Invited Webinar for Office of the National Coordinator for Health Information Technology

Introduction to LOINC
The global vocabulary for identifying health measurements,
observations, and documents

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

© 2018 © 2019
Slides available at:
danielvreeeman.com/loinc-101
Disclosure
I’m President of Blue Sky Premise, LLC which published the book LOINC
Essentials.

I’m PI on contracts from bioMérieux and BD for LOINC content

development (and many federal and non-profit funding sources for LOINC).

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.
 High Level Outline

1. Superhero origin story

2. A shallow LOINC dive
3. Resources for implementers

📷 Vernio77 | cc-by-sa
The Superhero Origin Story
A non-profit research organization with a mission to
connect and innovate for better health.

We envision a world where better information

empowers people to end disease and realize true health.
The industrialist pioneer of automatic dishwashers sought to
apply technological and engineering advances to medicine.

Samuel Nathan Regenstrief

Est. Regenstrief Foundation and Institute in 1969
Clem McDonald, MD in the Regenstrief computer terminal room
Circa 1974

McDonald CJ. Protocol-based computer reminders, the quality of care

and the non-perfectability of man. N Engl J Med 1976;295:1351–5
A long history in pioneering clinical data standards

“The early years of standards development were lonely. No longer.”

Clem McDonald, MD
1990
Lots of practical experience
connecting many data sources.

Current State
Patients too often (still) move faster and
further than their health information.

Overhage JM, Tierney WM, McDonald CJ. Design and implementation of the Indianapolis
Network for Patient Care and Research. Bull Med Libr Assoc 1995;83:48–56.
Solving this problem requires different
kinds of data standards
Syntax Standards
Messages, Documents, APIs, CDMs
Regenstrief is the SDO home for two key HL7v2, C-CDA, FHIR

interoperability standards:
LOINC and UCUM Semantic Standards
Vocabulary/code systems
LOINC, RxNorm, HPO, ICD,
We actively participate in the MONDO, UCUM

development (and use) of many others

 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
 Est. 1994

The universal standard for identifying health

measurements, observations, and documents.

Terms have the specificity to distinguish between

clinically important differences.
📷 puuikibeach | cc-by
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.

No single vocabulary
standard covers it all
Observables (and collections of them): LOINC
Units of measure: UCUM
Problems, Organisms, Conditions, etc: SNOMED CT, ICD, HPO
Medications: RxNorm, ACT
Reimbursement: National codesets (e.g. CPT)
 {
"resourceType": "Observation",
"id": "body-height",
"meta": {…},
"text": {…},
"status": "final",
"category": [
{

LOINC is designed for

"coding": […],
"text": "Vital Signs"
}
],

Observations (and Orders)

"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8302-2",
"display": "Body height"

It works equally well in:

}
],
"text": "Body height"

HL7 v2, CDA, FHIR

},
"subject": {
"reference": "Patient/example"
},
"effectiveDateTime": "1999-07-02",
"valueQuantity": {
Or any structure with a two part "value": 66.899999999999991,
"unit": "in",

(observation, observation value) data model

"system": "http://unitsofmeasure.org",
"code": "[in_i]"
}
}
 LOINC is a rich trove of 89,000+ standardized variables
Genetics Lifestyle

21654-9 CFTR gene targeted mutation analysis

41950-7 Number of steps in 24 hour Measured
24475-6 F2 gene c.20210G>A [Presence]
75296-4 Carbohydrate intake 24 hour Estimated
75547-0 Noninvasive prenatal fetal aneuploidy
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

📷 glasgowamateur | cc-by-sa
📷 unamid-photo | cc-by-nd
LOINC Distribution
Major releases twice per year
Rich collection release artifacts
Documentation
Online and desktop browser, API (via FHIR)
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.
 77,000+ registered users from 175 countries

🌐 loinc.org/atlas
 Registered Users
80,000
75,000 search.loinc.org
70,000
login requirement
65,000
60,000
De-dupe & Purge!
55,000
50,000
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
/0 8 08 /0 9 09 /1 0 10 /1 1 11 /1 2 12 /1 3 13 /1 4 14 /1 5 15 /1 6 16 /1 7 17 /1 8 18
1 1/ 1 1/ 1 1/ 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 / 6/ 12 / 6/ 12 / 6/ 12 / 6/ 12 /

Current pace is about 16,000 new users per year

Today, there are hundreds of
millions of patients with billions
of discrete results stored in
systems around the world that
are coded with LOINC.
Taking a little deeper
LOINC dive
LOINC’s content scope
Where to use LOINC codes
Key features of LOINC’s development approach
 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
 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

Display Name
New provider-friendly display name (rules are still under development)

Consumer Name
New consumer-friendly display name (rules are still under development…stay tuned)
 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

Display Name
Urea nitrogen [Mass/Vol]

Consumer Name
Urea Nitrogen (BUN), Blood
 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
 Anatomy of a LOINC FSN
18262-6 Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay

Component Cholesterol.in LDL

Property MCnc

Timing Pt

System Ser/Plas

Scale Qn

Method Direct assay

There are six major LOINC name axes

High Level LOINC Landscape
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

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
Structured Answer Lists

LOINC Answer Lists LOINC Answers

ID (contains “LL” prefix) ID (contains “LA” prefix)
Can be defined as enumerated or pointers String-based, not truly “concept” based
Contains extra attributes about the package Have some mappings to external codes (e.g. SNOMED CT)
LOINC is famous for lab test content,
but you still might not know about…

Newborn screening
Full set of terms, included in HL7 IG Lab Results Interface (LRI)

Genetic reporting
2000+ tests, including collections for structured reporting of simple variants, structural and copy number variants, complex variants,
and pharmacogenomic studies. [PMID: 25656513] See HL7 LRI and the developing FHIR CG IG.

Orders
Not only single tests, but 1,000+ order panels and a consensus-vetted list of 1,500 order codes covering 95% of common volume. See
loinc.org/usage/orders

Public health
Close work with CDC on emerging diseases and reportable conditions
 Clinical Notes and Documents
2,700+ terms with a specialized structure
loinc.org/document-ontology

Radiology Procedures
Wonderful collaboration with RSNA [PMID: 29850823]
5,800 terms with rich metadata
loinc.org/radiology

📷 unamid-photo | cc-by-nd
Broad collection of other clinical variables
Vital signs
CDC’s vital statistics forms (birth, death, etc)
CMS’s patient assessment instruments
Nursing Assessments
Physical Therapy National Outcomes Database
NEMSIS and NTDS
ESRD variables
Chronic kidney disease management
Ophthalmology variables
Medical device measurements via IEEE 11073
ECG, PFT, spirometry, etc
…10,000+ assessment and patient reported outcome terms
Where to use LOINC terms
HL7 v2 Lab Standards Quartet: LRI, LOI, ELR, eDOS
Observation Identifier (OBX-3) and Universal Service ID (OBR-4)
LOINC shall be used as the standard coding system for this field if an appropriate LOINC code exists,
i.e., the LOINC concept is available in the LOINC database, accurately represents the observation, and has
a status that allows its use…If a local coding system is in use, a local code should also be sent to help
with identification of coding issues. When no valid LOINC exists the local code may be the only code sent.

Producer’s Obs ID (OM1-2), Other Obs ID (OM1-7) Obs in an ordered

test (OM5-2), Clinical Info Request (OMC-4)
The laboratory’s local test code and coding system shall be used to identify the orderable test in its
electronic Directory of Services. LOINC shall be used as the standard alternate vocabulary to identify
an orderable test. The performing laboratory makes the determination of an applicable LOINC order
code. When no applicable LOINC code exists, the local code may be the only code defined in the eDOS.

📷 beatlesmania11 | cc-by
 Using LOINC in HL7 version 2.x

NM (numeric) means the

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

LOINC Units
Argonaut Project FHIR IG / US Core IG
Data element query of the ONC Common Clinical Data Set and Document query

Observation.code

Each observation must have a LOINC code, if available. Other

(e.g. local) codes allowed if no suitable LOINC exists

DocumentReference.Type, SmokingStatus Observation.Code, VitalSigns

All bound to value sets of LOINC codes
C-CDA 2.1
Result Observation

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
Key IHE Profiles with
LOINC support
Laboratory Analytical Workflow (LAW)
Laboratory Testing Workflow (LTW)
Laboratory Code Sets Distribution (LCSD)

Sharing Laboratory Reports (XD-LAB)

Cross-Enterprise Document Sharing (XDS*)
Same idea with CDMs
PCORnet
OHDSI
Mini-Sentinel
 LOINC Development
We’ll focus on the key features

📷 jurvetson | cc-by
Guiding Principles
Openness
Accessibility
Growth
Pragmatics
Agility
Diligence
Respect

Read more in our draft LOINC Manifesto

 !
Financial Support for LOINC
Regenstrief Institute Grant 1R24ES028479-01
Regenstrief Foundation Research Triangle Institute International via CMS
U.S. National Library of Medicine Contract 0-312-0209853
Contracts NO1-LM-4-3510, N01-LM-6-3546, N01-LM-9-3517, and John A. Hartford Foundation
HHSN276200800006C, HHSN276201400138P,
Agency for Health Care Policy and Research
HHSN276201400239P
Grants HS 08750 and HS 07719-03
U.S. Food and Drug Administration
Centers for Disease Control and Prevention
Contracts HHSF223201710178P, HHS223201810268P
Grant and Contracts R13/CCR517099 and H75/CCH520501
American Physical Therapy Association
Centers for Medicare and Medicaid Services
BD
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 Institute of
Biomedical Imaging and Bioengineering Contract HHSN275201600752P
Contract HHSN268201500247A Office of the National Coordinator for Health IT
AHIMA Foundation Grant 90AX0021/01-00
Contract FORE-ASPE-2007-5 Members of the LOINC Community who have made donations or
became Premium Members
Research Triangle Institute International via NIEHS

🌐 loinc.org/funding-support
 This is the LOINC Team
(they rock)

! loinc.org/team
LOINC Committee
Advisory body to Regenstrief that sets naming conventions and
development policies.

Open, international membership (individuals, orgs, etc).

Comprised of 3 composite committees by domain:

Laboratory Clinical LOINC/RadLex

 0
10,000
20,000
30,000
40,000
50,000
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90,000
1.
0
1.
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1.
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1.
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0f
1.
1. 0g
0h
(
1. 2)
0h
(3
)
LOINC Terms

1.
0
1. i
0j
-a
1.
0k
1.
0
Only Lab LOINC Terms

1. l
0m
1.
0m
a
1.
0n
1.
00
2.
00
2.
01
2.
03
2.
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2.
05
2.
06
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07
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LOINC Terms Over Time

2.
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21
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24
2.
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2.
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2.
58
2.
61
2.
63
2.
laboratory terms only

64
2.
65
Vocabulary standards grow
because USERS ask
(broad user community drives new content)

Medicine keeps evolving

If we’re missing content, just ask: loinc.org/submissions
https://loinc.org/submissions/queue/
Implementing LOINC
many tools for implementers
Many resources
loinc.org/downloads

“Raw” release artifacts

Online and desktop browser (RELMA)
API (via FHIR)
Documentation
Community resources

Most require a free loinc.org account

https://loinc.org/downloads/loinc/

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 New!

Each has a detailed ReadMe and Release Notes

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
https://search.loinc.org
RELMA: the gold standard mapping tool

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 mappings
Submit new LOINC term requests
https://loinc.org/fhir
Bonus Tip
 Go upstream
Map more efficiently and consistently by getting
LOINC coding recommendations from lab test
manufacturers

📷 Fishking_1 | cc-by
https://ivdconnectivity.org/livd/
https://usdiagnostics.roche.com/en/documentation.html#/q/loinc/s/SCORE_DESC
 Collect once. Use many.
Clinical care, public health reporting, quality management, clinical and
epidemiological research, etc…

📷 pagedooley | cc-by
If this, then that…

If {symptomatic pregnant woman <12 weeks after onset}

Then
Order {81154-7 Dengue & Chikungunya & Zika virus panel}
Population Health Analytics

WHO Zika Strategic Response Plan Quarterly Update: July-September 2016

Same data for…
Informing clinical care
Population health analytics / registry
Electronic quality measure analysis
Observational/epidemiological research
 Take home lesson:
When clinical data is coded with LOINC, diverse IT
applications can understand and interact with it for
the benefit of many in the health ecosystem.

📷 proimos | cc-by-nc
Happy LOINCing!