2015 06 03 - LOINC Introduction

Laboratory LOINC Workshop - Indianapolis, IN USA
An Introduction to LOINC
Daniel J. Vreeman, PT, DPT, MSc
Associate Research Professor, Indiana University School of Medicine
Associate Director for Terminology Services, Regenstrief Institute, Inc
@djvreeman
2015
Acknowledgements
LOINC Development Team
Clem McDonald, Jami Deckard, David Baorto, Katy Holck,
Swapna Abhyankar, Theresa Pritchard, Rachel Fuhr, Sara Armson
RELMA Development Team
John Hook, Anandhi Sowmyan, James Dennis
LOINC Committee
Supporters
NLM, Regenstrief Institute, Regenstrief Foundation, APTA,
RSNA, the LOINC Premium Members and Donors
Overview
1.
2.
3.
4.
Origins and purpose of LOINC

The LOINC way
LOINC today
Overview of implementation resources
photo via Vernio77
Origins of LOINC
McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.
Informatics Pioneers
40 years of EMR work
Indiana Network for Patient Care
Most comprehensive and longest tenured Health Information
Exchange (HIE) in USA
Regenstrief serves as neutral 3rd party

convener
Crash Test Dummies
Informatics Pioneers
40 years of EMR work
Most comprehensive and longest tenured Health Information

Exchange (HIE) in USA
Regenstrief serves as neutral 3rd party

convener
photo via nosha
The rain forest canopy is a

seamless web through which
arboreal creatures efficiently
move to reach the edible
fruits without any attention
to the individual trees.
photo via nosha
In each case, the goals are stymied

or delayed by the work and
expense of translating the Babellike proliferation of different codes
used by different sources for the
same tests even when the sources
comply with existing electronic
message standards.
Forrey AW, McDonald CJ, et al. Logical observation identifier names and codes (LOINC) database: a public use set of codes and names for electronic
reporting of clinical laboratory test results. Clin Chem. 1996 Jan;42(1):81-90. PubMed PMID: 8565239.
More than Meets the Eye
photo via chadlewis
Fundamental challenges:
Local systems have different ways of
identifying the same concept.
Things that look alike arent the same.
This problem would not

exist if all laboratories used
the same universal set of
test identifiers when
electronically transmitting
test results.
Forrey AW, McDonald CJ, et al. Logical observation identifier names and codes (LOINC) database: a public use set of codes and names for electronic
reporting of clinical laboratory test results. Clin Chem. 1996 Jan;42(1):81-90. PubMed PMID: 8565239.
Logical
Observation
Identifiers
Names and
Codes
A universal code system that facilitates exchange,
pooling, and processing of clinical data.
Established in 1994 by
Regenstrief Institute.
Vocabulary standard for
observation identifiers.
LOINC is like a bar code for

test data
WE DO
MEASUREMENTS
photo via puuikibeach
Laboratory LOINC
Top 10 Lab Domain Overview

Microbiology
Chemistry
Drug/Toxicology
Allergy
Chemistry - Challenge
Serology
Hematology
Antibiotic Susceptibilities
Cell Markers
Molecular Pathology
10,700
9,200
7,200
3,900
3,700
2,500
2,100
1,700
1,500
900
Clinical LOINC
If an observation is a question
and the observation value is
an answer
LOINC provides codes for questions
Where needed, other vocabularies

provide codes for answers
What is my patients
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
photo via Ed Yourdon

HL7 v2.x Message

HL7 v2.x Message
MSH|^~\&|HOSPITAL_A|SAMPLE_HOSPITAL_A|||$YearMonthDay|||||||||||||||
PID|||$patientId$||$patientName$||||||||||||||||||||
PV1|||||||$attendingDoctor$||$consultingDoctor$||||||||
OBR|1|||012^CBC/Auto Diff^HSPA^57021-8^CBC W Auto Diff^LN||$reqDate|||||||||
OBX|2|NM|123^WBC^HSP_A^26464-8^Leukocytes [#/volume] in Blood^LN||10.8|K/MM3|||||F|
OBX|3|NM|234^RBC^HSP_A^26453-1^Erythrocytes [#/volume] in Blood^LN||4.82|MIL/MM3|||||F|
OBX|4|NM|345^HGB^HSP_A^718-7^Hemoglobin [Mass/volume] in Blood^LN||15.7|GM/DL|||||F|
OBX|5|NM|456^HCT^HSP_A^20570-8^Hematocrit [Volume Fraction] of Blood^LN||45|%|||||||F|

HL7 v2.x Message

HL7 v2.x Message

HL7 v2.x Message
LocalCode^LocalName^CodeSystem^LOINCcode^LOINCname^CodeSystem

HL7 v2.x Message

HL7 v2.x Message

HL7 v2.x Message

HL7 v2.x Message
Codes for individual observations

Leukocytes [#/volume] in Blood by Automated count
Erythrocytes [#/volume] in Blood by Automated count
Hematocrit [Volume Fraction] of Blood by Automated count
and collections of observations

CBC W Auto Differential panel - Blood
Vital signs, weight and height panel

PHQ-9 quick depression assessment panel
Result with a Coded Value
OBX||CE|600-7^Bacteria Bld Cult^LN||56415008^Klebsiella pneumoniae^SCT

Data type of result
(OBX-5) is a coded
element

Data type of result
(OBX-5) is a coded
element
This code is from

LOINC
Code identifying this

observation
(what are these results?
Bacteria identified by
Blood Culture )

Data type of result
(OBX-5) is a coded
element
This code is from

LOINC
This code is from

SNOMED
Code identifying this

observation
(what are these results?
Bacteria identified by
Blood Culture )
Code identifying the result

(K. pneumoniae)
LOINC fits well with

other data standards
photo via Temari 09
The LOINC Way

Open. Nimble. Pragmatic.
Development Approach
Worldwide distribution at no cost
New terms requested by end-users
Welcome all comers
Committees are volunteers
Welcome all comers
Its free, but invaluable

Welcome all comers
Financial Support
Many sources
AHCPR, ASPE, CDC, CHCF, CMS, Hartford Foundation, IN
CTSA, Regenstrief Foundation*, Regenstrief Institute,
NCRR, NIBIB*, NLM*, LOINC User Community*
*active now
Today, the U.S. National Library of Medicine

(NLM) accounts for about 2/3 of our funding.
Major releases
twice per year
(June and December)
photo via striatic
4
5/ /24
6/ 24/ /19
2 1 9
6/ 3/ 99 5 |
1
7/ 28/ 99 5 | 1.0
1
9/14/ 1995 | 1 .0a
12 15 19 5 | .0
/2 /1 95 1. b
8/ 4/2 1/1995 | 1 0c
.
1229/ 8/1 99 | 1 0d
/3 19 99 5 | .0e
/ 9 6 1
1/ 1996 | | 1 .0f
10 8 6 1. .0
/9 /19 | 1 0h g
(
5//19 99 .0h 2)
2/ 1/197 7 | 1(3)
7/ 12 9 | 1 .0
9
2
8/ 3/ /19 8 | .0j-ai
6/ 19 99 1.
2/ 19999 | 10k
6/ 4/ 9 | 1 .0
13 20 | 1 .0 l
1/ /2 00 .0 m
1/ 1/ 00 | ma
31 20 0 1.0
7/ /2 01 | 1. n
0
0
1/1/2 01 | 2. 0
0
0
2/1/2 01 | 2. 0
2/ 1/ 00 | 2 01
19 20 2 .0
8/ /2 02 | 2. 3
0
0
9/1/2 02 | 2. 4
0
5/1/2 02 | 2.05
10 1/ 00 | 2 06
/ 20 2 .0
1/1/2 03 | 2. 7
0
0
2/1/2 03 | 2. 8
12 1/ 00 | 2 09
2
12/1/ 004 | 2.10
/ 20 4 .1
6/1/2 04 | 2. 1
12 1/ 00 | 2 12
/1 20 4 | .1
6 / 0 2 3
12 /1 2005 | .14
/2 /20 5 2.1
6/ 1/ 06 | 2 5
12 21 20 | .16
/ /2 0 2.
7/03/ 006|2 17
.
2
1/10/ 007|2 19
07 10 20 7| .21
2
12/06/2008| .22
/3 /2 09 2.2
2/ 0/ 00 |2 4
2
.
6/26/ 009|2 26
12 15 20 9| .27
2
06/29/2010| .29
2
12/30/2010| .30
/ /2 1 2.
6/30/ 010|2 32
12 30 20 1| .34
2
06/30/2011| .36
2
12/29/2012| .38
2
06/26/2012| .40
2
12/26/2013| .42
/2 /2 13 2.4
2/ 01 |2 4
20 4 .4
14|2.46
|2 8
.5
0
LOINC Codes Over Time by Release
80,000
70,000
10,000
LOINC Codes
Only Lab LOINC Codes
60,000
50,000
40,000
30,000
20,000
laboratory terms only
75,000 codeshavent
you finished yet?
Lots Cooking
Always more lab tests
Genetic testing
Patient reported outcomes
Translational research data
Document titles
Radiology reports
photo via liber
photo via liber
Deckard J, McDonald CJ, Vreeman DJ. Supporting interoperability of genetic data with LOINC. J Am Med Inform Assoc. 2015 Feb 5. PMID: 25656513.
Legal Stuff
http://loinc.org/terms-of-use
photo via 917press
Just kidding.
Copyright is a good thing for

standards.
Its the licensing part that is
sometimes interesting.
No cost
Worldwide
In perpetuity
Use
Copy
Distribute
Any purpose:
commercial
non-commercial
Encourages
translation into
other languages
CANNOT use any

Licensed Material to
develop or promulgate
a different standard for
orders or observations.
That would defeat

the purpose of
having a standard!
LOINC in action today
Data standards are like telephones.
They require a critical mass of users

before they become useful.
~ Clem McDonald, MD (1998)
photo via iboy_daniel
Our vision is for

LOINC to be
integrated into every
clinical information
system that shares or
aggregates data.
38,300+ registered users in 167 countries
loinc.org registered users

40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
8
1
2
3
8
1
2
3
9
0
4
9
0
4
0
1
1
1
0
1
1
1
0
1
1
0
1
1
/ /1/ /1/ /1/ /1/ /1/ /1/ /1/ /1/ /1/ /1/ /1/ /1/ /1/
1
/
6 12 6 12 6 12 6 12 6 12 6 12 6 12
loinc.org registered users

40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
6,000 new users per year
0
8
1
2
3
8
1
2
3
9
0
4
9
0
4
0
1
1
1
0
1
1
1
0
1
1
0
1
1
/ /1/ /1/ /1/ /1/ /1/ /1/ /1/ /1/ /1/ /1/ /1/ /1/ /1/
1
/
6 12 6 12 6 12 6 12 6 12 6 12 6 12
LOINC Translators
22 organizations.
Currently translations into 18 variants of 12 languages
Vreeman DJ, Chiaravalloti MT, Hook J, McDonald CJ. Enabling international adoption of LOINC through translation. J Biomed Inform.
2012 Aug;45(4):667-73. PMID: 22285984.
Adopted as National Standard

Australia
Mongolia
Austria
The Netherlands
Belgium
New Zealand
Brazil
Philippines
Canada
Portugal
Cyprus
Qatar
Estonia
Rwanda
Finland
Saudi Arabia
France
Slovakia
Germany
Slovenia
Iceland
Spain
India
Thailand
Malaysia
Turkey
Mexico
United States
Large Implementations
SIGA Sade project
7+ Provincial systems in Canada
8+ Regional Health Information Exchanges in Spain
ePSOS
Assistance publique - Hpitaux de Paris
Hong Kong Hospital Authority
Philippine Health Insurance Corporation
InFSE Project in 5 regions in Italy (LOINC Italia)
Many more...
Other Key Adoptions

Many big labs
All health-related federal agencies in USA
Lots of care organizations
Professional societies
Health information exchange networks
Insurance companies
EHR vendors
Instrument manufacturers (nascent)
For the last few years, the AP-HP has

been using the LOINC international
nomenclature
Thanks to this catalogue, the AP-HP
is able to use the nomenclature in its
treatment processes, whenever
biology analyses and test results are
requested.
Vandenbussche PY, Cormont S, Andr C, et al. Implementation and management of a biomedical observation dictionary in a large healthcare information system.
J Am Med Inform Assoc. 2013 May 1. PMID: 23635601.
The results of our work

validate the choice made to
develop a local dictionary
aligned with LOINC.
Members of the Korean National Standards
Committee have enthusiastically embraced LOINC
LOINCing in Hong Kong
Some ad hoc LOINCing
Talking about LOINC at the Thai Ministry of

Information and Communication Technology
Dr. Case leading some LOINCing in Cyprus
Support for LOINC in Ministry of Health Malaysia
Upstream standardization.
Ask your IVD vendor which LOINC codes
are appropriate for that test.
photo via Fishking_1
In USA, major driver of

eHealth standards adoption is
EHR Incentive Program
a.k.a. Meaningful Use

Blumenthal D, Tavenner M. The "meaningful use" regulation for electronic health records. N Engl J Med. 2010 Aug 5;363(6):501-4. Epub 2010 Jul 13. PubMed PMID: 20647183.
Stage 1
Stage 2
Stage 3
2011-2012
2014
2016
Data capture
and sharing
Advance clinical
processes
Improved care
outcomes
progressive requirements for data standards
LOINC adopted for:

1. View, download, transmit data to third party
2.Cancer case reporting to state registry
3.Send/receive electronic lab results in
ambulatory settings
4.Provide a care summary at care transition
5.Provide clinical summaries for patients
6.Submit reportable lab results to public health
Lab reporting to EHRs
Use in Quality Measures
LOINC Adopted For

Patient Characteristics
[Non-lab] Diagnostics studies
Patient experience
Family history
Functional status
Health record component
Interventions (that produce an assessment or measured results)
Laboratory tests
Physical exam
Patient preference
Risk evaluation
System resources (healthcare resources)
An Example Quality Measure

National Committee for Quality Assurance
Diabetes: Hemoglobin A1c

Poor Control
Percentage of patients 18-75 years of age with diabetes who had
hemoglobin A1c > 9.0% during the measurement period.
Find HbA1c in the EHR with LOINC
Proposed MU3
ONC 2015 Standards and Certification Criteria
Notice of Proposed Rule Making (NPRM)
March 30, 2015
118 pages.
119 mentions of LOINC.
Need LOINC for these Criteria

Computerized provider order entrylaboratory
Vital signs, body mass index, and growth charts
Clinical Decision Support
Patient-specific education
Social, psychological, and behavioral data
Transitions of care
Incorporate laboratory tests and values/results
Transmission of laboratory test reports
Data portability
Care Plan
Clinical Quality measures - record and export
Clinical Quality measures - import and calculate
View, download, transmit to 3rd party
Transmission to public health agencies - reportable lab tests and values
Transmission to cancer registries
Transmission to public health agencies - antimicrobial use and resistance reporting
Transmission to public health agencies - health care surveys
Consolidated CDA creation performance
Application access to Common Clinical Data Set
Electronic submission of medical documentation
FDA Adoption and

Promotion of LOINC
January 27, 2015 and May 14, 2015
Know LOINC? Get Hired!

June 1, 2015
Many unexpected
successes along the way
photo via heyyu
Everyone loves LOINC
photo via mccaughan
The LOINC Distribution

LOINC Table, Accessory Files, and Tools and
Resources for Implementers
loinc.org/downloads
LOINC Table
The main LOINC database content
One Record Per Term

Long Common Name
Cholesterol in LDL [Mass/volume] in Serum

or Plasma by Direct assay
Short Name
LDLc SerPl Direct Assay-mCnc
Class Type
Lab
Class
Chem
Example Units (local)
mg/dL
Example Units
mg/dL
Order/Obs
Both
A Rich Encyclopedia
Cells.HPV E6+E7 mRNA/cells [Presence] in
Cervix by Flow cytometry (FC)
Most human papilloma virus (HPV) genomes encode for eight major proteins, six
"early" (E1, E2, E3, E4, E6, and E7) and two "late" (L1 and L2). The "early" are regulatory in
function. E6 and E7 genes in high-risk HPV genotypes are known as oncogenes because
of their continuous expression, which leads to disruption of cell-cycle check points and
cell genome instability through alteration of cellular p53 and retinoblastoma protein
functions. This test identifies cervical cells containing HPV E6 and E7 polycistronic mRNA
using in situ hybridization with oligonucleotides specific for the mRNA transcripts. The
cells remain intact, and following fixation and permeabilization, the probes enter the
cells. The flow cytometer measures two things: 1. Quantification of E6 and E7 mRNA in
each cell and 2. The percentage of cells over-expressing E6 and E7 mRNA.
LOINC Accessory Files

Special representations of LOINC content
Accessory Files
LOINC Panels and Forms File
An export of key panels, survey instruments, and forms in a
detailed data structure.
LOINC Multiaxial Hierarchy File

Hierarchical organization of LOINC terms based on their axes.
Lab terms are organized first by Component, then by System.
LOINC Document Ontology File

Special file for the detailed naming conventions for clinical
document titles (e.g. Discharge Summary, Progress Note, etc).
Tools for
Implementers
photo via Robert S Donovan
loinc.org/mailing-lists
search.loinc.org
Alternate Language Search
Alternate Language Search
Everything in Italian!
forum.loinc.org
loinc.org/usage
@LOINC
@LOINC
loinc.org/slideshows
loinc.org/adopters
loinc.org/adopters
List your organization. Free!
RELMA
REgenstrief LOINC Mapping Assistant
RELMA Features
Browse LOINC content
Map local terms to LOINC
import/export
translate local words to LOINC-speak
manual/automated mapping
Search Window
Mapping Screen
22 organizations, 5 countries, 102,000 mappings
Dixon BE, Hook J, Vreeman DJ. Learning From the Crowd in Terminology Mapping: The LOINC Experience. Lab Med. 2015 Spring;46(2):168-74. PMID: 25918199.
LOINC Premium
Membership Program
members.loinc.org
Individual Memberships
Donations (Sponsorships)
Share the love.
Donate to LOINC.
members.loinc.org/donate
members.loinc.org/donate
Whats still free?
All the Usual Awesomeness

LOINC Table
Accessory Files
RELMA Program
Documentation
Web search app (search.loinc.org)
Participation in the LOINC Community
Access to submit new concepts to LOINC
In closing...
photo via janeandd
Glad youre here to at least

get your feet wet...
photo via gmayster01 on & off ...
Jump in!
photo via Justin Ornellas
The Race is On!
photo via ryarwood
Happy LOINCing!
photo via milos milosevic

2015 06 03 - LOINC Introduction

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Laboratory LOINC Workshop - Indianapolis, IN USA

Origins and purpose of LOINC

photo via Vernio77

Regenstrief serves as neutral 3rd party

Crash Test Dummies

Most comprehensive and longest tenured Health Information

Regenstrief serves as neutral 3rd party

photo via nosha

The rain forest canopy is a

photo via nosha

In each case, the goals are stymied

More than Meets the Eye

photo via chadlewis

This problem would not

LOINC is like a bar code for

Top 10 Lab Domain Overview

LOINC provides codes for questions

Where needed, other vocabularies

How fast does my

photo via Ed Yourdon

Indiana Network for Patient Care

Indiana Network for Patient Care

Indiana Network for Patient Care

Indiana Network for Patient Care

Indiana Network for Patient Care

Indiana Network for Patient Care

Indiana Network for Patient Care

Indiana Network for Patient Care

Indiana Network for Patient Care

Codes for individual observations

and collections of observations

Vital signs, weight and height panel

Result with a Coded Value

OBX||CE|600-7^Bacteria Bld Cult^LN||56415008^Klebsiella pneumoniae^SCT

Result with a Coded Value

Result with a Coded Value

This code is from

OBX||CE|600-7^Bacteria Bld Cult^LN||56415008^Klebsiella pneumoniae^SCT

Code identifying this

Result with a Coded Value

This code is from

This code is from

OBX||CE|600-7^Bacteria Bld Cult^LN||56415008^Klebsiella pneumoniae^SCT

Code identifying this

Code identifying the result

LOINC fits well with

photo via Temari 09

The LOINC Way

Its free, but invaluable

Worldwide distribution at no cost

Today, the U.S. National Library of Medicine

LOINC Codes Over Time by Release

Only Lab LOINC Codes

laboratory terms only

photo via liber

photo via 917press

Copyright is a good thing for

CANNOT use any

That would defeat

LOINC in action today

Data standards are like telephones.

They require a critical mass of users

~ Clem McDonald, MD (1998)

photo via iboy_daniel