This document summarizes a presentation on the clinical document ontology (CDO) developed by LOINC. It describes the origins and development of having a standardized vocabulary for clinical document names, including empirical analysis of local document names. The presentation reviews the multi-axial model used by LOINC for document names, provides examples, and discusses ongoing evaluation and expansion efforts through collaboration. Future directions include further harmonization of CDO terms and analyzing document content.

1. Clinical LOINC Meeting
LOINC Tutorial
Documents
Daniel J. Vreeman, PT, DPT, MSc
Assistant Research Professor, Indiana University School of Medicine
Research Scientist, Regenstrief Institute, Inc
08.15.2011
dvreeman@regenstrief.org
© 2011

2. Overview
1. Origins of a Document Ontology
2. HL7/LOINC Model
3. Evaluation and Ongoing
Development
4. Future Directions
photo via Vernio77

3. Origins of a Document
Ontology

4. Local systems have idiosyncratic names…
Outpatient Pain Dr. Smith’s Tues Chronic Pain
Note
Pain Clinic Note
Clinic
…need a common, controlled vocabulary

5. 06/2000
• Document Ontology
Task Force
09/2003
• First Axis Values and LOINC
06/2005
Codes
• Expanded SMD Domain
10/2007
• Revised Axis
Value Approval
Ongoing
• Harmonization Efforts
• New Content Creation

6. Document Type Codes
Provide consistent semantics for names of
documents exchanged b/w systems
Preparation of
Display
Templates
Organization
Retrieval
Frazier P, Rossi-Mori A, Dolin RH, Alschuler L, Huff SM. The creation of an ontology of clinical document names. Stud Health Technol Inform. 2001;84(Pt 1):94-8.

7. What is a Document?
a collection of information
photo via striatic

8. Sections
Sentences
Sentences
Other content
an information collection
Different than a panel
enumerated, discrete elements
photo via karen horton

9. Clinical Notes
Clinical Note
A clinical document, produced by clinicians
spontaneously or in response to a request for
consultation.
Clinical Report
A clinical document, produced in response to an
order for a procedure.
Formal Document Ontology model and rules
apply to clinical notes, but not (yet) to reports.

10. Approach
Empiric analysis of >2000
document names
Mayo, 3M/Intermountain, VA in SLC, VA
in Nashville
Find the level of granularity that
best meets exchange use case
Photo via Jeffrey Beall

11. Ultra-specific local names
• Dr. Evil’s Friday Afternoon Pain
Clinic Note
Commonly
understood elements
• Outpatient Pain Clinic
Note

12. Local Codes and Names
Still probably needed
Can send both in HL7
Mapping to a standard enables:
Interoperability
Aggregation

13. Document Ontology Model
Multi-axial / Poly-hierarchical

14. Names are based on
expected information
content
NOT document format
photo via karen horton

15. Names Based on Content
Same LOINC code for…
…if information content is the same

16. Not Part of the Name
Author
Location of service
Date of service
Status (e.g. signed, unsigned)
Security/privacy flags (e.g. protected)
Updates or amendments to a document

17. Assume that these other
important attributes would
be sent in different fields of
the message

18. Model of Document Names
Subject Matter Domain
• e.g. Cardiology, Pediatric Cardiology, Physical Therapy
Role
• Author training/professional classification (not @ subspecialty)
• e.g. Physician, Nursing, Case Manager, Therapist, Patient
Setting
• Modest extension of CMS’s definition (not equivalent to location)
• E.g. Hospital, Outpatient, Emergency Department
Type of Service
• Service or activity provided to patient
• Eg. Consultation, History and Physical, Discharge Summary
Kind of Document
• General structure of the document
• E.g. Note, Letter, Consent

19. Rules for
Constructing Names
photo via Robert S Donovan

20. 1. Enumerated List
Document names are constructed from
enumerated lists of values for each axis.

21. 2. Document + One Other
Document name needs specification of a Kind
of Document value and at least one of the
other four axes.
Component
• <Type of Service> <Kind of Document>
Property
• Find
Time
• Pt
System
• <Setting>
Scale
• Doc
Method
• <SMD>.<Role>

22. 3. Combinations
Combinations from within an axis are allowed
where they make sense (SMD, Service).
Assessment + Plan

23. Example LOINC Names
Component
Prop
Time
System
Scale
Method
Group counseling note
Find
Pt
Hospital
Doc
{Provider}
Evaluation and management note
Find
Pt
Outpatient
Doc
{Provider}
Evaluation and management note
Find
Pt
{Setting}
Doc
{Provider}
History and physical note
Find
Pt
{Setting}
Doc
{Provider}
Initial evaluation note
Find
Pt
{Setting}
Doc
Physician
{curly braces} notation: send that content as a
separate item in the message (field or segment).

24. Hierarchy
Made a 1st pass Component hierarchy
– Based on Type of Service Axis
– Ignored Kind of Document
Multi-axial hierarchy is auto-generated
– Available as a separate download
Custom hierarchies (e.g. context-
specific) ones are easily imagined

25. Hierarchy in RELMA

26. Evolution,
Evaluation
We’re not done yet

27. Evolution
Ongoing evaluation and evolution
Exceptional contributions from Columbia
University and the VA
Expanded original SMD values with ABMS
specialty names and iterative discussion
More ontology additions from submissions

28. Iterative Evaluation
Case Study
NYPH-CUMC

29. Case Study
SMD
Role
Setting
Type Service
Kind of Doc
Overall
Distinct
Original
26.7%
99.9%
99.9%
43.5%
100%
23.4%
7.9%
CDO
(n=894)
Expanded
98.6%
100%
100%
99.9%
99.9%
98.5%
39.1%
CDO
(n=935)
1. Expanded CDO is better
2. Many local documents map to 1 LOINC
3. Inter-rater reliability was good
Hyun S, Shapiro JS, Melton G, Schlegel C, Stetson PD, Johnson SB, Bakken S. Iterative
evaluation of the Health Level 7--Logical Observation Identifiers Names and Codes
Clinical Document Ontology for representing clinical document names: a case report. J Am
Med Inform Assoc. 2009 May-Jun;16(3):395-9.

30. Nursing
SMD
Role
Setting
Type Service
Kind of Doc
Overall
Distinct
SMD ++
74%
100%
100%
100%
100%
74.5%
33%
CDO
(n=94)
Hyun S, Shapiro JS, Melton G, Schlegel C, Stetson PD, Johnson SB, Bakken S. Iterative
evaluation of the Health Level 7--Logical Observation Identifiers Names and Codes
Clinical Document Ontology for representing clinical document names: a case report. J Am
Med Inform Assoc. 2009 May-Jun;16(3):395-9.
In a separate analysis…
Section headings from nursing
documents that could be mapped
to existing LOINCs
Hyun S, Bakken S. Toward the creation of an ontology for nursing document sections:
mapping section names to the LOINC semantic model. AMIA Annu Symp Proc. 2006:364-8.

31. Case Study
German University Hospital

32. German University Hospital
Used LOINC v2.24 (original DocOnt terms)
86 Document Types (1.2 mil documents)
12%
Mapped to LOINC
44%
Not specific enough mapping
44%
No LOINC match
Dugas M, Thun S, Frankewitsch T, Heitmann KU. LOINC codes for hospital information
systems documents: a case study. J Am Med Inform Assoc. 2009 May-Jun;16(3):400-3.

33. German University Hospital
LOINC codes that existed for
documents in their set (by volume)

34. Ongoing Development

35. A Work-in-Progress
LOINC User’s Guide is definitive
source for current policy
Collaboration/discussion
Clinical LOINC Meetings
HL7 SDTC
Online

36. The Future
Great Scott!

37. Future Directions
More v1 and v2 axis value harmonization
Axis definitions
Extension to other Kind of Documents
Empiric analysis of document contents

38. photo via milos milosevic