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Introduction to LOINC
The global vocabulary for identifying health measurements, observations, and documents
Swapna Abhyankar, MD
Associate Director for Content Development,
LOINC and Health Data Standards
@sa_abhyankar Regenstrief Center for Biomedical Informatics
© 2018 © 2018
High Level Schedule
1. An overview of LOINC
2. The LOINC Concept Model and other
Data Structures
3. Implementing LOINC
📷 Vernio77 | cc-by-sa
Slides available at:
https://danielvreeman.com/amia2018
Session Objectives
1. Explain the LOINC development process
2. Apply key features of the LOINC concept model in
selecting appropriate codes
3. Design a query using metadata and relationships about
LOINC concepts beyond the concept name
4. Identify and select the key implementation tools
appropriate for their use case
5. Apply best practices for using LOINC
📷 Vernio77 | cc-by-sa
Disclosure
I’m President of Blue Sky Premise, LLC which published the book LOINC
Essentials.
This material contains content from LOINC® (http://loinc.org). The LOINC Table, LOINC Table Core, LOINC Panels and
Forms File, LOINC Answer File, LOINC Part File, LOINC Group File, LOINC Document Ontology File, LOINC Hierarchies,
LOINC Linguistic Variants File, LOINC/RSNA Radiology Playbook, and LOINC/IEEE Medical Device Code Mapping Table are
copyright © 1995-2018, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC)
Committee and is available at no cost under the license at http://loinc.org/license.
Financial Support for LOINC
Regenstrief Institute AHIMA Foundation
Regenstrief Foundation Contract FORE-ASPE-2007-5
U.S. National Library of Medicine RTI International
Contracts NO1-LM-4-3510, N01-LM-6-3546, N01- Contract 0-312-0209853
LM-9-3517, and HHSN276200800006C,
John A. Hartford Foundation
HHSN276201400138P, HHSN276201400239P
Agency for Health Care Policy and Research
Office of the National Coordinator for Health Information
Technology (ONC) Grants HS 08750 and HS 07719-03
Contract 90AX0021 Centers for Disease Control and Prevention
U.S. Food and Drug Administration Grant and Contracts R13/CCR517099 and H75/CCH520501
Contract HHSF223201710178P, HHS223201810268P Centers for Medicare and Medicaid Services
American Physical Therapy Association Contract HHSM-500-2016-00040C
bioMérieux National Center for Advancing Translational Sciences
Indiana Clinical and Translational Sciences Institute Grant 3UL1TR001108-04S1
California Healthcare Foundation National Institute of Diabetes and Digestive and Kidney Diseases
Radiological Society of North America through the National Contract HHSN275201600752P
Institute of Biomedical Imaging and Bioengineering Members of the LOINC Community who have made donations or
Contract HHSN268201500247A became Premium Members
Before we jump in,
you might be wondering…
Laboratory professional
Physician
Nurse
Other health professional
Just love working with Health IT / data
https://danielvreeman.com/poll
Data exchange
Analytics or quality metrics
App design or decision support
Research
Other
Welcome to the
LOINC Community
📷 jamescridland | cc-by
Interoperability
Why it matters
Connecting Many Data Sources
McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.
Many forces converging on the need for
interoperable EHRs
the more
problems we see
Problems
Health IT systems often lack common
mechanisms for exchanging data.
📷 tgerus | cc-by-sa
Syntax Standards
Messages, Documents, APIs
HL7v2, C-CDA, FHIR
Semantic Standards
Vocabulary/code systems
LOINC, SNOMED CT, RxNorm, HPO, ICD, MONDO
The Superhero Origin Story
meerkat meerkat mere cat meerkat
📷 CaptionTime
The universal standard for identifying health
measurements, observations, and documents.
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?
📷 glasgowamateur | cc-by-sa
📷 unamid-photo | cc-by-nd
Codes for individual observations
6690-2 Leukocytes [#/volume] in Blood by Automated
2339-0 count
Glucose [Mass/volume] in Blood
29463-7 Body weight
55423-8 Number of steps in unspecified time Pedometer
📷 beatlesmania11 | cc-by
Using LOINC in HL7 version 2.x
LOINC Units
Argonaut Project FHIR IG / US Core IG
Data element query of the ONC Common Clinical Data Set and Document query
Observation.code
Other uses
All Document type codes
All Section codes
Vital sign observations
ADL result type
Food and Nutrition and anthropometric variables
Skin and wound measurements
Same idea with CDMs
PCORnet
OHDSI
Mini-Sentinel
But I LOVE maintaining my local dictionary!
📷 Jonathan McIntosh | cc-by-sa
Relax…
OBX||NM|123^RBC^MyHosp^26453-1^RBC # Bld^LN||4.82|10*6/uL
Local term LOINC term
📷 jurvetson | cc-by
LOINC is free,
but invaluable
LOINC License
No cost use
Worldwide
In perpetuity
Commercial or noncommercial
Encourages translation
One major prohibition…
CANNOT use any Licensed
Material to develop or
promulgate a different standard
for orders or observations.
Read more about
Regenstrief’s approach
to licensing LOINC
danielvreeman.com/licensing-loinc
Major releases twice
per year
(June and December)
📷 striatic | cc-by
0
10,000
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laboratory terms only
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There will come a time
when you believe
everything is finished.
📷 Wikipedia | cc-by-sa
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]
Patient reported outcomes [PCORI]
Social determinants of health [many]
MANY active collaborations with other orgs…
📷 liber | cc-by
Vocabulary standards grow
because USERS ask
(we don’t need to invent new standards)
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6/ 12 / 6/ 12 / 6/ 12 / 6/ 12 / 6/ 12 / 6/ 12 / 6/ 12 / 6/ 12 / 6/ 12 / 6/ 12 / 6/1 1 1 1 1
Registered Users: Last 24 Months
70,000
65,000
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10 1 4 7 10 1 4 7 10
https://www.ehealthontario.on.ca/en/
https://infocentral.infoway-inforoute.ca/en/standards/international/loinc
France
https://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000031922237&categorieLien=id
http://esante.gouv.fr/sites/default/files/CI-SIS_CONTENU_VOLET-CR-BIOLOGIE_v1.2.0.0.pdf
Austria
Seerainer C, Sabutsch SW. eHealth Terminology Management in Austria. Stud Health Technol Inform. 2016;228:426-30. PubMed PMID: 27577418.
Netherlands
Nictiz
Many national projects are using LOINC
https://www.rivm.nl/Documenten_en_publicaties/Algemeen_Actueel/Nieuwsberichten/2018/Vijf_labs_operationeel_bij_Eenheid_van_Taal_in_antibioticaresistentie
http://www.cchi.gov.sa/en/Projects/SHIP/Pages/Dictionary.aspx
Qatar
http://www.sch.gov.qa/announcements/announcement-details?item=257&backArt=180&page=1
Brazil
Used in São Paulo regional data exchange project for many years
http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2073_31_08_2011.html
Malaysia
Ministry of Health
National Health Informatics Committee and Ministry pathologist
adopted LOINC for lab data standardization (in LIS’s)
https://myhdw.moh.gov.my/public/documents/20186/169489/MyHDW+2015-2016/86b7603a-eab4-40c0-aa94-35ded673838d
https://myhdw.moh.gov.my/public/home
Turkey
http://www.cchi.gov.sa/en/Projects/SHIP/Pages/Dictionary.aspx
China
China
EHRSC Interoperability Profile: Clinical Laboratory Test Results Sharing adopted LOINC; used in
several regional health information sharing projects
Integrated disease surveillance system in Beijing 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) evaluated LOINC use
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
International Collaborations
http://international-patient-summary.net
And so many more…
Current U.S. Landscape
Brief Summary of LOINC Adoptions
ONC
CMS
Many eCQM definitions expressed with LOINC (per HITSC advice)
https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/Inclusion-of-Recognized-Terminologies-Supporting-Nursing-Practice-within-Electronic-Health-Records/
https://www.nursingoutlook.org/article/S0029-6554(13)00247-9/pdf
https://www.allianceni.org/statements-positions
Real world LOINC use (U.S.)
Reference labs have mapped observations
Orders are a work in progress
The big research networks use it in CDMs: OHDSI, PCORnet, Mini-Sentinel, etc.
PCORnet reports 94% LOINCed lab results in its network
📷 mccaughan | cc-by-sa
Q & A
AMIA Annual Symposium 2018 | San Francisco, CA USA
Swapna Abhyankar, MD
Associate Director for Content Development
Part 2 overview
• LOINC concept model
• Other LOINC data structures and ancillary data
• LOINC content domains
• Domain specializations
• Query design
• Q&A
Anatomy of a LOINC term
LOINC term = LOINC code + LOINC name
• We are moving away from specifying conditionality due to the variability across
institutions and impracticality of keeping up with panel definitions, except in
certain situations, e.g., a clinical guidelines, regulations
Attributes Assigned at the Term Level
• Most attributes of a given term apply to the term whether it is
on its own or within a panel
• Units of Measure (UCUM)
• Term description/definition
• Term status
• External Copyright
• Terms of Use
Attributes Assigned at the Panel Level
• Some attributes can be assigned to a term within the context of
a panel
• Display name override
• Form coding instructions
• Form context
• Cardinality
• Observation ID in form
• Skip logic
• Override answer list
• Images
Where to get LOINC panels
• LOINC detail pages in RELMA and http://search.loinc.org
• Show the full panel structure ± details about panel children
• Comprehensive details pages have info about children; Simple pages don’t
• Panels and forms file (https://loinc.org/downloads/accessory-files/)
• Contains the full panel structure for all panels in LOINC
• Use together with the LOINC table, AnswerList file, and LOINCAnswerListLink
file
• RELMA “Export full panel structure”
• Export a single panel with all of its attributes from RELMA
• 4 tabs that include all of the information about the panel structure, LOINC
terms, Answer lists, and links between LOINCs and Answer lists included in
that panel
A closer look at LOINC
Document Ontology
The Problem
Local systems have idiosyncratic names...
Dr. Smith’s
Outpatient
Silver Spring Pediatrics
Pediatrics
Peds Office Clinic Note
Note
Note
…that make it difficult to exchange and organize
documents across systems
The Solution
A common, controlled vocabulary for
representing clinical documents
Frazier P, Rossi-Mori A, Dolin RH, Alschuler L, Huff SM. The creation of an ontology of clinical document names. Stud Health
Technol Inform. 2001;84(Pt 1):94-8.
Names are based on
expected information
content, NOT on document
format
NOT part of a LOINC document name
• Author name
• Location of service
• Date of service
• Status (e.g. signed, unsigned)
• Security/privacy flags (e.g. protected)
• Updates or amendments to a document
https://loinc.org/document-
ontology/current-version/
Rules for creating document terms
• Different combinations of values from each axis = unique LOINC
terms
• Terms must have Kind of Document + ≥ 1 other axis value
• Combinations are only created if they make sense clinically
• Can have more than one value within an axis (not common)
• Evaluation+Plan note
• Plan of care+summary note
• Hematology+Medical oncology
Cross-mapping between LOINC Document
Ontology and non-document parts
LOINC non-document part LOINC Document Ontology part
Component Type of Service + Kind of Document
System Setting
Method Subject Matter Domain + Role
Subject Matter Domain.Role
Putting the Doc Ontology parts together
Component Property Time aspect System Scale Method
Examples
View descriptor View, Multisection
Aggregation 2, greater than 3 (GT3)
View type AP, lateral, oblique
Guidance
Guidance for <Approach> <Action> of <Object>
Examples
Approach percutaneous, deep
Action aspiration, placement, drainage
Object cyst, catheter, abscess
Reason for exam
Indication or purpose of study
Examples
for shunt patency, for vertebral fracture
Timing
<Timing>
Used with both maneuver and pharmaceutical
Examples
Timing W, WO, WO & W
Maneuver
<Timing> <Maneuver>
Examples
Maneuver type flexion, extension, standing
Pharmaceutical
<Timing> <Pharmaceutical> <Route>
Examples
Pharmaceutical contrast, 18-F FDG
Route IV, PO, via nephrostomy
tube, intra fistula
Anatomy
<Region imaged> “>” <Imaging focus>
laterality attached as appropriate
Examples
Region imaged head, abdomen, lower extremity
Imaging focus brain, clavicle, liver, thigh, ankle
Laterality.Presence true, false
Laterality right, left, bilateral, unspecified
Subject
Examples
fetus, surgical specimen
Modality
<Modality>.<Modality subtype>
Examples
Modality XR, CT, MR, NM,
US, PT, MG, RF
Modality subtype angio, densitometry,
spectroscopy, tomography
Cross-mapping between LOINC radiology and
non-radiology parts
LOINC non-radiology part Unified model attribute (LOINC radiology part)
Component – 1st part View
Guidance
Reason for exam
Component – 2nd part (challenge) Timing + Maneuver
Timing + Pharmaceutical
System Anatomy (Region imaged, Imaging focus, Laterality)
Subject
Method Modality
Relationship of unified model to LOINC and
Playbook concepts
Unified
LOINC model RadLex
RadLex
LOINC non- attributes Playbook
attributes
term radiology (LOINC concept
(RID)
parts radiology (RPID)
parts)
Examples
Phew - we’re almost
done with Part 2!
Are you ready to do
some hands-on
LOINCing?
LOINC Query Design
• Tools
• RELMA
• http://search.loinc.org
• Search based on
• LOINC 6-part concept model
• Other attributes
• Search syntax
• AND (implied)
• OR
• *
• {Attribute}:
Query #1
How do I find all terms added in the latest version of LOINC?
Versionfirstreleased:2.64
Alternatively,
Versionlastchanged:2.64 Chngtype:Add
Query #2
How do I find all terms updated in the latest version of LOINC?
Versionlastchanged:2.64 – Chngtype:Add
Relatedcodes:RPID*
Query #3a
How do I find all terms mapped to RadLex Playbook MR or CT codes?
Component:Influenza System:CSF
Component:anxiety Answerlist:true
Note – if you don’t include Component: your search will return any
terms with “anxiety” in any of the Parts or in the Related Names for
one of the Parts
Query #6
How do I find all panels that contain glucose in the name?
Component:glucose Orderobs:order
Alternatively,
Component:glucose panel
Part 3:
Implementing LOINC
many tools for implementers
Part 3 Overview
📷 Vernio77 | cc-by-sa
Many free resources
loinc.org/downloads
Formats for
importing into
Health IT
applications
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
LOINC Display Name File
LOINC Linguistic Variants
LOINC Group File we’ll come back to this one
!
Open the Encyclopedia of LOINC
Two ways
Context menu
Hit the View Details button
📷 john_fielding | cc-by
Creating your source file
for mapping to LOINC
danielvreeman.com/source-file
Panel Code Panel Description Test Code Test Description Units Tag
GLUCWB GLUCOSE WHOLE BLOOD GLUCWB GLUCOSE WHOLE BLOOD MG/DL chem
📷 dvids | cc-by
Export Options
File -> Export Local Terms and Their LOINC Mappings to
Delimited File
Choose Format
Choose Stuff
Oh no, roadblock!
Can’t install RELMA?
📷 brizo_the_scot | cc-by
https://search.loinc.org
Other Implementation Resources
API, Documentation, Community
FHIR Terminology Services with
LOINC enable an exciting set of
capabilities that were much
harder before!
https://loinc.org/fhir
Enhanced LOINC features now available in HAPI FHIR
Get info about your favorite
LOINC term
https://fhir.loinc.org/CodeSystem/$lookup?system=http://
loinc.org&code=4544-3
Every Answer List is available
as a ValueSet
Get a particular Answer List as a ValueSet
https://fhir.loinc.org/ValueSet/?
url=http://loinc.org/vs/LL1162-8
Get the LOINC to IEEE
Mapping
https://fhir.loinc.org/ConceptMap/?url=http://loinc.org/cm/
loinc-to-ieee-device-codes
Get some help from
trusted friends…
https://loinc.org/guides/micro
FDA-funded development of
Guide for Using LOINC
Microbiology Terms
Grant HHSF223201710178P and HHS223201810268P from U.S. Food and Drug Administration
What LOINC Essentials covers…
LOINC basics
A framework and techniques for picking out the subtle but important
distinctions between LOINC terms
Best practices in LOINC mapping and how to set yourself up for success in
the long run
This tutorial is based on content from the book
https://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
Many ways to learn more and
participate in LOINC Community
Mailing list
User Forum
In-person LOINC Conferences
Special Topics Workgroups
Committees
Adopter directory
General Approach to Mapping
The LOINC term name is key
📷 quinnanya | cc-by-sa
LOINC Fully Specified Name
Includes the info necessary to distinguish among clinically
important differences
Body height:Len:Pt:^Patient:Qn:
Local tests names are:
Notoriously short
Lacking info needed for mapping
📷 jdhancock | cc-by
"
For qualitative tests, use
LOINC Answer Lists to
inform your mapping
Mapping Exercise
Your turn!
https://danielvreeman.com/poll
ACnc
MoM
MFr
MCnc
https://danielvreeman.com/poll
📷 pagedooley | cc-by
75856-5
#Falls in past 1Y
66247-8
Sit to stand [30 sec]
8454-1
DBP - standing
8460-8
SBP - standing
If this, then that…
Then
initiate {gait, strength, balance evaluation}
Reporting / Analytics
% patients 65 years of age and older who were screened for future fall risk
83280-8 Has the patient had any falls since admission [CMS Assessment]
…
Same data for…
Informing clinical care
Population health analytics / registry
Electronic quality measure analysis
Observational/epidemiological research
A sample of LOINC-powered
informatics innovations
Hall PL, Marquardt G, McHugh DM, et al. Postanalytical tools improve performance of newborn screening by tandem mass spectrometry. Genet Med. 2014 Dec;16(12):889-95. Epub 2014 May 29. PubMed PMID: 24875301.
Based on the Argonaut FHIR profile
https://www.apple.com/healthcare/health-records/
https://support.apple.com/en-us/HT208647
New and Noteworthy
LOINC Groups
LOINC Groups
loinc.org/groups
A flexible, computable tool for rolling up groups of LOINC codes that can
be considered equivalent for a particular purpose
LOINC Groups content also
available via FHIR
Get a specific LOINC Group as a ValueSet
https://fhir.loinc.org/ValueSet/$expand?url=http://
loinc.org/vs/LG9568-9
https://loinc.org/groups/community/
Come see LOINC Groups in action
AMIA 2018 Session
LOINC Groups: A novel tool for data aggregation
Monday Nov 5, 10:30 AM–12:00 PM
Yosemite A/B
📷 brett-sayer | cc-by-nd
Top 3 Tips for Using LOINC
Key principles for smart LOINCing
Not all juice is worth the squeeze
What do you really need to standardize?
Pareto principle
A few tests account for most volume
70% of tests take 30% of mapping time
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.
📷 elwillo | cc-by http://www.himss.org/news/interoperability-not-all-juice-worth-squeeze-0
Go upstream
Map more efficiently and consistently
📷 Fishking_1 | cc-by
Trust, but verify
Don’t make assumptions…
Review commentary