MedInfo 2017 | Hangzhou City, Zhejiang Province, China

An Introduction to LOINC
the global vocabulary for tests, measurements, and observations in healthcare

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
Slide deck available at:
danielvreeman.com/medinfo2017
 Welcome to the
LOINC Community

photo via jamescridland | cc-by

 LOINC Overview

1. Origins and purpose

2. A flavor of its use
3. Resources and tools
4. Top tips for mapping

photo via Vernio77

 Why
interoperability
matters
photo via proimos
Interoperability
The ability of health IT to communicate, exchange
data, and use the information that has been exchanged.

Foundational Structural Semantic

HIMSS Definition. Available at: http://www.himss.org/library/interoperability-standards/what-is-interoperability

 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.
McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329. photo via nosha | cc-by-sa
To achieve that vision, we
need to incorporate many
different types of data
that are generated and
stored in many different
places and formats.
photo via nasamarshall | cc-by-nc
Patients move faster
and further than their
health information
Local systems have
different ways of
identifying the
same concept.

Only way to
overcome is with
standards.
LOINCs superhero
origin story

McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.
 Logical Observation Identifiers Names and Codes

The universal standard for

identifying health measurements,
observations, and documents.
Est. 1994
 Generous financial support
Many sources over the 20+ years of LOINC
AHCPR, ASPE, CDC, CHCF, CMS*, Hartford Foundation, IN
CTSA, Regenstrief Foundation*, Regenstrief Institute,
bioMrieux*, NCATS*, NCRR, NIBIB*, NIDDK*, NLM*,
LOINC User Community*
*active now

Today, the U.S. National Library of Medicine

(NLM) accounts for about 2/3 of our funding.
LOINC makes health
data more portable
and understandable
to different
computer systems.
LOINC is free,
but invaluable
Our vision is for
LOINC to be
integrated into every
clinical information
system that shares or
aggregates data.
 Collect once. Use many.
Clinical care, public health reporting, quality
management, clinical and epidemiological research, etc

photo via pagedooley | cc-by

 LOINC does
measurements
photo via puuikibeach | cc-by
Laboratory LOINC
Clinical LOINC
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
Discharge summary
 A rich trove of 84,000+ 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
work or daily life
24725-4 Head CT
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
Anatomy of a LOINC Term
18262-6:Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay

LOINC Code 18262-6

Component Cholesterol.in LDL

Property MCnc

Timing Pt

System Ser/Plas

Scale Qn

Method Direct assay

There are six major LOINC axes

Anatomy of a LOINC Term
8302-2:Body height:Len:Pt:^Patient:Qn:

LOINC Code 8302-2

Component Body height

Property Len

Timing Pt

System ^Patient

Scale Qn

Method

Method is the only optional axis

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
LOINC fits well with
other data standards

photo via Temari 09 | cc-by-nc

 Numeric Results
Using Hl7 version 2.x + LOINC

NM (numeric) means the

answer will be a numeric value Result Value
OBX||NM|26453-1^RBC # Bld^LN||4.82|10*6/uL|

Units
Same thing, different format
Using Hl7 FHIR + LOINC
 Coded Result Values
Using Hl7 version 2.x + LOINC + SNOMED CT

CE (coded element) Observation Identifier: LN means this code

means the answer is from LOINC
will be coded this is a blood culture

OBX||CE|600-7^Bacteria identified in Blood by Culture^LN||

17872004^Neisseria meningitidis^SCT

Answer Identifier: SCT means this

code is from
meningococcus (trouble) SNOMED CT
 One more thing
whats with the pig?
Grown in Indiana
Serving a global community
Translations
into 18 variants
of 12 languages
Translation into Chinese by Lin Zhang, a LOINC
volunteer from China.
50,500+ registered users from 167 countries

6,000 new users per year

Many kinds of LOINC Users
Referral / reference labs and radiology centers
Health-related federal agencies
Care organizations
Professional societies
Health information exchange networks
Insurance companies
Health IT vendors
Instrument manufacturers
Health app developers
Official national standard in 30+ countries
A small taste of LOINC
adoption around the world
Nictiz

Many national projects in the

Netherlands are using LOINC
Nationwide surveillance network for bacterial
typing and antibiotic resistance surveillance
National laboratory code list (selected by NVKC
and NVMM societies)
National special test registry (WieDoetWat-
database)

Nictiz is a LOINC Premium Member

http://www.cchi.gov.sa/en/Projects/SHIP/Pages/Dictionary.aspx
International Patient
Summary (IPS)
A non-exhaustive patient summary, specialty-
agnostic, condition-independent, but readily
usable by clinicians for the cross-border
unscheduled care of a patient.

Coordinated with the IPS project mandated to

CEN TC 251 by the European Commission.

Uses LOINC for:

Document type, sections, lab results, other clinical
observations, and radiology reports

http://international-patient-summary.net
Ministrio da Sade Brasil

Official adoption of LOINC for laboratory test

reporting

Used in large-scale regional data exchange

project in So Paulo for many years

Instituto HL7 Brasil has organized the

Portuguese LOINC translation

http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2073_31_08_2011.html
Thai Health Information
Standards Development Center

The study shows that LOINC can

be used and should be adopted in
Thailand.

Adoption of LOINC will facilitate

electronic health record
interoperability in Thailand.

http://www.this.or.th/files/interopbook.pdf
Pontongmak W, Kijsanayotin B, Min Thit W, Looareesuwan P. Mapping Thai local laboratory codes with LOINC: the preliminary report. Journal of the Thai Medical Informatics Association. 2015; 1: 44-50.
Pontongmak W, Kijsanayotin B, Rattanapradit A, Min Thit W. Mapping local clinical chemistry code with LOINC. Journal of the Thai Medical Informatics Association. 2015; 1: 38-43.
Saudi Arabia s Council of
Cooperative Health Insurance
Project aims to provide all 12 million
beneficiaries with first class medical
insurance services and improve
information exchange between various
stakeholders (beneficiaries, companies,
and health providers).

Adopted LOINC for lab orders/results

http://www.cchi.gov.sa/en/Projects/SHIP/Pages/Dictionary.aspx
Turkish Ministry of
Health

General Directorate of Health

Services recently mandated LOINC
for laboratory results in public,
university, and private health facilities

Maintain a Turkish translation of LOINC and

mapping to national billing codes (plus online
search/mapping tool).

http://www.cchi.gov.sa/en/Projects/SHIP/Pages/Dictionary.aspx
China
EHRSC Interoperability Profile: Clinical Laboratory Test
Results Sharing adopted LOINC; used in several regional
health information sharing projects

Beijing launched an integrated disease surveillance system

with lab data standardized with LOINC

Experts from six AAA-level hospitals in Zhejiang mapped

province social insurance codes to LOINC in this
interoperability framework

National Health and Family Planning Commission

(NHFPC) has sponsored studies evaluating LOINC

Jun Liang, MeiFang Xu, LiZhong Zhang, LanJuan Li, XiaoLin Zheng, DeRen Chen, ShengLi Yang, BaoLuo Li, Ou Jin, Zhou Ji, JunXiang Sun. Developing Interoperable Electronic Health Record Service in China. International Journal of Digital Content Technology and its Applications. 2011 (5):4 pp 280-295.

Xiaohui Zhang, Yun Ding, Zhijue Chen, Charles Schable. Development of an Integrated Surveillance System for Beijing. Advances in Disease Surveillance 2007;2:127
And so many more

Australia, Canada, Estonia, France, Italy, Malaysia,

New Zealand, Qatar, South Africa, etc
A few highlights from the USA
87 mentions of LOINC
 Lots of LOINC
Representing Patient Allergic Reactions
Representing Patient Family Health History
Representing Patient Functional Status and/
or Disability
Representing Imaging Diagnostics,
Interventions and Procedures
Representing Laboratory Tests
Nursing
Representing Nursing Assessments
Representing Nursing Interventions
Representing Outcomes for Nursing
Representing Patient Clinical
Problems (i.e., Conditions)
Sex at Birth, Sexual Orientation and
Gender Identity
Representing Patient Gender Identity
Representing Patient Sex (At Birth)
Representing Patient-Identified Sexual
Orientation
Social Determinants
Representing Financial Resource
Strain
Representing Level of Education
Representing Stress
Representing Depression
Representing Physical Activity
Representing Alcohol Use
Representing Social Connection and
Isolation
Representing Exposure to Violence
(Intimate Partner Violence)
Representing Patient Tobacco Use (Smoking
Status)
Representing Patient Vital Signs
U.S. Food and Drug
Administration

LOINC codes will be required for

laboratory test data in studies
starting after March 2018

Actively facilitating discussion

with IVD vendors about
identifying the LOINC codes
associated with their products
Centers for Disease Control
and Prevention

Longtime users of LOINC:

Electronic Laboratory Reporting

Case Reporting
Reportable Condition Mapping Table
Immunization Messaging
National Emergency Medical Services Info System
National Trauma Data Standards
National Healthcare Safety Network - Healthcare
Associated Infection (HAI)

https://phinvads.cdc.gov/
Banding together
for global good
photo via scarlatti2004_images | cc-by-sa
Many Active Collaborations
IICC
HL7
IEEE
SNOMED International
RSNA
CDISC
 The LOINC
Distribution
LOINC Table, Accessory Files, and Tools and
Resources for Implementers
Major releases
twice per year
(June and December)

photo via striatic | cc-by

 LOINC Codes Over Time by Release
90,000
LOINC Codes

80,000 Only Lab LOINC Codes

70,000

60,000

50,000

40,000

30,000

20,000
laboratory terms only
10,000

0
Lots cooking
Always new lab tests
Public health: emergent issues, surveillance, case reports
Document titles
Patient reported outcomes
Cardiovascular and other clinical measurements
New data models for genetics [HL7]
Structured path reporting for cancer [CAP, ICCR]
Patient reported outcomes [PCORI]
Social determinants of health [many]
MANY active collaborations with other orgs
photo via liber | cc-by
LOINC grows
because USERS ask
 Last Year:
New term requests from 50+ organizations in 14 countries
 LOINC Table
The main LOINC database content
 One Record Per Term
Cholesterol in LDL [Mass/volume] in Serum
Long Common Name
or Plasma by Direct assay
Short Name LDLc SerPl Direct Assay-mCnc

Class Type Lab

Class Chem

Example UCUM Units mg/dL

Status Active

Order/Obs Both
LOINC Accessory Files
Special representations of LOINC content
 Accessory Files
LOINC Part File
LOINC Answer File
LOINC Panels and Forms File
LOINC Document Ontology File
LOINC Multiaxial Hierarchy File
LOINC/IEEE Medical Device Code Mapping File
LOINC/RSNA Radiology Playbook File
LOINC/SNOMED CT Expression Association and Map Sets
Legal Stuff
http://loinc.org/license
 LOINC License
No cost use
Worldwide
In perpetuity
Commercial or noncommercial
purposes
Encourages translation
One major prohibition
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!
 Read more about
Regenstriefs approach
to licensing LOINC
danielvreeman.com/licensing-loinc

Chinese translation available

A big toolbox for
Implementers
All available at loinc.org

photo via Robert S Donovan | cc-by-nc

Many free
resources:
RELMA
search.loinc.org
Community resources
Reference material
LForms
FHIR Vocabulary server
and more!
loinc.org/members
An exceptional value

Takes as input
Local test codes, names, units, and mappings

Returns
Spreadsheet with issues detected by the evaluation process
Sample of Evaluation Rules
Unknown local units
Deprecated LOINC
Discouraged LOINC
Property/units mismatch
Scale/units mismatch
Concentration missing denominator
What LOINC Essentials covers
LOINC basics

A framework and techniques for picking out the subtle

but important distinctions between LOINC terms

Step by step guidance for mapping with RELMA

Best practices in LOINC mapping and how to set

yourself up for success in the long run
Disclosure
Im the author of the book LOINC Essentials
published by Blue Sky Premise, LLC where I
serve as President.

Net profit going to a special charitable project:

danielvreeman.com/build-a-school
 Top 3 Tips for
Mapping to LOINC
Tip 1: Not all juice is
worth the squeeze
In standards, Pareto principle > Long Tail
photo via elwillo | cc-by
Pareto Principle 100%

Cumulative Laboratory Observation Volume (%)

90%

80%

70%

A few tests account for most volume

60%

50%

40%

30%

70% of tests take 30% of mapping time 20%

10%

0%
0 500 1000 1500 2000 2500 3000 3500 4000

Not all variables will have a LOINC Number of Laboratory Observation Codes (N)

Vreeman DJ, Finnell JT, Overhage JM. A rationale for parsimonious laboratory term mapping by frequency. AMIA Annu Symp Proc. 2007 Oct 11:771-5. PMID:
18693941.
 Tip 2: Go upstream
Let all the downstream data recipients benefit
photo via Fishking_1 | cc-by
https://ivdconnectivity.org/livd
Tip 3: Dont make
assumptions
photo via tgerus | cc-by-sa
Ambiguous test names are the norm

Units of measure are critical

You must know the specifics of what

this test actually measures

Use local experts, package inserts, etc

Sample results can help:
identify the correct LOINC Scale
get the observation/result boundary correct

Does this test measure something quantitatively?

Does it only identify positive/negative?
Does it identify or classify what was found?
Complete Top 10 Tips available at:

danielvreeman.com/tips
Chinese translation available

Happy LOINCing!

danielvreeman.com/medinfo2017