LOINC/RSNA Playbook Summary for U.S.

Department of Defense and National Institutes of Health

LOINC/RSNA Playbook
Intro to LOINC and RSNA Collaboration

Daniel J. Vreeman, PT, DPT, MS

Regenstrief-McDonald Scholar in Data Standards
Indiana University School of Medicine

Director, LOINC and Health Data Standards

@djvreeman Regenstrief Center for Biomedical Informatics

2017
 LOINC
Universal standard for identifying health
measurements, observations, and documents

Makes data more portable and understandable to

different computer systems

Developed by the Regenstrief Institute, Inc

Its free, but invaluable

 A rich trove of 83,000+ standardized variables
Genetics Lifestyle

21654-9 CFTR gene targeted mutation analysis

24475-6 F2 gene c.20210G>A [Presence] 41950-7 Number of steps in 24 hour Measured

75547-0 Noninvasive prenatal fetal aneuploidy 75296-4 Carbohydrate intake 24 hour Estimated
and microdeletion panel based on Plasma cell- 82289-0 Rating of perceived exertion [Score]
free+WBC DNA by Dosage of chromosome-specific
circulating cell free (ccf) DNA 72166-2 Tobacco smoking status NHIS

82245-2 Chromosome region 22q11.2 deletion in 64098-7 Distance walked in 6 minutes

Amniotic fluid or CVS by FISH

Lab and clinical Environmental

82464-9 Mosquito count [#] in Environmental
specimen
4548-4 Hgb A1c MFr Bld
67784-9 Individuals below poverty line Neighborhood
8462-4 Diastolic blood pressure 63736-3 Materials to which you were exposed in your
24725-4 CT Head work or daily life
63805-6 How long did you handle paints or solvents
57021-8 CBC W Auto Differential panel - Blood
yourself?
8633-0 QRS duration 67640-3 My teachers believe that I can do well in
my school work
Translations
into 18 variants
of 12 languages
50,000 registered users from 167 countries

6,000 new users per year

Official national standard in 30+ countries
LOINC Radiology

photo via Karen Roe

In diagnostic imaging,
LOINC provides codes for:

Ordered (and returned) imaging study

Sections within a report
Measurements or observations made
Diagnostic Imaging Report
Structure from things like:
 Document Level Codes
CT Abdomen
MR Brain W & WO Contrast IV
XR Orbit for foreign body
This is our
bread and
butter
Recommended in ONCs ISA

Prior work showed LOINCs good coverage (91-92%) of

the codes found in local radiology systems.
Vreeman DJ, McDonald CJ. Automated mapping of local radiology terms to LOINC. AMIA Annu Symp Proc. 2005:769-73. PubMed PMID: 16779144.
Vreeman DJ, McDonald CJ. A comparison of Intelligent Mapper and document similarity scores for mapping local radiology terms to LOINC. AMIA Annu Symp Proc. 2006:809-13. PubMed PMID: 17238453.
Radiology Procedure Terms
> 5400 active terms in v2.61

Modality # LOINC Terms

CT 794
Mammography 158
MRI 871
Nuclear Medicine 500
Ultrasound 505
XR 1898
Fluoroscopy 681
 Sections within a Report
18785-6 Reason for study
55108-5 Clinical presentation
55111-9 Current imaging procedure descriptions
11329-0 History general
18782-3 Study observation (Findings)
55107-7 Addendum
55109-3 Complications
55114-3 Prior imaging procedure descriptions
55113-5 Key images
19005-8 Impressions
18834-2 Comparison study
18783-1 Recommendation
55115-0 Requested imaging studies information
55112-7 Document summary
55110-1 Conclusions
Measurements / Observations
38261-4 Hip DXA Bone density
38264-8 Hip DXA [T-score] Bone density
53626-8 CT Cerebral atrophic index
8294-1 Chest XR Diameter.anterior-posterior

In other domains, this is LOINCs

main content
LOINC Radiology Model
General Principles
Multiple Levels of Specificity
Views
named, counted, no specification
Laterality
right, left, bilateral, unilateral, unspecified
Contrast
W, WO, WO&W, unspecified
Anatomy of a LOINC Term
37842-2:View AP:Find:Pt:Shoulder:Doc:XR

37842-2 LOINC Code

View AP Component
Find Property Measured
Pt Timing

Shoulder System
Doc Scale

XR Method

There are six major LOINC axes

 LOINC Radiology Naming
Radiology names are constructed within the six
major, and up to four minor, attributes of the LOINC
concept model.

Circa ~2000, developed some specialized

conventions for radiology, expressed as a syntax and
consistent order in existing attributes.

Unification process made these specialized radiology

conventions explicit as new structured attributes.
 LOINC Names
Fully-Specified Name
Multisection^WO & W contrast IV:Find:Pt:Chest:Doc:CT

Long Name
CT Chest WO and W contrast IV

Short Name
CT Chest WO+W contr IV
LOINC/RSNA Playbook
Governance
Goal: single integrated governance process for
managing the unified terminology
Transitioning into an ongoing,
sustained activity

Jointly maintained and governed by the

two organizations.

Agreed to create the LOINC/RadLex

Committee, which oversees the
development, use, and modification of
The LOINC/RSNA Radiology Playbook.
 Committee Structure
Co-chaired by RI and RSNA

Each co-chair appoints (3) additional committee

members.

Co-chairs, by mutual agreement, will select up to three

(3) at-large members representing other stakeholders.

Total number of committee members will thus not

exceed eleven (11).
 Decision-making
Operation similar to existing LOINC and RSNA Committees

Sets overall policies, reviews hard cases, etc

Consensus-driven where possible, voting on big changes

In-scope topics include:

Whether to include or exclude edge case terms from the LOINC/RSNA Radiology
Playbook

Changes to the information model for the LOINC/RSNA Radiology Playbook

Editorial control over LOINC/RSNA Radiology Playbook User Guide
 Requests for New Content
Requests for new procedure codes received from any
user (using template)

Triage/processing by RI

Modeling questions issues discussed by Committee

Coordinated mapping (may need new RIDs by RSNA)

Maintenance of Core set jointly decided

Organizational Prerogatives
Create/distribute other resources,
services leveraging joint work

Training/education

Whether to expand collaboration in

areas outside Playbook
Creating a HIE-based prior
CT alerting system
NLM funded 5R01LM012196-02
Terminology Services to Reduce Avoidable CT Imaging

DV serves as consultant on this award

Healthix, a large New York City area
HIE is mapping all local institution
exam codes to LOINC.

Mapping is complete for top 200

diagnostic codes for 25 of 41 sites

Intent is to drive an order-time, HIE-

based alerting system for same,
similar, or proximate CT studies
Current award is focused on CT, but
anticipate expanding to other modalities

Current study is evaluating fitness of

LOINC/RSNA modeling/attributes for
this use case.

Same/Similar/Proximate is based on
modeling of Anatomy in procedure
name and hierarchical relationships
 Alert firing example
About to order
CT Neck without IV contrast

Same
(obvious)

Similar
CT Neck with IV contrast

Proximate
CT Head without IV contrast
 Lessons
This use case informed our
representation of Region Imaged and
Imaging Focus

The large scale mapping effort

generated new term requests, which
helped exercise our governance model
Adoption Challenges
Common implementation issues
Mapping might not be
rocket science, but
It does require specialized expertise and
dedicated resources
Problem 1
Variation abounds
Radiology term names are more
descriptive than lab tests, but

Local nomenclature is still the

wild wild west.

photo via mikemartelli

Variations in kinds of specificity
laterality, views, contrast, etc

Many systems invent multiple

codes for the same test to
distinguish facilities
ZXR1234 STERNOCLAVICULAR JOINTS MIN 3V
CXR1234 STERNOCLAVICULAR JOINTS MIN 3 V
VXR1234 STERNOCLAVICULAR JOINTS MIN 3VWS
XRW1234 STERNOCLAVICULAR JOINTS MIN 3 VI
photo via mikemartelli
Problem 2
Its an ongoing journey
Across many INPC
institutions, in 2 years after
go live we saw half as many
new local terms appear as
what we started with.
Vreeman DJ, Stark M, Tomashefski GL, Phillips DR, Dexter PR. Embracing change in a health information exchange. AMIA Annu Symp Proc. 2008 Nov 6:768-72.
For radiology terms, in 2
years after go live we saw
71% as many new local
terms appear as what we
started with.
Vreeman DJ, Stark M, Tomashefski GL, Phillips DR, Dexter PR. Embracing change in a health information exchange. AMIA Annu Symp Proc. 2008 Nov 6:768-72.
 900
New Post-Implementation Local Terms (n)

800

700

600

500

400

300

200

100

0
0 2 4 6 8 10 12 14 16 18 20 22 24
Months Post Initial System Implementation
Vreeman DJ, Stark M, Tomashefski GL, Phillips DR, Dexter PR. Embracing change in a health information exchange. AMIA Annu Symp Proc. 2008 Nov 6:768-72.
Why all the change?
Source system testing may have
changed

Source system codes may have changed

Standard terminologies evolve over time

 Dissemination Activities
Getting the word out

photo via Stig Nygaard

Under Development
Landing page on loinc.org/radiology

photo via shutterrunner | cc-by-nc