2011 01 27 - Clinical LOINC Tutorial - Intro and Foundations
Upcoming SlideShare
Loading in...5
×
 

2011 01 27 - Clinical LOINC Tutorial - Intro and Foundations

on

  • 1,586 views

 

Statistics

Views

Total Views
1,586
Views on SlideShare
1,357
Embed Views
229

Actions

Likes
0
Downloads
27
Comments
0

2 Embeds 229

http://loinc.org 217
https://loinc.org 12

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • 02/07/11
  • 02/07/11
  • 02/07/11
  • 02/07/11
  • 02/07/11 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)
  • 02/07/11
  • 02/07/11
  • 02/07/11
  • 02/07/11
  • 02/07/11
  • 02/07/11
  • 02/07/11
  • 02/07/11
  • 02/07/11
  • 02/07/11
  • 02/07/11
  • 02/07/11
  • 02/07/11

2011 01 27 - Clinical LOINC Tutorial - Intro and Foundations 2011 01 27 - Clinical LOINC Tutorial - Intro and Foundations Presentation Transcript

  • An Introduction to Clinical LOINC Stanley M. Huff, M.D. Intermountain Healthcare [email_address]
  • Outline for All Tutorials
    • LOINC Introduction and Foundation
    • Documents
    • Assessment Instruments and Survey Instruments
    • Radiology and Imaging
    02/07/11
  • Outline
    • LOINC background and goals
    • LOINC structure and content
      • Clinical LOINC
      • Examples
    • Attachments
    • Context specific hierarchies
    • Collections
    02/07/11
  • Important facts
    • LOINC 2.27 (June 2009) contains 55,056 codes
      • 40,302 Lab LOINC codes
      • 10,773 Clinical LOINC codes
      • 1,354 Claims Attachment codes
      • 2,629 Survey codes
    • LOINC is protected by copyright, but is licensed Free for Use
    • Download files and tools from Regenstrief Web Site
      • http://loinc.org/
      • Reference manual, submission database, RELMA
    • RELMA – a tool for mapping local codes to LOINC
    02/07/11
  • Coverage
    • Laboratory LOINC
      • All laboratory categories including genetic testing , veterinary medicine testing
    • Clinical LOINC
      • Many routine measures, parts of H+P, EKG, Cardiac echoes, OB ultrasound, Nursing survey instruments, Much more
    • HIPAA attachments
      • (Content managed by HL7)
    • Survey Questions
      • Skilled nursing facility Minimum Data Set (MDS)
    02/07/11
  • The Messaging Paradigm 02/07/11 System A System B Trigger Event Network Order Result
  • HL7 Result Message (ORU) 02/07/11 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
  • OBX: a name-value pair approach 02/07/11 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
  • OBX: with a coded value 02/07/11 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)
  • So we are all using HL7, what is the problem?
    • Site 1:
      • OBX|1|CE| SysBP ^ Systolic BP || 132 ||mmHg|
    • Site 2:
      • OBX|1|CE| SBP ^ Systolic BP || 132 ||mmHg|
    • Site 3:
      • OBX|1|CE| BP ^ Systolic BP || 132/70 ||mmHg|
    You and I may know that these are similar results, but our computers will not.
    • Site 1:
      • OBX|1|CE| 8479-8 ^ SysBP ^ LN || 132 ||mmHg|
    • Site 2:
      • OBX|1|CE| 8479-8 ^ SBP ^ LN || 132 ||mmHg|
    • Site 3:
      • OBX|1|CE| 8479-8 ^ Systolic BP ^ LN || 132/70 ||mmHg|
    The Goal 02/07/11 Agree on a universal coding system for clinical observations.
  • How terminologies fit into the model
    • LOINC – attributes/observables
    • SNOMED CT – findings/values (mostly) and observables (some)
    • First Data Bank - values
    • RxNORM - values
    02/07/11
  • Focus of LOINC
    • Value for ‘Observation Identifier’ (Seq. #3) of OBX
      • Or the name of the observation in other standards, such as ASTM or DICOM
    • Individual result names first, then panels
      • Panels are built based on the tests they contain
      • Panels can contain other panels
    • Name should facilitate automated or manual matching (fully specified)
      • Create local labels as needed
      • Standard LOINC short names
    • One common identifier for tests that are ‘clinically’ the same
    02/07/11
  • Brief History of LOINC
    • Logical Observation Identifier Names and Codes
    • Organized by Clement McDonald, 1994
    • Supported by Regenstrief Institute and NLM
    • Create a universal language for observation identifiers
    • Laboratory observations were created first
    • Creation of clinical observations began in 1996
    02/07/11
  • Approach
    • Collect result names and descriptions
      • IHC, VA, Regenstrief, Mayo Clinic, 3M, Vendors
    • Formulate a model to represent the individual pieces of information in the name
      • Avoid strategies that lead to “combinatorial explosion”
    • Create “fully specified names”
    • Adjust model as needed
      • Do any distinct entities have the same name?
      • Do any entities that are the same have different names?
    • Repeat the process until no more adjustments are needed
    02/07/11
  • LOINC makes names for things in use
    • We do not make all possible permutations that the six axes would allow (no blind cross products)
    • We try to only make names and codes for things that are real (exist in someone’s system)
    • We do make names that allow both atomic (post coordinated) and molecular (pre coordinated) styles
      • Some people wish we would be more prescriptive
      • Name everything, let others dictate usage
    • We do object to violations of the HL7 model
      • No names that include post coordinated fields from other parts of the HL7 message (status, priority, user role)
    02/07/11
  • Two LOINC committees
    • Laboratory LOINC
      • Clem McDonald, Chair
      • All aspects of tests/measurements done on specimens
        • Chemistry, Hematology, Microbiology, Histology, Cytology, etc.
    • Clinical LOINC
      • Stan Huff, Chair
      • All aspects of tests/measurements on a patient
        • Vital signs, Hemodynamic measurements, Physical findings, Radiology, Ultrasound, etc.
    • Both committees meet at least 2-3 times each year
    02/07/11
  • Current and Former Clinical LOINC Members
    • 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
    02/07/11
  • Clinical LOINC Subject Areas
    • Vital Signs
    • Hemodynamics
    • Fluid Intake/Output
    • Body Measurements
    • Operative Notes
    • Emergency Department
    • Respiratory Therapy
    • Documents (collections)
    • Standard survey instruments
    • EKG (ECG)
    • Cardiac Ultrasound
    • Obstetrical Ultrasound
    • Discharge Summary
    • History & Physical
    • Pathology Findings
    • Colonoscopy/Endoscopy
    • Radiology reports
    • Clinical Documents
    • Tumor Registry
    02/07/11
  • LOINC Mascot 02/07/11
  • Outline
    • LOINC background and goals
    • LOINC structure and content
      • Clinical LOINC
      • Examples
    • Attachments
    • Context specific hierarchies
    • Collections
    02/07/11
    • LOINC codes are created systematically using a six axis model
    General Form of Clinical LOINC Names 02/07/11 <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
  • Summary of the six primary axes (clinical)
    • Component
      • Ejection fraction, heart beats, cardiac output, circumference
    • Kind of property
      • Angle, area, length, mass, pressure, temperature
    • Timing
      • Point in time, study minimum, maximum in 8 hours
    • System
      • Head of fetus, tricuspid valve, ventilator setting
    • Scale
      • Quantitative, ordinal, nominal (coded), narrative
    • Method
      • Stated, measured, estimated, ultrasound, spirometry
    02/07/11
  • Component 02/07/11
    • The substance or entity that is measured,
    • evaluated, or observed.
    • RR INTERVAL
    • ORIFICE (OF A HEART VALVE)
    • EJECTION FRACTION
    • HEART BEATS
    • BREATHS
    • CARDIAC OUTPUT
    • SEGMENTAL WALL MOTION
    • PROSTHETIC VALVE TYPE
    • FLUID INTAKE
  • Subtypes – period as a separator
    • CAPACITY.VITAL.FORCED
    • GRADIENT.MAX (as across a valve)
    • INTERNAL DIAMETER.MINOR AXIS.SYSTOLE
    • BIRTHS.TERM
    • GLASGOW SCORE.VERBAL
    • R' WAVE AMPLITUDE.LEAD II
    • ST SEGMENT AXIS.HORIZONTAL PLANE
    • PHYSICAL FINDINGS.SENSATION
    • CALORIE INTAKE.TOTAL
    • TIDAL VOLUME MAX.SETTING
    02/07/11
  • Challenge/Pre condition - ^ as a separator
    • FLUID OUTPUT.URINE ^ POST VOID
    • FRACTIONAL COLLAPSE ^ INSPIRATION
    • BREATHS ^ AT MAX VOLUNTARY VENTILATION
    • RR INTERVAL ^ AT TRICUSPID FLOW MEASUREMENT
    • GAS FLOW.MIN ^ PRE THERAPY
    • FLOW ^ AT 25-75% OF FORCED EXPIRATION
    • INTRAVASCULAR DIASTOLIC ^ STANDING
    • NEONATAL APGAR ^ 5M POST BIRTH
    • MULTISECTION ^ WITH ANESTHESIA
    • BODY WEIGHT ^ WITH CLOTHES
    02/07/11
  • Adjustments - ^ ^ as a separator
    • DIFFUSION CAPACITY.CARBON MONOXIDE ^ ^ ADJUSTED FOR HEMOGLOBIN
    • DIFFUSION CAPACITY ^ ^ ADJUSTED TO BODY CONDITIONS
    02/07/11
  • Kind of Property
    • TYPE – selection of subtype (nominal items)
    • PRID – presence or identified (nominal items)
    • TIME – duration of time
    • COLOR – color
    • ANGLE – degrees of arch
    • APER – appearance
    • AREA - area
    • ELPOT – voltage
    • LEN – length
    • MASS – mass
    • MRAT – mass rate (gm/hr)
    • PRES – pressure
    • TEMP – temperature
    • FCN – function (of a body part or system)
    02/07/11 The characteristic or attribute of the component that is measured, evaluated, or observed.
  • Timing
    • PT - at a point in time
    • STDY^MIN – minimum over the period of a study
    • 24H - a twenty four hour shift
    • 10H^MEAN – mean value for a ten hour period
    • 8H^MAX – maximum value in an eight hour period
    02/07/11 The interval of time over which the observation or measurement was made.
  • System
    • YOLK SAC^FETUS
    • UPPER GI TRACT
    • TRICUSPID VALVE^PATIENT
    • TRICUSPID VALVE^FETUS
    • SYNOVIAL SPACE
    • HEART.VENTRICLE.RIGHT
    • VENTILATOR
    • ARTERIAL SYSTEM
    • BLADDER
    • EYE.LEFT
    02/07/11 The system (context) or body part about which the observation was made.
  • Patient, Control, or Donor (as part of system)
    • CONTROL
    • PATIENT
    • DONOR
    • BABY
    • FETUS
    02/07/11 Non-patient values for this axis should be used with care, or combinatorial explosion could result
  • Scale
    • QN - quantitative
      • 4, 7.4, 1:8
    • ORD - ordinal, the answers can be ranked
      • +/-, 1+, 2+, 3+ ….
      • mild, moderate, severe
      • none, rare, few, moderate, many, loaded
    • NOM - nominal, answers are coded but unranked
      • Stool appearance – liquid, formed
      • Skin color – pink, dusky, cyanotic
      • Chest tube type
    • NAR - answer is a two or more words of natural language, or as much as a paragraph of text
    02/07/11
  • Method
    • STATED – reported verbally
    • MEASURED – actually observed
    • CALCULATED – numeric calculation
    • US – ultrasound
    • EKG – electrocardiogram
    • ESTIMATED – an educated guess at the real value
    • HELIUM REBREATHING – helium rebreathing
    • SPIROMETRY – spirometry
    • MANUAL – done by hand
    • AUTOMATED – used an instrument
    02/07/11 Procedure used to make the measurement or observation. Only used when it makes an important distinction in sensitivity or specificity.
  • Putting it all together
    • Code Component Prop TIME System Scale Method
    • 8302-2 BODY HGHT LEN PT ^PATIENT QN
    • 3140-1 BODY SURF AREA PT ^PATIENT QN DERIVED
    • 8331-1 BODY TEMP TEMP PT MOUTH QN
    • 8319-6 BODY TEMP TEMP 12H^MIN XXX QN
    • 8629-8 Q WAVE DPT ELPOT PT HEART QN EKG
    • 8632-2 QRS AXIS ANGLE PT HEART QN EKG
    • 8642-1 PUPIL DIA LEN PT EYE.RIGHT QN AUTO
    • 21611-9 AGE TIME PT ^PATIENT QN EST
    • 21612-7 AGE TIME PT ^PATIENT QN REPORT
    • 19867-1 CAPACITY.VITAL VOL PT RESP SYS QN
    • 9279-1 BREATHS NRAT PT RESP SYS QN
    • 11882-8 GENDER FIND PT ^FETUS NOM US
    02/07/11
  • Use of XXX and {} (curly braces)
    • Old style
      • 8319-6 BODY TEMP TEMP 12H^MIN XXX QN
    • New style
      • 8319-6 BODY TEMP TEMP 12H^MIN {Body Loc} QN
    • LOINC codes of these styles imply that the code may be used in post-coordinated expressions
    02/07/11
  • Pre and post coordination with LOINC codes # 70 Dry Weight: Site #1 kg Weight: Site #2 kg 70 70 70 Dry Wet Ideal
  • Two ways to say the same thing
    • A single name/code and value
      • Dry Weight is 70 kg
    • Combination of two names/codes and values
      • Weight is 70 kg
        • Weight type is dry
    #
  • Model fragment in XML
    • Pre-coordinated representation
    • <observation>
    • <cd> Dry weight (LOINC 8340-2) </cd>
    • <value> 70 kg </value>
    • </observation>
    • Post-coordinated (compositional) representation
    • <observation>
    • <cd> Weight (LOINC 3141-9) </cd>
    • <qualifier>
    • <cd> Weight type (LOINC 8337-8) </cd>
    • <value> Dry (SNOMED CT 13880007) </value>
    • <qualifier>
    • <value> 70 kg </value>
    • </observation>
    #
  • Relational database implications # How would you calculate the desired weight loss during the hospital stay? Patient Identifier Date and Time Observation Type Observation Value Units 123456789 7/4/2005 Dry Weight 70 kg 123456789 7/19/2005 Current Weight 73 kg Patient Identifier Date and Time Observation Type Weight type Observation Value Units 123456789 7/4/2005 Weight Dry 70 kg 123456789 7/19/2005 Weight Current 73 kg
  • More complex examples
    • 9273-4 NEONATAL APGAR^ 2M POST BIRTH FCN PT ^PATIENT ORD
    • 9192-6 FLUID OUTPUT.URINE VRAT 24H URINARY TRACT QN
    • 11892-7 GESTATIONAL AGE TIME PT ^FETUS QN US.ESTIMATED FROM AC.HADLOCK84
    • 10105-5 ST SLOPE.LEAD V6 ELPOTRAT PT HEART QN EKG
    • 8431-9 INTRACHAMBER SYSTOLIC PRES PT HEART.VENTRICLE.LEFT.OUTFLOW TRACT QN
    • 8283-4 CIRCUMFERENCE. MAX LEN PT CALF.RIGHT QN
    02/07/11
  • Outline
    • LOINC background and goals
    • LOINC structure and content
      • Clinical LOINC
      • Examples
    • Attachments
    • Context specific hierarchies
    • Collections
    02/07/11
  • HL7 & the Claims Attachment Recommendation
    • HIPAA Legislation was passed in Aug 1996
    • Extended debate
      • Different motivations for payers and providers
    • Initial proposal to use X12 messages, HL7 Version 2 messages, LOINC
    • Notice of proposed rule making (NPRM) in Sept 2005
      • X12 messages
      • HL7 CDA Release 1 standard (probably will now be R2)
        • XML based standard for transmitting documents
      • LOINC codes
    • No final rule yet
    02/07/11
  • Unsolicited Attachment 02/07/11
  • Request for Additional Information 02/07/11
  • Organizations & Documents 02/07/11 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
  • Attachment Types Selected for HIPAA
    • Attachment types ultimately selected for development and HIPAA recommendation:
        • Ambulance
        • Emergency Department
        • Rehabilitative Services
        • Lab Results
        • Medications
        • Clinical Notes
    02/07/11
  • CDA: Semi- or fully-structured HIPAA Claims Attachments 02/07/11 Autoadjudicate Provider Payer Transcription * Scanned Paper or Document Imaging * Level 3 CPR Image + XML Semistructured Structured and coded Specific XML forms *
  • Outline
    • LOINC background and goals
    • LOINC structure and content
      • Clinical LOINC
      • Examples
    • Attachments
    • Context specific hierarchies
    • Collections
    02/07/11
  • Use cases for Context Specific Hierarchies
    • Roll-up in decision support
      • Body weight
      • Body height
      • Blood pressure
    • Basis for queries
      • “ All surgery notes”
      • “ All head x-ray reports”
      • “ All hematology lab results”
    • Control of data access
      • Tabs for document types
        • Radiology
          • (by body region) – Head, neck, chest, abdomen, …
          • (by modality) – X-ray, CT, Ultrasound, Scans, …
        • Documents
          • (by subject) – cardiology, ob-gyn, heme-onc, surgery, internal medicine, …
          • (by setting) – inpatient, ambulatory, home care, SNF, …
    02/07/11
  • Consultation Note Example
    • 11488-4 Consultation note Find Pt {Setting} Doc {Provider}
    • 34100-8 Consultation note Find Pt Critical care unit Doc {Provider}
    • 34101-6 Consultation note Find Pt Outpatient Doc {Provider}
    • 34101-6 Consultation note Find Pt Outpatient Doc General medicine
    • 34749-2 Consultation note Find Pt Outpatient Doc Anesthesia
    • 34104-0 Consultation note Find Pt Hospital Doc {Provider}
    • 34102-4 Consultation note Find Pt Hospital Doc Psychiatry
    • NewCD Consultation note Find Pt {Setting} Doc Internal medicine
    • 34764-1 Consultation note Find Pt {Setting} Doc General Medicine
    • 34776-5 Consultation note Find Pt {Setting} Doc Gerontology
    • 34781-5 Consultation note Find Pt {Setting} Doc Infect. Disease
    • 34795-5 Consultation note Find Pt {Setting} Doc Nephrology
    • 34797-1 Consultation note Find Pt {Setting} Doc Neurology
    02/07/11
  • Outline
    • LOINC background and goals
    • LOINC structure and content
      • Clinical LOINC
      • Examples
    • Attachments
    • Context specific hierarchies
    • Collections
    02/07/11
  • Issues related to “collections”
    • Two “kinds” of items within LOINC
      • Individual measurements/observations/data elements
      • Collections of measurements/observations/data elements
    • Different codes for orders versus results?
    • Different codes for narrative vs nominal?
      • Medication history – paragraph versus coded list
      • Want to have a single code to get all medication history
    • Two kinds of “collections” but different things
      • Panels (known explicit content)
        • Vital Signs, ABGs, CBC, Chem 7 panel (known explicit content)
      • Documents (vague or abstract content)
        • Operative note, discharge summary, consult
        • Bone marrow exam – text table of discreet data
        • Separate codes for: rtf, Word, pdf, scanned images?
    02/07/11
  • Proposed stragegy
    • For individual measurements
      • Continue to create codes that distinguish between character identifiers, strings, codes, dates, numbers
      • Create generic parents as needed, relate parent to children using new hierarchies
    • For collections
      • Continue to distinguish panels (explicit list of contained elements) from documents (ill defined or vague contents)
      • For documents, do not make distinct names based on narrative, nominal, pdf, Word, scanned image
    • Use the same codes for orders as for results
      • Just a code for “hematocrit”, no code for “hematocrit order” or “hematocrit result”
      • Use context to complete the meaning
    02/07/11
  • Literature References
    • McDonald CJ, Huff SM, etal. LOINC® a universal standard for identifying laboratory observations – a 5-year Update . Clinical Chemistry , 2003
    • 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.
    • 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.
    • 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.
    02/07/11