LOINC Conference Winter 2017 | Indianapolis, IN USA

LOINC for Beginners

Daniel J. Vreeman, PT, DPT, MS, FACMI
Regenstrief-McDonald Scholar in Data Standards
Indiana University School of Medicine

Director, LOINC and Health Data Standards

@djvreeman Regenstrief Center for Biomedical Informatics

2017
 High Level Schedule

1. An overview of LOINC
2. The LOINC Concept Model and
other Data Structures
3. The LOINC Distribution
4. Quick tips for mapping

photo via Vernio77

Disclosure
Im the author of the book LOINC Essentials published
by Blue Sky Premise, LLC where I serve as President.

Not a NYT Best Seller. Net profit going to a special

charitable project: danielvreeman.com/build-a-school

PI on a contract from bioMrieux for LOINC content

 Objectives
When its all said and done, youll be able to

1. Explain the primary purpose and scope of

LOINC
2. Identify and select the key implementation
tools appropriate for your use of LOINC

photo via Vernio77

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

LOINCs superhero
origin story

McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.
 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
Connecting Many Data Sources
Social and community determinants

Lifestyle and behavioral

Health history

Patient-generated
EHR
Genetics
Basic science
photo via Heather | cc-by-sa
The big problem
MO MONEY MO PROBLEMS
 data
It's like, the more money
we come across
The more problems we see
MO DATA MO PROBLEMS
Problems
Health IT systems often lack
common mechanisms for MO DATA MO PROBLEMS

exchanging data.

Even when they do, they use

different ways of identifying the
same concept.

Only way to overcome these problems is

with data standards
 Life without LOINC
CODE NAME
AGTCE Angiotensin Converting Enzyme
5523 ACE SerPl Qn
ACE ACE
22441 AngioTens Conv Enz
99234 ACE (angiotensin)
25284D Angiotensin-1-Converting Enzyme
2737317 ACE (serum)
6881A Angiotensin Converting Enzyme, Ser
3800ACE ANGIOTENSIN CONVERTING ENZYME, S
77934A Angio Convt Enzym
919109 ACE, SERUM
34ACE Angiotensin Con. Enz
ANGCE Angiotensin CE
6621456 Angio. Conv. Enzyme
photo via chadlewis | cc-by-sa
Reality:
patients move faster and further
than their health information
The solution
Standards make
health data more
portable and
understandable to
different computer
systems.
Syntax Standards
Messages, Documents, APIs
HL7v2, C-CDA, FHIR
Also called technical standards

Semantic Standards
Vocabulary/code systems
LOINC, SNOMED CT, RxNorm, ATC, ICD, etc
The global standard for
identifying health
measurements,
observations, and
documents.

Est. 1994
Forrey AW, McDonald CJ, DeMoor G, 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. PMID: 8565239.
LOINC is
a freely available global standard

delivered with a rich set of

implementation tools

used by a diverse global community

who propel its continuous development.

LOINC is free,
but invaluable
We do measurements
LOINC is focused on one piece of
the interoperability puzzle

photo via puuikibeach| cc-by

 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
Laboratory LOINC
Clinical LOINC
Codes for individual observations
6690-2 Leukocytes [#/volume] in Blood by Automated count
2339-0 Glucose [Mass/volume] in Blood
29463-7 Body weight
55423-8 Number of steps in unspecified time Pedometer

Codes for collections (panels and documents)

57021-8 CBC W Auto Differential panel - Blood
34565-2 Vital signs, weight and height panel
44249-1 PHQ-9 quick depression assessment panel
36813-4 CT Abdomen and Pelvis W contrast IV
18842-5 Discharge summary
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
 {
"resourceType": "Observation",
"id": "body-height",
"meta": {
"profile": [
"http://hl7.org/fhir/StructureDefinition/
vitalsigns"
]
},
"text": {
"status": "generated",
"div": ""
},

Same thing.
"status": "final",
"code": {
"coding": [
{
"system": "http://loinc.org",

Different format.
"code": "8302-2",
"display": "Body height"
}
],
"text": "Body height"
},

Using Hl7 FHIR + LOINC

"subject": {
"reference": "Patient/example"
},
"effectiveDateTime": "1999-07-02",
"valueQuantity": {
"value": 66.899999999999991,
"unit": "in",
"system": "http://unitsofmeasure.org",
"code": "[in_i]"
}
}
 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
photo via Jonathan McIntosh | cc-by-sa

But I love maintaining my local dictionary,

what will happen to my precious codes?
Relax

OBX||NM|123^RBC^MyHosp^26453-1^RBC # Bld^LN||4.82|10*6/uL

Local Code LOINC Code

photo via Julien Haler | cc-by
 The LOINC Concept Model
The Fully Specified Name is the key

photo via quinnanya | cc-by-sa

 LOINC Term
A representation of a question about a
clinical phenomenon that can be
observed or measured.

Two essential attributes:

LOINC Code
LOINC Fully Specified Name
 LOINC Code
18262-6
The unique, permanent identifier that
serves as a computer processable
representation of a LOINC Term

Sequential hints at relative age

Penultimate dash
Final character is Mod-10 check digit
Carries no intrinsic meaning
Once released, never removed
LOINC Names
Julius Winfield Erving II
The Doctor
Dr. J
 LOINC Name
The visible display text of a
LOINC Term.

A LOINC Name provides

the human-readable text rendering
of its associated LOINC Code.
Official LOINC Name Types
Fully-Specified Name (FSN)
Mapping

Long Common Name (LCN)

Primary display name

Short Name
Column header, old-school systems with character limits
 Example LOINC Names
Fully-Specified Name (FSN)
Urea nitrogen:MCnc:Pt:Ser/Plas:Qn:

Long Common Name (LCN)

Urea nitrogen [Mass/volume] in Serum or Plasma

Short Name
BUN SerPl-mCnc
LOINC Fully Specified Name
Includes the info necessary to distinguish
among clinically important differences

Defines the essential uniqueness of each

term in LOINC

Recommended name to help you choose

the right LOINC term
NOT part of a LOINC Name
Reason for the test (disease it diagnoses)
Testing instrument
Specific details about the specimen
Priority (e.g. STAT)
Where testing was done
Who did the test
Test interpretation
Anything not part of naming the test
Stuff carried in other parts of HL7 message
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

 Component
The substance or entity that is
measured, evaluated, or observed

Examples
Component
Sodium
Glucose
Brucella sp. identified
HIV 1 p24 antigen
Cytomegalovirus antibody
Body weight

Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay

 Component Subparts
Analyte Name^Challenge^Adjustments

Formal analyte name Calcium

Specify subanalytes Coronavirus Ag
May have subclasses Calcium.ionized

Challenge 1H post 100 g Glucose PO

Chemical or physiologic stimulus <time delay>post<challenge type>
given before analyte is measured

Adjustments to patients actual body temperature

 Property
The characteristic or attribute of
the analyte that is measured,
evaluated, or observed.

Example Properties
LOINC Abbreviation Property Example units
MCnc Mass concentration mg/dL
SCnc Substance concentration umol/L
MCnt Mass content mg/g
CCnc Catalytic concentration U/L
Prid Presence or identity

Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay

Mapping Caution!

photo via SMcGarigle | cc-by

The Property is the most difficult axis.

If youre mapping, spend the time to

dig into understanding it.

For all quantitative measurements,

you must choose a LOINC with a
Property that reflects the reported
units of measure.
 Has a whole chapter on LOINC Property and
another chapter with detailed examples of
using Property to locate the right LOINC code

danielvreeman.com/loinc-essentials
 Timing
The interval of time over which the
observation or measurement was made

Examples
LOINC Abbreviation Time Aspect
Pt Point in time
12H 12 hour collection
24H 24 hour collection
7D 7 days (look back period)

Tip: If Timing != Pt, Property is often a Rate

Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay
 System
The system (context) or specimen type
upon which the observation was made.

Examples
LOINC Abbreviation System
Bld Whole blood
Ser/Plas Serum or plasma
Tiss Tissue
Unknown, unspecified in the test name, and/or
XXX
specified in another part of the message.
*See LOINC Users Guide for further discussion
Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay
photo via AlishaV | cc-by
 Super System
System^Supersystem

Super System
Patient is the default (not specified)
Supersystem identifies a sample from a source other than the patient whose
record the result is being store in

LOINC Abbreviation Super System

BPU Blood product unit
Fetus Fetus
Donor Donor

818-5:A Ag:ACnc:Pt:RBC^BPU:Ord:
11670-7:Blood flow.mean:Vel:Pt:Aortic arch^fetus:Qn:US.doppler
 Scale
A classification of the result type

Examples
LOINC Abbreviation Scale
Qn Quantitative * can have operators

Ord Ordinal
Nom Nominal
Nar Narrative
Doc Document

Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay

photo via puuikibeach| cc-by
 Method
A classification of how the analyte was
measured or the information was obtained

Only needed if interpretation affected

different normal ranges, test sensitivities, etc
Specified at a generic level
LOINC Abbreviation Method
IA Immunoassay
LC/MS/MS Liquid Chromatography-Tandem Mass Spectrometry
Molgen Molecular genetics
CT Computer tomography
Estimated Estimated
Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay
photo via puuikibeach| cc-by
Advanced LOINC
Structures
A brief overview
 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
A big toolbox for
Implementers
All available at loinc.org

photo via Robert S Donovan | cc-by-nc

Many free
resources:
LOINC Table
RELMA
search.loinc.org
Community resources
Reference material
FHIR Vocabulary server
and more!
Most require a free loinc.org account
 LOINC Table
The main LOINC database content
Two Flavors:

Core: crucial fields with stable structure

Full: all the LOINC term attributes

Both come with MapTo file for

traversing deprecated to
superseding terms
 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

Each has a detailed ReadMe and Release Notes

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

Need a loinc.org account
Need Windows
Need admin privileges
Install RELMA!
 RELMA Highlights
Browse LOINC database
Map local codes to LOINC
import/export
translate local words to LOINC-speak
powerful searching capabilities
review all the details about a LOINC term
Maintain your mappings
Submit new LOINC term requests
RELMA Search Screen
search.loinc.org
Pros
Always up to date
Nothing to install
Fast loading
Easy access to detail pages
Same search syntax as RELMA
Saves settings
Cons
Doesnt import local terms
Doesnt store mappings
Two more resources to
help implement LOINC
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
Two Quick Tips for
Mapping to LOINC
Tip 1: 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,

sample results, 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?
Tip 2: Plan to stay
up to date

photo via Arul Irudayam | by-nd

LOINC recommends
that users update to
the current version of
LOINC within 90 days
of its publication.
Why?
The most recent release is always our best
release ever.

The world moves fast.

Maximize the potential benefit of

standardized data.
Other Updates to Your Terms
Your testing may have changed

Your codes may have changed

Watch changes to codes, names, or units
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.
Complete Top 10 Tips available at:

danielvreeman.com/tips
Chinese translation available

Happy LOINCing!