Outline

LOINC background and goals LOINC structure and content

Clinical LOINC Examples

Attachments Context specific hierarchies

2/19/13

Important facts
LOINC 2.27 (June 2009) contains 55,056 codes
40,302 10,773 1,354 2,629 Lab LOINC codes Clinical LOINC codes Claims Attachment codes 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

2/19/13 2

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)
2/19/13 3

The Messaging Paradigm

System A

System B

2/19/13

HL7 Result Message (ORU)

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| Segment

Data Field Component

2/19/13

OBX: a name-value pair approach

A code that identifies the datatype of OBX-5
Other data fields include: date of observation, identity of provider giving observation, normal ranges, abnormal flags

OBX-5: Data

Status

OBX||NM|11289-6^^LN||38|C^^ISO+|||||F
A code that identifies the data in OBX-5 (Temp Reading) A code that identifies the units of numerical data in OBX-5
6

2/19/13

OBX: with a coded value

A code that identifies the datatype as a coded element

The code is from LOINC

The code is from SNOMED

OBX||CE|883-9^Blood Group^LN||58460004^Group O^SCT|

A code that identifies the data in OBX-5 (ABO Blood Group)

OBX-5: Data A code for Group O

2/19/13

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.

The Goal
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|

Agree on a universal coding system for clinical observations.

2/19/13 9

How terminologies fit into the model

LOINC attributes/observables SNOMED CT findings/values (mostly) and observables (some) First Data Bank - values RxNORM - values

2/19/13

10

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
2/19/13 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

2/19/13

12

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

2/19/13 13

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 someones 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)
2/19/13 14

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

2/19/13

15

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
2/19/13 16

Clinical LOINC Subject Areas

Vital Signs Hemodynamics Fluid Intake/Output Body Measurements Operative Notes Emergency Department Respiratory Therapy Documents (collections) Standard survey instruments
2/19/13

EKG (ECG) Cardiac Ultrasound Obstetrical Ultrasound Discharge Summary History & Physical Pathology Findings Colonoscopy/Endoscopy Radiology reports Clinical Documents Tumor Registry
17

LOINC Mascot

2/19/13

18

Outline
LOINC background and goals LOINC structure and content
Clinical LOINC Examples

Attachments Context specific hierarchies

2/19/13

19

General Form of Clinical LOINC Names LOINC codes are created systematically using a six axis model
<component> : <property> : <timing> : <system> : <scale> : <method>
8331-1 Body Temperature :TEMP :PT :MOUTH :QN

The first 5 parts are mandatory, but method is optional. Subparts of the six axes are created as needed in specific subject areas.
2/19/13 20

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
2/19/13 21

Component
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
22

2/19/13

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

2/19/13

23

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
2/19/13 24

Adjustments - ^ ^ as a separator
DIFFUSION CAPACITY.CARBON MONOXIDE ^ ^ ADJUSTED FOR HEMOGLOBIN DIFFUSION CAPACITY ^ ^ ADJUSTED TO BODY CONDITIONS

2/19/13

25

Kind of Property
The characteristic or attribute of the component that is measured, evaluated, or observed.
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)
26

2/19/13

Timing
The interval of time over which the observation or measurement was made.

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

2/19/13

27

System
The system (context) or body part about which the observation was made.
YOLK SAC^FETUS UPPER GI TRACT TRICUSPID VALVE^PATIENT TRICUSPID VALVE^FETUS SYNOVIAL SPACE HEART.VENTRICLE.RIGHT VENTILATOR ARTERIAL SYSTEM BLADDER EYE.LEFT
28

2/19/13

Patient, Control, or Donor (as part of system)

CONTROL PATIENT DONOR BABY FETUS
Non-patient values for this axis should be used with care, or combinatorial explosion could result
2/19/13 29

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
2/19/13 30

Method
Procedure used to make the measurement or observation. Only used when it makes an important distinction in sensitivity or specificity.
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
2/19/13 31

Putting it all together

Code Component Prop LEN TIME PT System ^PATIENT ^PATIENT MOUTH Scale QN QN QN QN QN QN QN QN QN QN QN NOM US
32

Method DERIVED

8302-2 BODY HGHT 3140-1 BODY SURF 8331-1 BODY TEMP 8319-6 BODY TEMP 8629-8 Q WAVE DPT 8632-2 QRS AXIS 8642-1 PUPIL DIA 21611-9 AGE 21612-7 AGE 9279-1 BREATHS 11882-8 GENDER
2/19/13

AREA PT TEMP PT ELPOT PT ANGLE PT LEN TIME TIME PT PT PT

TEMP 12H^MIN

XXX

HEART HEART EYE.RIGHT ^PATIENT ^PATIENT RESP SYS RESP SYS ^FETUS

EKG EKG AUTO EST REPORT

19867-1 CAPACITY.VITAL VOL PT NRAT PT FIND PT

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

2/19/13

33

More complex examples

9273-4 NEONATAL APGAR^2M POST BIRTH FCN PT ^PATIENT ORD 9192-6 FLUID OUTPUT.URINE VRAT 24H TRACT QN URINARY

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
2/19/13 34

Outline
LOINC background and goals LOINC structure and content
Clinical LOINC Examples

Attachments Context specific hierarchies

2/19/13

35

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 HITECH legislation reiterated a new deadline for attachments No final rule yet

2/19/13

36

Outline
LOINC background and goals LOINC structure and content
Clinical LOINC Examples

Attachments Context specific hierarchies

2/19/13

37

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,

2/19/13

38

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
2/19/13 39

Outline
LOINC background and goals LOINC structure and content
Clinical LOINC Examples

Attachments Context specific hierarchies

2/19/13

40

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 RefineStrategy 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.
2/19/13 41