </li></ul></ul><ul><li>Survey Questions </li></ul><ul><ul><li>Skilled nursing facility Minimum Data Set (MDS) </li></ul></ul>07/19/10
    6. 6. The Messaging Paradigm 07/19/10 System A System B Trigger Event Network Order Result
    7. 7. HL7 Result Message (ORU) 07/19/10 Segment Data Field MSH|^~&|||||19981105131523||ORU^R01| PID|||100928782^9^M11||Smith^John^J| OBR||||Z0063-0^BP^LN| OBX||CE|8361-4^POSITION^LN||SIT^Sitting| OBX||NM|8479-8^SBP^LN||138|mmHg| Component
    8. 8. OBX: a name-value pair approach 07/19/10 A code that identifies the data in OBX-5 (Temp Reading) OBX||NM|11289-6^^LN||38|C^^ISO+|||||F Other data fields include: date of observation, identity of provider giving observation, normal ranges, abnormal flags Status A code that identifies the units of numerical data in OBX-5 A code that identifies the datatype of OBX-5 OBX-5: Data
    9. 9. OBX: with a coded value 07/19/10 OBX||CE|883-9^ Blood Group ^LN||58460004^ Group O ^SCT| The code is from SNOMED The code is from LOINC OBX-5: Data A code for Group O A code that identifies the datatype as a coded element A code that identifies the data in OBX-5 (ABO Blood Group)
    10. 10. So we are all using HL7, what is the problem? <ul><li>Site 1: </li></ul><ul><ul><li>OBX|1|CE| SysBP ^ Systolic BP || 132 ||mmHg| </li></ul></ul><ul><li>Site 2: </li></ul><ul><ul><li>OBX|1|CE| SBP ^ Systolic BP || 132 ||mmHg| </li></ul></ul><ul><li>Site 3: </li></ul><ul><ul><li>OBX|1|CE| BP ^ Systolic BP || 132/70 ||mmHg| </li></ul></ul>You and I may know that these are similar results, but our computers will not.
    11. 11. <ul><li>Site 1: </li></ul><ul><ul><li>OBX|1|CE| 8479-8 ^ SysBP ^ LN || 132 ||mmHg| </li></ul></ul><ul><li>Site 2: </li></ul><ul><ul><li>OBX|1|CE| 8479-8 ^ SBP ^ LN || 132 ||mmHg| </li></ul></ul><ul><li>Site 3: </li></ul><ul><ul><li>OBX|1|CE| 8479-8 ^ Systolic BP ^ LN || 132/70 ||mmHg| </li></ul></ul>The Goal 07/19/10 Agree on a universal coding system for clinical observations.
    12. 12. How terminologies fit into the model <ul><li>LOINC – attributes/observables </li></ul><ul><li>SNOMED CT – findings/values (mostly) and observables (some) </li></ul><ul><li>First Data Bank - values </li></ul><ul><li>RxNORM - values </li></ul>07/19/10
    13. 13. Focus of LOINC <ul><li>Value for ‘Observation Identifier’ (Seq. #3) of OBX </li></ul><ul><ul><li>Or the name of the observation in other standards, such as ASTM or DICOM </li></ul></ul><ul><li>Individual result names first, then panels </li></ul><ul><ul><li>Panels are built based on the tests they contain </li></ul></ul><ul><ul><li>Panels can contain other panels </li></ul></ul><ul><li>Name should facilitate automated or manual matching (fully specified) </li></ul><ul><ul><li>Create local labels as needed </li></ul></ul><ul><ul><li>Standard LOINC short names </li></ul></ul><ul><li>One common identifier for tests that are ‘clinically’ the same </li></ul>07/19/10
    14. 14. Brief History of LOINC <ul><li>Logical Observation Identifier Names and Codes </li></ul><ul><li>Organized by Clement McDonald, 1994 </li></ul><ul><li>Supported by Regenstrief Institute and NLM </li></ul><ul><li>Create a universal language for observation identifiers </li></ul><ul><li>Laboratory observations were created first </li></ul><ul><li>Creation of clinical observations began in 1996 </li></ul>07/19/10
    15. 15. Approach <ul><li>Collect result names and descriptions </li></ul><ul><ul><li>IHC, VA, Regenstrief, Mayo Clinic, 3M, Vendors </li></ul></ul><ul><li>Formulate a model to represent the individual pieces of information in the name </li></ul><ul><ul><li>Avoid strategies that lead to “combinatorial explosion” </li></ul></ul><ul><li>Create “fully specified names” </li></ul><ul><li>Adjust model as needed </li></ul><ul><ul><li>Do any distinct entities have the same name? </li></ul></ul><ul><ul><li>Do any entities that are the same have different names? </li></ul></ul><ul><li>Repeat the process until no more adjustments are needed </li></ul>07/19/10
    16. 16. LOINC makes names for things in use <ul><li>We do not make all possible permutations that the six axes would allow (no blind cross products) </li></ul><ul><li>We try to only make names and codes for things that are real (exist in someone’s system) </li></ul><ul><li>We do make names that allow both atomic (post coordinated) and molecular (pre coordinated) styles </li></ul><ul><ul><li>Some people wish we would be more prescriptive </li></ul></ul><ul><ul><li>Name everything, let others dictate usage </li></ul></ul><ul><li>We do object to violations of the HL7 model </li></ul><ul><ul><li>No names that include post coordinated fields from other parts of the HL7 message (status, priority, user role) </li></ul></ul>07/19/10
    17. 17. Two LOINC committees <ul><li>Laboratory LOINC </li></ul><ul><ul><li>Clem McDonald, Chair </li></ul></ul><ul><ul><li>All aspects of tests/measurements done on specimens </li></ul></ul><ul><ul><ul><li>Chemistry, Hematology, Microbiology, Histology, Cytology, etc. </li></ul></ul></ul><ul><li>Clinical LOINC </li></ul><ul><ul><li>Stan Huff, Chair </li></ul></ul><ul><ul><li>All aspects of tests/measurements on a patient </li></ul></ul><ul><ul><ul><li>Vital signs, Hemodynamic measurements, Physical findings, Radiology, Ultrasound, etc. </li></ul></ul></ul><ul><li>Both committees meet at least 2-3 times each year </li></ul>07/19/10
    18. 18. Current and Former Clinical LOINC Members <ul><li>James Barthel , Dean Bidgood, Bruce Bray, Bill Francis, Alan Golichowski, Daniel Vreeman, Karl Hammermeister, Anders Thurin, Barry Gordon, Warren Williams, James Campbell, Jim Cimino, Sue Bakken, Pat Wilson, Stan Huff, Doug Martin, Clem McDonald, Dan Pollock, Angelo Rossi Mori, Susan Matney, Jeff Suico, Wayne Tracy, Pavla Frazier, Pat Wilson, Lee Min Lau, Shawn Shakib, Bill Karitis, Thomas White, Steven Steindel, Elizabeth King, Loren Stevenson, Sundak Ganesan, Ted Klein, Vivian Auld </li></ul>07/19/10
    19. 19. Clinical LOINC Subject Areas <ul><li>Vital Signs </li></ul><ul><li>Hemodynamics </li></ul><ul><li>Fluid Intake/Output </li></ul><ul><li>Body Measurements </li></ul><ul><li>Operative Notes </li></ul><ul><li>Emergency Department </li></ul><ul><li>Respiratory Therapy </li></ul><ul><li>Documents (collections) </li></ul><ul><li>Standard survey instruments </li></ul><ul><li>EKG (ECG) </li></ul><ul><li>Cardiac Ultrasound </li></ul><ul><li>Obstetrical Ultrasound </li></ul><ul><li>Discharge Summary </li></ul><ul><li>History & Physical </li></ul><ul><li>Pathology Findings </li></ul><ul><li>Colonoscopy/Endoscopy </li></ul><ul><li>Radiology reports </li></ul><ul><li>Clinical Documents </li></ul><ul><li>Tumor Registry </li></ul>07/19/10
    20. 20. LOINC Mascot 07/19/10
    21. 21. Outline <ul><li>LOINC background and goals </li></ul><ul><li>LOINC structure and content </li></ul><ul><ul><li>Clinical LOINC </li></ul></ul><ul><ul><li>Examples </li></ul></ul><ul><li>Attachments </li></ul><ul><li>Context specific hierarchies </li></ul><ul><li>Collections </li></ul>07/19/10
    22. 22. <ul><li>LOINC codes are created systematically using a six axis model </li></ul>General Form of Clinical LOINC Names 07/19/10 <component> : <property> : <timing> : <system> : <scale> : <method> The first 5 parts are mandatory, but method is optional. Subparts of the six axes are created as needed in specific subject areas. 8331-1 Body Temperature :TEMP :PT :MOUTH :QN
    23. 23. Summary of the six primary axes (clinical) <ul><li>Component </li></ul><ul><ul><li>Ejection fraction, heart beats, cardiac output, circumference </li></ul></ul><ul><li>Kind of property </li></ul><ul><ul><li>Angle, area, length, mass, pressure, temperature </li></ul></ul><ul><li>Timing </li></ul><ul><ul><li>Point in time, study minimum, maximum in 8 hours </li></ul></ul><ul><li>System </li></ul><ul><ul><li>Head of fetus, tricuspid valve, ventilator setting </li></ul></ul><ul><li>Scale </li></ul><ul><ul><li>Quantitative, ordinal, nominal (coded), narrative </li></ul></ul><ul><li>Method </li></ul><ul><ul><li>Stated, measured, estimated, ultrasound, spirometry </li></ul></ul>07/19/10
    24. 24. Component 07/19/10 <ul><li>The substance or entity that is measured, </li></ul><ul><li>evaluated, or observed. </li></ul><ul><li>RR INTERVAL </li></ul><ul><li>ORIFICE (OF A HEART VALVE) </li></ul><ul><li>EJECTION FRACTION </li></ul><ul><li>HEART BEATS </li></ul><ul><li>BREATHS </li></ul><ul><li>CARDIAC OUTPUT </li></ul><ul><li>SEGMENTAL WALL MOTION </li></ul><ul><li>PROSTHETIC VALVE TYPE </li></ul><ul><li>FLUID INTAKE </li></ul>
    25. 25. Subtypes – period as a separator <ul><li>CAPACITY.VITAL.FORCED </li></ul><ul><li>GRADIENT.MAX (as across a valve) </li></ul><ul><li>INTERNAL DIAMETER.MINOR AXIS.SYSTOLE </li></ul><ul><li>BIRTHS.TERM </li></ul><ul><li>GLASGOW SCORE.VERBAL </li></ul><ul><li>R' WAVE AMPLITUDE.LEAD II </li></ul><ul><li>ST SEGMENT AXIS.HORIZONTAL PLANE </li></ul><ul><li>PHYSICAL FINDINGS.SENSATION </li></ul><ul><li>CALORIE INTAKE.TOTAL </li></ul><ul><li>TIDAL VOLUME MAX.SETTING </li></ul>07/19/10
    26. 26. Challenge/Pre condition - ^ as a separator <ul><li>FLUID OUTPUT.URINE ^ POST VOID </li></ul><ul><li>FRACTIONAL COLLAPSE ^ INSPIRATION </li></ul><ul><li>BREATHS ^ AT MAX VOLUNTARY VENTILATION </li></ul><ul><li>RR INTERVAL ^ AT TRICUSPID FLOW MEASUREMENT </li></ul><ul><li>GAS FLOW.MIN ^ PRE THERAPY </li></ul><ul><li>FLOW ^ AT 25-75% OF FORCED EXPIRATION </li></ul><ul><li>INTRAVASCULAR DIASTOLIC ^ STANDING </li></ul><ul><li>NEONATAL APGAR ^ 5M POST BIRTH </li></ul><ul><li>MULTISECTION ^ WITH ANESTHESIA </li></ul><ul><li>BODY WEIGHT ^ WITH CLOTHES </li></ul>07/19/10
    27. 27. Adjustments - ^ ^ as a separator <ul><li>DIFFUSION CAPACITY.CARBON MONOXIDE ^ ^ ADJUSTED FOR HEMOGLOBIN </li></ul><ul><li>DIFFUSION CAPACITY ^ ^ ADJUSTED TO BODY CONDITIONS </li></ul>07/19/10
    28. 28. Kind of Property <ul><li>TYPE – selection of subtype (nominal items) </li></ul><ul><li>PRID – presence or identified (nominal items) </li></ul><ul><li>TIME – duration of time </li></ul><ul><li>COLOR – color </li></ul><ul><li>ANGLE – degrees of arch </li></ul><ul><li>APER – appearance </li></ul><ul><li>AREA - area </li></ul><ul><li>ELPOT – voltage </li></ul><ul><li>LEN – length </li></ul><ul><li>MASS – mass </li></ul><ul><li>MRAT – mass rate (gm/hr) </li></ul><ul><li>PRES – pressure </li></ul><ul><li>TEMP – temperature </li></ul><ul><li>FCN – function (of a body part or system) </li></ul>07/19/10 The characteristic or attribute of the component that is measured, evaluated, or observed.
    29. 29. Timing <ul><li>PT - at a point in time </li></ul><ul><li>STDY^MIN – minimum over the period of a study </li></ul><ul><li>24H - a twenty four hour shift </li></ul><ul><li>10H^MEAN – mean value for a ten hour period </li></ul><ul><li>8H^MAX – maximum value in an eight hour period </li></ul>07/19/10 The interval of time over which the observation or measurement was made.
    30. 30. System <ul><li>YOLK SAC^FETUS </li></ul><ul><li>UPPER GI TRACT </li></ul><ul><li>TRICUSPID VALVE^PATIENT </li></ul><ul><li>TRICUSPID VALVE^FETUS </li></ul><ul><li>SYNOVIAL SPACE </li></ul><ul><li>HEART.VENTRICLE.RIGHT </li></ul><ul><li>VENTILATOR </li></ul><ul><li>ARTERIAL SYSTEM </li></ul><ul><li>BLADDER </li></ul><ul><li>EYE.LEFT </li></ul>07/19/10 The system (context) or body part about which the observation was made.
    31. 31. Patient, Control, or Donor (as part of system) <ul><li>CONTROL </li></ul><ul><li>PATIENT </li></ul><ul><li>DONOR </li></ul><ul><li>BABY </li></ul><ul><li>FETUS </li></ul>07/19/10 Non-patient values for this axis should be used with care, or combinatorial explosion could result
    32. 32. Scale <ul><li>QN - quantitative </li></ul><ul><ul><li>4, 7.4, 1:8 </li></ul></ul><ul><li>ORD - ordinal, the answers can be ranked </li></ul><ul><ul><li>+/-, 1+, 2+, 3+ …. </li></ul></ul><ul><ul><li>mild, moderate, severe </li></ul></ul><ul><li>NOM - nominal, answers are unranked </li></ul><ul><ul><li>Stool appearance </li></ul></ul><ul><ul><li>Chest tube type </li></ul></ul><ul><li>NAR - answer is a paragraph of text </li></ul>07/19/10
    33. 33. Method <ul><li>STATED – reported verbally </li></ul><ul><li>MEASURED – actually observed </li></ul><ul><li>CALCULATED – numeric calculation </li></ul><ul><li>US – ultrasound </li></ul><ul><li>EKG – electrocardiogram </li></ul><ul><li>ESTIMATED – an educated guess at the real value </li></ul><ul><li>HELIUM REBREATHING – helium rebreathing </li></ul><ul><li>SPIROMETRY – spirometry </li></ul><ul><li>MANUAL – done by hand </li></ul><ul><li>AUTOMATED – used an instrument </li></ul>07/19/10 Procedure used to make the measurement or observation. Only used when it makes an important distinction in sensitivity or specificity.
    34. 34. Putting it all together <ul><li>Code Component Prop TIME System Scale Method </li></ul><ul><li>8302-2 BODY HGHT LEN PT ^PATIENT QN </li></ul><ul><li>3140-1 BODY SURF AREA PT ^PATIENT QN DERIVED </li></ul><ul><li>8331-1 BODY TEMP TEMP PT MOUTH QN </li></ul><ul><li>8319-6 BODY TEMP TEMP 12H^MIN XXX QN </li></ul><ul><li>8629-8 Q WAVE DPT ELPOT PT HEART QN EKG </li></ul><ul><li>8632-2 QRS AXIS ANGLE PT HEART QN EKG </li></ul><ul><li>8642-1 PUPIL DIA LEN PT EYE.RIGHT QN AUTO </li></ul><ul><li>21611-9 AGE TIME PT ^PATIENT QN EST </li></ul><ul><li>21612-7 AGE TIME PT ^PATIENT QN REPORT </li></ul><ul><li>19867-1 CAPACITY.VITAL VOL PT RESP SYS QN </li></ul><ul><li>9279-1 BREATHS NRAT PT RESP SYS QN </li></ul><ul><li>11882-8 GENDER FIND PT ^FETUS NOM US </li></ul>07/19/10
    35. 35. More complex examples <ul><li>9273-4 NEONATAL APGAR^ 2M POST BIRTH FCN PT ^PATIENT ORD </li></ul><ul><li>9192-6 FLUID OUTPUT.URINE VRAT 24H URINARY TRACT QN </li></ul><ul><li>11892-7 GESTATIONAL AGE TIME PT ^FETUS QN US.ESTIMATED FROM AC.HADLOCK84 </li></ul><ul><li>10105-5 ST SLOPE.LEAD V6 ELPOTRAT PT HEART QN EKG </li></ul><ul><li>8431-9 INTRACHAMBER SYSTOLIC PRES PT HEART.VENTRICLE.LEFT.OUTFLOW TRACT QN </li></ul><ul><li>8283-4 CIRCUMFERENCE. MAX LEN PT CALF.RIGHT QN </li></ul>07/19/10
    36. 36. Outline <ul><li>LOINC background and goals </li></ul><ul><li>LOINC structure and content </li></ul><ul><ul><li>Clinical LOINC </li></ul></ul><ul><ul><li>Examples </li></ul></ul><ul><li>Attachments </li></ul><ul><li>Context specific hierarchies </li></ul><ul><li>Collections </li></ul>07/19/10
    37. 37. HL7 & the Claims Attachment Recommendation <ul><li>HIPAA Legislation was passed in Aug 1996 </li></ul><ul><li>Extended debate </li></ul><ul><ul><li>Different motivations for payers and providers </li></ul></ul><ul><li>Initial proposal to use X12 messages, HL7 Version 2 messages, LOINC </li></ul><ul><li>Notice of proposed rule making (NPRM) in Sept 2005 </li></ul><ul><ul><li>X12 messages </li></ul></ul><ul><ul><li>HL7 CDA Release 1 standard (probably will now be R2) </li></ul></ul><ul><ul><ul><li>XML based standard for transmitting documents </li></ul></ul></ul><ul><ul><li>LOINC codes </li></ul></ul><ul><li>No final rule yet </li></ul>07/19/10
    38. 38. Unsolicited Attachment 07/19/10
    39. 39. Request for Additional Information 07/19/10
    40. 40. Organizations & Documents 07/19/10 X12 277 Transaction 12748-1 9832-1 X12 275 Transaction HL7 CDA R1 15748-3 7832-8 20118-5 4332-7 12748-1 9832-1 ASC X12 & Subcommittee X12N X12 Trans. Sets 277, 275 TG2 Impl. Guides 277, 275 Health Level Seven HL7 CDA R 1 HL7 Claims Attachments Impl. Guide LOINC Consortium LOINC Codes LOINC Attachment Booklets
    41. 41. Attachment Types Selected for HIPAA <ul><li>Attachment types ultimately selected for development and HIPAA recommendation: </li></ul><ul><ul><ul><li>Ambulance </li></ul></ul></ul><ul><ul><ul><li>Emergency Department </li></ul></ul></ul><ul><ul><ul><li>Rehabilitative Services </li></ul></ul></ul><ul><ul><ul><li>Lab Results </li></ul></ul></ul><ul><ul><ul><li>Medications </li></ul></ul></ul><ul><ul><ul><li>Clinical Notes </li></ul></ul></ul>07/19/10
    42. 42. CDA: Semi- or fully-structured HIPAA Claims Attachments 07/19/10 Autoadjudicate Provider Payer Transcription * Scanned Paper or Document Imaging * Level 3 CPR Image + XML Semistructured Structured and coded Specific XML forms *
    43. 43. Outline <ul><li>LOINC background and goals </li></ul><ul><li>LOINC structure and content </li></ul><ul><ul><li>Clinical LOINC </li></ul></ul><ul><ul><li>Examples </li></ul></ul><ul><li>Attachments </li></ul><ul><li>Context specific hierarchies </li></ul><ul><li>Collections </li></ul>07/19/10
    44. 44. Use cases for Context Specific Hierarchies <ul><li>Roll-up in decision support </li></ul><ul><ul><li>Body weight </li></ul></ul><ul><ul><li>Body height </li></ul></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><li>Basis for queries </li></ul><ul><ul><li>“ All surgery notes” </li></ul></ul><ul><ul><li>“ All head x-ray reports” </li></ul></ul><ul><ul><li>“ All hematology lab results” </li></ul></ul><ul><li>Control of data access </li></ul><ul><ul><li>Tabs for document types </li></ul></ul><ul><ul><ul><li>Radiology </li></ul></ul></ul><ul><ul><ul><ul><li>(by body region) – Head, neck, chest, abdomen, … </li></ul></ul></ul></ul><ul><ul><ul><ul><li>(by modality) – X-ray, CT, Ultrasound, Scans, … </li></ul></ul></ul></ul><ul><ul><ul><li>Documents </li></ul></ul></ul><ul><ul><ul><ul><li>(by subject) – cardiology, ob-gyn, heme-onc, surgery, internal medicine, … </li></ul></ul></ul></ul><ul><ul><ul><ul><li>(by setting) – inpatient, ambulatory, home care, SNF, … </li></ul></ul></ul></ul>07/19/10
    45. 45. Consultation Note Example <ul><li>11488-4 Consultation note Find Pt {Setting} Doc {Provider} </li></ul><ul><li>34100-8 Consultation note Find Pt Critical care unit Doc {Provider} </li></ul><ul><li>34101-6 Consultation note Find Pt Outpatient Doc {Provider} </li></ul><ul><li>34101-6 Consultation note Find Pt Outpatient Doc General medicine </li></ul><ul><li>34749-2 Consultation note Find Pt Outpatient Doc Anesthesia </li></ul><ul><li>34104-0 Consultation note Find Pt Hospital Doc {Provider} </li></ul><ul><li>34102-4 Consultation note Find Pt Hospital Doc Psychiatry </li></ul><ul><li>NewCD Consultation note Find Pt {Setting} Doc Internal medicine </li></ul><ul><li>34764-1 Consultation note Find Pt {Setting} Doc General Medicine </li></ul><ul><li>34776-5 Consultation note Find Pt {Setting} Doc Gerontology </li></ul><ul><li>34781-5 Consultation note Find Pt {Setting} Doc Infect. Disease </li></ul><ul><li>34795-5 Consultation note Find Pt {Setting} Doc Nephrology </li></ul><ul><li>34797-1 Consultation note Find Pt {Setting} Doc Neurology </li></ul>07/19/10
    46. 46. Outline <ul><li>LOINC background and goals </li></ul><ul><li>LOINC structure and content </li></ul><ul><ul><li>Clinical LOINC </li></ul></ul><ul><ul><li>Examples </li></ul></ul><ul><li>Attachments </li></ul><ul><li>Context specific hierarchies </li></ul><ul><li>Collections </li></ul>07/19/10
    47. 47. Issues related to “collections” <ul><li>Two “kinds” of items within LOINC </li></ul><ul><ul><li>Individual measurements/observations/data elements </li></ul></ul><ul><ul><li>Collections of measurements/observations/data elements </li></ul></ul><ul><li>Different codes for orders versus results? </li></ul><ul><li>Different codes for narrative vs nominal? </li></ul><ul><ul><li>Medication history – paragraph versus coded list </li></ul></ul><ul><ul><li>Want to have a single code to get all medication history </li></ul></ul><ul><li>Two kinds of “collections” but different things </li></ul><ul><ul><li>Panels (known explicit content) </li></ul></ul><ul><ul><ul><li>Vital Signs, ABGs, CBC, Chem 7 panel (known explicit content) </li></ul></ul></ul><ul><ul><li>Documents (vague or abstract content) </li></ul></ul><ul><ul><ul><li>Operative note, discharge summary, consult </li></ul></ul></ul><ul><ul><ul><li>Bone marrow exam – text table of discreet data </li></ul></ul></ul><ul><ul><ul><li>Separate codes for: rtf, Word, pdf, scanned images? </li></ul></ul></ul>07/19/10
    48. 48. Proposed stragegy <ul><li>For individual measurements </li></ul><ul><ul><li>Continue to create codes that distinguish between character identifiers, strings, codes, dates, numbers </li></ul></ul><ul><ul><li>Create generic parents as needed, relate parent to children using new hierarchies </li></ul></ul><ul><li>For collections </li></ul><ul><ul><li>Continue to distinguish panels (explicit list of contained elements) from documents (ill defined or vague contents) </li></ul></ul><ul><ul><li>For documents, do not make distinct names based on narrative, nominal, pdf, Word, scanned image </li></ul></ul><ul><li>Use the same codes for orders as for results </li></ul><ul><ul><li>Just a code for “hematocrit”, no code for “hematocrit order” or “hematocrit result” </li></ul></ul><ul><ul><li>Use context to complete the meaning </li></ul></ul>07/19/10
    49. 49. Literature References <ul><li>McDonald CJ, Huff SM, etal. LOINC® a universal standard for identifying laboratory observations – a 5-year Update . Clinical Chemistry , 2003 </li></ul><ul><li>Huff SM, Rocha RA, McDonald CJ, De Moor GJE, etal. Development of the LOINC ® (Logical Observation Identifier Names and Codes) Vocabulary. Journal of American Medical Informatics Association , 1998, 5:276-292. </li></ul><ul><li>Dolin RH, Huff SM, Rocha RA, Spackman KA, Campbell, KE. Evaluation of a “Lexically Assign, Logically Refine”Strategy for Semi-Automated Integration of Overlapping Terminologies. Journal of American Medical Informatics Association , 1998, 5 : 203-213. </li></ul><ul><li>Forrey AW, McDonald CJ, DeMoor G, Huff SM , Leavelle D, Leland Fiers DT, Charles L, Griffin B, Stalling F, Tullis A, Hutchins K, Baenziger J. Logical Observation Identifier Names and Codes (LOINC) Database: A public use set of codes and names for electronic reporting of clinical laboratory test results . Clinical Chemistry , 1995. </li></ul>07/19/10
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