A proposal for interoperable health
    information exchange with two
      Esperantos: ICF and LOINC®
             ICF an...
Overview
•  Origins of LOINC
  –  Background, growth, and the LOINC
     Community
•  A Proposal for Effective use of ICF ...
Origins of LOINC
The lingua franca of clinical observation exchange
Introduction
•  Regenstrief’s 35-year history
•  Indiana Network for Patient Care
   –    A working HIE for 15 years
   – ...
Indiana Network for Patient Care
LOINC Background
•  Logical Observation Identifiers Names and Codes
•  Organized by Regenstrief Institute in 1994
  –  Ong...
LOINC’s General Role
•  If an observation is a question, and the
   observation value an answer:
   –  LOINC provides code...
Indiana Network for Patient Care
    HL7 v.2.X Message
MSH|^~&|HOSPITAL_A|SAMPLE_HOSPITAL_A|||$YearMonthDay|||||||||||||||...
A brief digression about
data models…
“Flat” Data Model
Patient_ID Provider_ID Date        Height   Weight    Heart_Rate

1111      77777       2010 04 09   183...
“Stacked” Data Model
Patient_ID Provider_ID Date        Observation_Code Observation_Name   Value   Units

1111      77777...
Laboratory LOINC
 Chemistry                      Allergy Testing
 Urinalysis                     Blood Bank
 Toxicology   ...
Clinical LOINC
 Vital Signs                       EKG
 Hemodynamic Measurements          Cardiac Ultrasound
 Fluid Intake/...
The LOINC Community
Open, Nimble, Pragmatic
A Highly ‘Open Source’ Model
•  LOINC (the database) and RELMA (the
   mapping program) are available freely
   worldwide ...
10 new members per day
300+ new members per month
Translation Efforts
Downloads:   ~1100/month
US Adoption
A few key highlights
Consolidated Health Informatics
•  CHI Goal:
  –  Adopting interoperability standards for all US federal
     health agenc...
Other Key US Adoptions
•  eLINCS
  –  Messaging standard for results delivery from LIS to an EHR

•  NAACCR
  –  Volumes I...
A Proposal for Effective
use of ICF and LOINC
Making complementary strengths productive
General Observations
•  No computer-interpretable version of ICF
•  Links with other vocabularies (UMLS, SNOMED)
   don’t ...
Goals
•  Send a person (or population)’s ICF
   classification using same machinery as other
   health data
  –  To reach ...
Original Option 1
•  Simplest Approach: One LOINC code
  –  NNNN-N:Functioning Classification:Imp:^Patient:Pt:Ord:ICF
  – ...
Original Option 2
•  Full LOINC Modeling including panels for
   ICF Sets
•  Example: d420 – Transferring oneself
  –  N-N...
Original Option 2
•  Problems with this approach
  –  Labor intensive
     •  Each ICF component + qualifier combination
 ...
New Inspiration
Clinical Genomics Model
Further Inspiration
HL7 CDA Framework for
              Questionnaire Assessments
•  Specifies a document package representing the
   full ass...
Proposed ICF Result Package in LOINC
ICF	
  classificaBon	
  panel	
  
          	
  ICF	
  collecBon,	
  populaBon	
  desc...
Example ICF Result Package in LOINC
                                                                                      ...
Benefits of Nested Model
•  Uses HL7-LOINC messaging framework while minimizing
   redundant modeling
•  Accommodates ‘met...
Next Steps
•  Looking for collaborators with live
   systems that have a need to exchange ICF
   classifications electroni...
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2010 06 - LOINC-ICF

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A proposal for interoperable health information exchange with two Esperantos: ICF and LOINC. Presented at the 2010 NAAC ICF Conference: Enhancing our Understanding of the ICF.

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2010 06 - LOINC-ICF

  1. 1. A proposal for interoperable health information exchange with two Esperantos: ICF and LOINC® ICF and Biomedical Informatics – Part II Daniel J. Vreeman, PT, DPT, MSc Assistant Research Professor, Indiana University School of Medicine Associate Director of Terminology Services, Regenstrief Institute, Inc 06.24.2010 Copyright © 2010
  2. 2. Overview •  Origins of LOINC –  Background, growth, and the LOINC Community •  A Proposal for Effective use of ICF with LOINC
  3. 3. Origins of LOINC The lingua franca of clinical observation exchange
  4. 4. Introduction •  Regenstrief’s 35-year history •  Indiana Network for Patient Care –  A working HIE for 15 years –  200+ source systems –  10.5 million patients, 3 billion results –  Regenstrief: 3rd party convener •  Regenstrief is the 1st WHO collaborating center in medical informatics •  A fundamental challenge –  Local systems use idiosyncratic codes •  Vocabulary standards –  Provide the lingua franca of information exchange
  5. 5. Indiana Network for Patient Care
  6. 6. LOINC Background •  Logical Observation Identifiers Names and Codes •  Organized by Regenstrief Institute in 1994 –  Ongoing support from NLM and Regenstrief •  Covers domain of Clinical Observations –  Laboratory Observations (since 1995) –  Clinical Observations (since 1996) •  A universal code system that facilitates exchange, pooling, and processing of results
  7. 7. 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} 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
  8. 8. 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 thing in last 2W^LN|1|3^More than half the days^LN||||||||||||| OBX|2|ST|44255-8^Feeling down, depressed, or hopeless in last 2W^LN|1|2^Several days||||||||||||| … OBX|10|ST|44261-6^PHQ-9 Total Score^LN|1|11||||||||||||| A   A  
  9. 9. A brief digression about data models…
  10. 10. “Flat” Data Model Patient_ID Provider_ID Date Height Weight Heart_Rate 1111 77777 2010 04 09 183 cm 90.7 kg 74 bpm 2222 77777 2010 04 09 152 cm 49.9 kg 65 bpm One record per patient
  11. 11. “Stacked” Data Model Patient_ID Provider_ID Date Observation_Code Observation_Name Value Units 1111 77777 2010 04 09 1234-5 Body Height 183 cm 1111 77777 2010 04 09 2345-6 Body Weight 90.7 kg 1111 77777 2010 04 09 3456-7 Heart Rate 74 bpm 2222 77777 2010 04 09 1234-5 Body Height 152 cm 2222 77777 2010 04 09 2345-6 Body Weight 49.9 kg 2222 77777 2010 04 09 3456-7 Heart Rate 65 bpm One record per observation
  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  Ophthalmology Measurements  Clinical Documents  Radiology Reports  Document Sections  Patient Assessment Instruments
  14. 14. The LOINC Community Open, Nimble, Pragmatic
  15. 15. A Highly ‘Open Source’ Model •  LOINC (the database) and RELMA (the mapping program) are available freely worldwide for nearly any purpose •  Much work is done by volunteers •  Content additions are end-user driven
  16. 16. 10 new members per day 300+ new members per month
  17. 17. Translation Efforts
  18. 18. Downloads: ~1100/month
  19. 19. US Adoption A few key highlights
  20. 20. Consolidated Health Informatics •  CHI Goal: –  Adopting interoperability standards for all US federal health agencies •  Adopted LOINC as standard –  Laboratory result names (2003) –  Laboratory test order names (2006) –  Meds: structured product labeling sections (2006) –  Federally-required patient assessment instruments with functioning and disability content (2007) •  Same process that adopted ICF as a standard for functioning and disability domain
  21. 21. Other Key US Adoptions •  eLINCS –  Messaging 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 by 90% of US health plans to measure quality •  HITSP –  C80: vital signs, lab results, lab orders, genetic results, other results –  IS92: newborn screening –  C83: Patient assessment instruments (sections, questions, answers)
  22. 22. A Proposal for Effective use of ICF and LOINC Making complementary strengths productive
  23. 23. General Observations •  No computer-interpretable version of ICF •  Links with other vocabularies (UMLS, SNOMED) don’t address qualified codes •  Several ICF item collections –  Full version, short version, ICF-CY, ICF core sets, more… •  Challenge: ICF classification blends several observation question/answer pairs into 1 code –  d410.1302 (changing basic body position) is really 4 “observations”
  24. 24. Goals •  Send a person (or population)’s ICF classification using same machinery as other health data –  To reach ICF’s goals, you need to share data •  Maximize strengths of each terminology (minimize duplication of effort) •  Be informed by real world use –  Need some interested parties! •  Facilitate addressing challenges in ICF use –  Relationship to standardized assessments and clinical measures
  25. 25. Original Option 1 •  Simplest Approach: One LOINC code –  NNNN-N:Functioning Classification:Imp:^Patient:Pt:Ord:ICF –  Expected “answer” in OBX-5 would be a ICF classification •  Problems with Simplest Approach –  Still have blending of question/answer in OBX-5 –  No indications of sets
  26. 26. Original Option 2 •  Full LOINC Modeling including panels for ICF Sets •  Example: d420 – Transferring oneself –  N-N:Transferring oneself.Performance:Imp:^Patient:Pt:Ord:ICF –  N-N:Transferring oneself.Capacity:Imp:^Patient:Pt:Ord:ICF –  Expected “answers” in OBX-5 would be the ICF qualifiers 0  –  No  setup  or  physical  help  from  staff   1  –  Setup  help  only   2  –  One  person  physical  assist   3  –  Two+  person  physical  assist   8  –  ADL  acBvity  itself  did  not  occur  during  enBre  7  days  
  27. 27. Original Option 2 •  Problems with this approach –  Labor intensive •  Each ICF component + qualifier combination would be a different LOINC code (assessing different attributes) •  Keeping up with sets would be very difficult –  Some modeling challenges (e.g. anatomy) –  Negotiating IP issues
  28. 28. New Inspiration
  29. 29. Clinical Genomics Model
  30. 30. Further Inspiration
  31. 31. HL7 CDA Framework for Questionnaire Assessments •  Specifies a document package representing the full assessment “form” •  For each observation/answer, enables concurrent transmission of: –  Model of Use (LOINC) •  Exact measurement, as on the assessment –  Model of Meaning (SNOMED, ICF) [optional] •  Representation of the conceptual assertion in another (standard) terminology/classification –  Supporting Clinical Observations (LOINC, SNOMED) [optional] •  Data from the EHR that supports the assessment decision
  32. 32. Proposed ICF Result Package in LOINC ICF  classificaBon  panel    ICF  collecBon,  populaBon  descriptor,  observaBon  Bme  period,  other  descriptors    of  the  observaBon  period   1 to many ICF  classificaBon  results  panel    ICF  component,  any  applicable  qualifiers,  fully-­‐qualified  ICF  item   0 to many ICF  supporBng  clinical  observaBons  panel    Any  supporBng  clinical  measurements  for  that  ICF    classificaBon  (direct  measures,  assessment  scores,  etc)  
  33. 33. Example ICF Result Package in LOINC R/O/C   Example  Answers   NN-­‐N          ICF  classifica9on  panel   NN-­‐N          ICF  classificaBon  collecBon   R Full NN-­‐N          PopulaBon  descripBon   O Clinic population >65 years NN-­‐N          DuraBon  of  observaBon  period   O Point in time R 1 to N NN-­‐N          ICF  classifica9on  results  panel             R d450 NN-­‐N          ICF  code  stem   O d450.12 NN-­‐N          ICF  funcBoning  classificaBon   C 1 – MILD difficulty NN-­‐N          AcBviBes  and  parBcipaBon  performance  qualifier   C 2 – MODERATE difficulty NN-­‐N          AcBviBes  and  parBcipaBon  capacity  without                                assistance  qualifier   O 0 to N NN-­‐N          ICF  suppor9ng  clinical  observa9ons  panel   59460-­‐6          Morse  Fall  Risk  Total   55 0.9 m/sec 4195703        Mean  walking  speed  24H  
  34. 34. Benefits of Nested Model •  Uses HL7-LOINC messaging framework while minimizing redundant modeling •  Accommodates ‘meta-data’ about the result package •  Flexes to accommodate large or small sets of ICF codes •  Enables explicit connection between ICF classification and supporting clinical data •  Accommodates sending alternate identifiers (e.g. UMLS or SNOMED) for ICF components •  Could also use the ICF classification result panel in another context –  nested under a regular clinical observation to convey the higher level interpretation of that result
  35. 35. Next Steps •  Looking for collaborators with live systems that have a need to exchange ICF classifications electronically –  And want to used established messaging standards •  Present to Clinical LOINC Committee 7/16/2010 •  To infinity and beyond…

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