2. Overview
• Origins
of
LOINC
– Background,
Growth,
and
Participation
• Successes
– International
– US
• LOINC
101
– Naming
conventions
– Microbiology
– Panels,
Forms,
Surveys
• RELMA
– Basic
searching
and
mapping
– Hierarchies
• Discussion
3. Origins
of
LOINC
The
Lingua
Franca
of
Clinical
Observation
Exchange
4. Introduction
• Regenstrief’s
35-‐year
history
• The
Indiana
Network
for
Patient
Care
– A
working
HIE
for
~15
years
– More
than
100
sources
– Regenstrief:
3rd
party
convener
• Local
systems
use
idiosyncratic
codes
• Vocabulary
standards
– LOINC
®
-‐
universal
code
system
for
clinical
observations
– The
lingua
franca
of
information
exchange
• Laboratory
and
Radiology
results*
– Often
unavailable
at
the
time
of
a
clinical
visit
(6%,
4%)
– Often
located
outside
of
their
clinical
system
*Smith
CP,
Araya-‐Guerra
R,
Bublitz
C,
et
al.
Missing
clinical
information
during
primary
care
visits.
JAMA.
2005;293(5):565-‐571
5. From
whence
comes
LOINC?
• LOINC®
– Logical
Observation
Identihiers
Names
and
Codes
– A
universal
code
system
for
laboratory
and
other
clinical
observations
– The
lingua
franca
of
information
exchange
for
clinical
observations
McDonald
CJ,
Huff
SM,
Suico
JG,
et
al.
LOINC,
a
universal
standard
for
identifying
laboratory
observations:
a
5-‐year
update.
Clin
Chem.
2003;49(4):624-‐633.
6. Indiana Network for Patient Care
HL7 v.2.X Message
MSH|^~&|HOSPITAL_A|SAMPLE_HOSPITAL_A|||$YearMonthDay|||||||||||||||
PID|||$patientId$||$patientName$||||||||||||||||||||
PV1|||||||$attendingDoctor$||$consultingDoctor$||||||||
OBR|1|||CBC^CBC/Auto Diff^HSPA^57021-8^CBC W Auto Diff^LN||$reqDate|||||||||
OBX|2|ST|WBC^WBC^HSP_A^26464-8^Leukocytes [#/volume] in Blood^LN||10.8|K/MM3|||||F|
OBX|3|ST|RBC^RBC^HSP_A^26453-1^Erythrocytes [#/volume] in Blood^LN||4.82|MIL/MM3|||||F|
OBX|4|ST|HGB^HGB^HSP_A^718-7^Hemoglobin [Mass/volume] in Blood^LN||15.7|GM/DL|||||F|
OBX|5|CE|HCT^HCT^HSP_A^20570-8^Hematocrit [Volume Fraction] of Blood^LN||45|%|||||||F|
A
A
7. Indiana Network for Patient Care
HL7 v.2.X Message
MSH|^~&|HOSPITAL_A|SAMPLE_HOSPITAL_A|||$YearMonthDay|||||||||||||||
PID|||$patientId$||$patientName$||||||||||||||||||||
PV1|||||||$attendingDoctor$||$consultingDoctor$||||||||
OBR|1|||44249-1^PHQ-9 Quick Depression Assessment Pnl^LN||$requestDate|||||||||
OBX|1|ST|44250-9^Little interest or pleasure in doing things:Find:Pt:^Patient:Ord:Reported.PHQ-9^LN|
1|3^More than half the days^Pfizer^LA6570-1^More than half the days^LN|||||||||||||
OBX|2|ST|44255-8^Feeling down, depressed, or hopeless^LN|1|2^Several days^Pfizer^LA6569-3^Several
days^LN|||||||||||||
…
OBX|10|ST|44261-6^PHQ-9 Total Score^LN|1|11|||||||||||||
A
A
8. LOINC
Purpose
To
facilitate
the
exchange
and
pooling
of
results
for
clinical
care,
outcomes
management,
and
research
• Specihically,
to
provide
a
universal
ID
for
the
OBX-‐3
hield
in
HL7
ORU
messages
• LOINC
codes
“questions”,
not
answers
– Orders/Panels
(OBR-‐4)
– Questions
(OBX-‐3)
– NOT
Values
(OBX-‐5)
• Numbers,
organisms
(E.
coli)
McDonald
CJ,
Huff
SM,
Suico
JG,
et
al.
LOINC,
a
universal
standard
for
identifying
laboratory
observations:
a
5-‐year
update.
Clin
Chem.
2003;49(4):624-‐633.
9. LOINC’s
General
Role
• If
an
observation
is
a
question,
and
the
observation
value
an
answer:
– LOINC
provides
codes
for
the
questions
{OBR-4,
OBX-3}
– Other
systems
(eg
SNOMED)
provide
codes
for
the
answers
What
is
my
patient’s
hemoglobin
level?
718-‐7:Hemoglobin:MCnc:Pt:Bld:Qn
How
fast
does
my
patient
usually
walk?
41959-‐8:Walking
speed:Vel:1W^mean:^Patient:Qn:Calculated
10. LOINC
Background
• Organized
by
Regenstrief
Institute
in
1994
– Ongoing
support
from
NLM
and
Regenstrief
– Guided
by
the
LOINC
Committee
(Lab
+
Clinical)
• Covers
domain
of
Clinical
Observations
– Laboratory
observations
(since
1995)
– Clinical
observations
(since
1996)
• LOINC
development
is
a
highly
‘open
source’
model
– Open,
nimble,
pragmatic
– LOINC
and
RELMA
program
are
freely
available
– Much
work
is
done
by
volunteers
– Additions
to
the
database
are
end-‐user
driven
21. International
Adoption
• Brazil
–
SIGA
Saúde
lab
integration
project
in
São
Paulo
city
• Canada
–
Adopted
by
Canada
Health
Infoway,
incorporated
into
many
efforts,
e.g.
the
eCHN
network
(province-‐wide)
• China
–Lab
interoperability
prohile
with
gov’t,
academic,
hospital,
and
vendor
participation
• France
-‐
Assistance
Publique-‐Paris
Hospitals
(AP-‐HP)
• Germany
–
DIMI
produces
a
companion
LOINC
website
• Korea
–
Support
from
Korean
Ministry
for
Health,
Welfare,
and
Family
Affairs
• The
Netherlands
–
Dutch
National
Institute
for
ICT
in
Healthcare
has
2
mapping
efforts
underway
22. International
Adoption
• Spain
–
Extensive
use
in
HIE
efforts
by
BiTAC
and
others,
Red
Agrolab
network
(49
labs)
for
food
safety/animal
health
• Mexico
–
Mexican
Institute
of
Social
Security
uses
in
more
than
850
medical
services
• Taiwan
–
Adoption
supported
by
Department
of
Health
since
2004,
large
mapping
project
between
National
Health
Insurance
(NHI)
codes
and
LOINC
• Europe-wide
–
being
used
in
European
Patients
Smart
Open
Services
(epSOS)
project
23. Translations
• Spanish,
French,
Simplihied
Chinese,
German,
Korean,
Estonian,
Portuguese,
Italian
• More
coming:
Catalan,
Dutch,
Russian,
Ukrainian
• See
http://loinc.org/international
26. Consolidated
Health
Informatics
Initiative
• CHI
Goal:
– Adopting
interoperability
standards
to
enable
all
agencies
in
the
federal
health
enterprise
to
“speak
the
same
language”
• Adopted
LOINC
as
standard
– Laboratory
results
names
(2003)
– Laboratory
test
order
names
(2006)
– Medications:
Structured
Product
Labeling
Sections
(2006)
– Federally-‐required
assessments
with
functioning
and
disability
content
(2007)
27. US
Federal
Agencies
• NLM
– Source
vocabulary
in
UMLS
– Principal
funder
of
LOINC
development
• VA
(Standards
and
Terminology
Service)
– VistA
Lab
interfaces
to/from:
• VA,
DoD,
Commercial
References
labs
• Clinical
laboratory
automated
instruments
• Clinical
decision
support
systems
• Health
data
repositories/data
warehouse
– Document
Title
Ontology
28. US
Federal
Agencies
• DoD
– Incorporated
into
Composite
Health
Care
System,
used
by
100+
systems
supporting
500+
hospitals
and
clinics
– Mappings
to
LOINC
support
the
Global
Laboratory
Information
Transfer
Project
for
lab
orders/results
between
DoD,
VA,
and
commercial
labs
• IHS
– After
pilot
project,
now
embarking
on
~250
facility
mapping
process
• NCI
–
caBIG
– Lab
portion
of
LOINC
adopted
as
caBIG
vocab
standard
29. US
Federal
Agencies
• CDC
(why
we’re
talking!)
–
Many
projects
underway
in
various
stages
– Notihiable
condition
mapping
– NHANES
– Data
elements
in
CTSE
position
statements
– National
immunization
program
– CDA
IG
for
Case
Reporting
– Inhluenza
program
– Lab
response
network-‐C,
-‐B
– NHSN
– DEEDs
–
Release
1.0
and
1.1
30. Other
Key
US
Adoptions
• ARRA
“Meaningful
Use”
• HITSP
– C80:
vital
signs,
lab
results,
lab
orders,
genetic
results,
other
results
– IS92:
newborn
screening
• eLINCS
– Standard
for
results
delivery
from
LIS
to
an
EHR
• NAACCR
– Volumes
II
(Data
Standards/Dictionary)
and
V
(Path
Lab
e-‐Reporting)
• CDISC
– Pharmaceutical
research
specs
• NCQA/HEDIS
– Used
90%
of
health
plans
to
measure
quality
31. Other
Key
US
Adoptions
• HL7
–
many
implementation
guides,
CDA,
etc
• HIPAA
Claims
Attachments
• Many
Regional
HIEs
– Indiana
Network
for
Patient
Care
– Maine
Health
InfoNet
– Florida
Health
Information
Network
– Vermont
Information
Technology
Leaders
• Many
large
care
delivery
organizations
– Intermountain
Healthcare
– Kaiser
Permanente
33. The
LOINC
Distribution
• Free
worldwide!
– Copyrighted,
but
open
terms
of
use
– Releases
~2x/year
(June
and
December)
• LOINC,
RELMA,
or
LOINC+RELMA
– LOINC
Table
as
ascii
text
or
.mdb
– RELMA
• Easy
searching
of
LOINC
• Helps
map
local
terms
to
LOINC
• LOINC
Accessory
Files
– LOINC
Panels
and
Forms
– LOINC
Multiaxial
Hierarchy
– LOINC
Context-‐specihic
Hierarchy
Template
34. Anatomy
of
a
LOINC
Term
5193-‐8:Hepatitis
B
virus
surface
Ab:ACnc:Pt:Ser:Qn:EIA
5193-8 LOINC Code
Hepatitis B virus surface Ab Component
ACnc Property Measured
Pt Timing
Ser System
Qn Scale
EIA Method
There
are
six
major
LOINC
axes
35. What
is
NOT
part
of
a
LOINC
Name?
• The
instrument
used
in
testing
• Specihic
details
about
the
specimen
• Priority
(e.g.
STAT)
• Where
testing
was
done
• Who
did
the
test
• Test
interpretation
• Anything
that
is
not
an
intrinsic
part
of
the
name
of
the
result
• Other
things
that
are
carried
in;
• The
OBR
or
OBX
segment
• An
HL7
Version
3
Observation
Object
36. Component/Analyte
The substance or entity that is measured,
evaluated, or observed
-‐
Sodium
-‐
Glucose
-‐
Brucella
sp.
organism
-‐
Inhluenza
A
Virus
antigen
-‐ Cytomegalovirus
Virus
antibody
-‐ Lipids.Total
5193-‐8:Hepatitis
B
virus
surface
Ab:ACnc:Pt:Ser:Qn:EIA
37. Component/Analyte
Structure
Analyte Name^Challenge^Adjustments
• Formal
name
of
Analyte
(e.g.
Calcium)
• Must
specify
any
“subanalyte”
• e.g.
Coronavirus
Ag
• May
have
a
subclass
–
separated
by
“.”
• e.g.
Calcium.ionized
• Challenge
-‐
e.g,
1H
post
100
gm
Glucose
PO
• Two
subparts
separated
by
“post”
• <time
delay>
post
<challenge
type>
• Adjustments/corrections
• E.g.
Adjusted
to
pH
7.4
38. Property
the most difficult LOINC axis
The characteristic or attribute of the analyte that
is measured, evaluated, or observed
• MCnc
–
mass
concentration
(mass/unit
vol)
• MCnt
–
mass
content
(mass/unit
mass)
• NCnc
–
number
concentration
(number/unit
vol)
• TmStp
–
time
• CCnc
–
catalytic
concentration
(activity)
• Prid
–
presence
or
identity
• Imp
–
impression/interpretation
• Find
–
subjective
or
objective
observation
• Type
–
“Kind-‐of”
5193-‐8:Hepatitis
B
virus
surface
Ab:ACnc:Pt:Ser:Qn:EIA
39. Timing*
The interval of time over which the
observation or measurement was made
• Pt
-‐
at
a
point
in
time
• 12H
-‐
a
twelve
hour
collection
• 24H
-‐
a
twenty
four
hour
collection
*non-Pt timings are usually associated with Ratio Property
40. System
The system (context) or specimen type upon
which the observation was made.
• Ser
-‐
Serum
• Gast
–
Gastric
hluid/contents
• Bld
-‐
Whole
blood
(RBC)
• Food
–
Food
or
feedstuff
• Ur-‐
Urine
• Tiss
–
Tissue
• BldA
-‐
Arterial
blood
• XXX
–
To
be
specihied
in
• Liver
-‐
Liver
another
part
of
the
message
• Flu
–
Body
Fluid,
unspecihied
Super
System
Second
subpart
(^).
When
not
included,
“patient”
is
the
default.
Used
to
indicated
blood
product
unit
(BPU),
a
bone
marrow
donor,
or
a
fetus.
41. Scale
• Qn
-‐
quantitative
• Continuous
numeric
(real,
integer,
ratio)
• Optional
operator
(>,
≥,
≤,
<)
• When
assay
detection
limits
are
exceeded
• Ord
-‐
ordinal
• a
ranked
set
of
possible
values
(1+,
2+,
3+)
• Nom
-‐
nominal
• an
unranked
collection
of
possible
values
• a
taxonomy
(e.g
list
of
bacteria)
• Nar
-‐
narrative
• free
text
narrative
(e.g.,
visit
note)
42. Method
• Methods
only
needed
if
interpretation
affected
• Different
normal
ranges
• Test
Sensitivity
• Listed
only
at
the
generic
level
• Agglutination
• Immunoassay
• Probe
with
target
amplihication
43. LOINC
“Parts”
• Pieces
of
a
LOINC
term
name
are
called
“parts”
and
are
given
an
“LP*”
code
– E.g
“LP14635-‐4”
is
Glucose
• LOINC
parts
are
used
for
synonymy,
building
hierarchies,
algorithmically
creating
alternate
names,
and
attaching
descriptions
44. Hierarchies
• LOINC
‘class’
attribute
• Trees
constructed
for
the
parts
that
make
up
the
system,
component,
method
axes
(in
RELMA)
• Multi-‐axial
hierarchy
– Component
|
System
– Available
as
separate
download
45. Microbiology
Basics
An
inherently
complex
result
structure
Local
HIE
experience:
very
challenging,
systems
don’t
follow
HL7
guidelines
46. LOINC’s
General
Approach
• Result
Status
– Not
a
separate
observation
or
part
of
name
– Send
in
HL7
hield
OBR-‐25
• Specimen
Type
– Send
in
HL7
hield
OBR-‐15
– May
also
be
part
of
name
• Details
of
Specimen
Collection
– Usually
sent
as
OBX
segments
or
comments
under
culture
results
47. LOINC’s
General
Approach
• Culture
growth
descriptions
and
measurement
– Sent
as
separate
OBX
segments
– E.g
a
qn
test
of
bacteria
in
a
specimen:
• 564-‐5:Colony
count:Num:Pt:XXX:Qn:VC
• Gram
stain
hindings
– Sent
as
separate
OBX
segments
– 664-‐3:Microscopic
observation:Prid:Pt:
XXX:Nom:Gram
stain
48. Organisms
Identihied
in
a
Culture
• Sent
as
results
in
OBX
segments
– Coding
organisms
with
SNOMED
is
good
• Example
name
of
culture
results
– 6463-‐4:Bacteria
identihied:Prid:Pt:
XXX
Nom:Culture
• Example
names
of
methods
of
staining
directly
on
a
sample/material
– 664-‐3:Microscopic
observation:Prid:Pt:
XXX:Nom:Gram
stain
49. Organisms
Identihied
in
a
Culture
• Names
for
results
of
staining
procedures
on
organisms
growing
in
culture
–
use
Isolate
as
system
– 613-‐0:Fungus
identihied:Prid:Pt
Isolate:Nom:Fungal
subtyping
• Names
for
organism-‐specihic
cultures
– 557-‐9:Chlamydia
sp
identihied:Prid:Pt:
Genital:Nom:Organism
specihic
culture
50. Other
Notes
on
LOINC
Property
• Presence
or
Identity
(Prid)
with
Nominal
(Nom)
Scale
– Should
be
used
when
the
value
of
a
test
can
come
from
a
taxonomy
or
spectrum
of
possible
species/subspecies
• Arbitrary
Concentration
(Acnc)
with
Ordinal
(Ord)
Scale
– For
when
the
answer
is
positive/negative
or
yes/no
51. Antimicrobial
Susceptibilities
Class
=
ABXBACT
• Named
with
generic
name
of
drug,
Property
of
susceptibility
(Susc),
and
appropriate
method,
scale
• Example
E-‐tests:
• Special
Scale:
OrdQn
• Observations
reported
as
resistant,
intermediate,
susceptible,
or
as
mm
diameter
of
inhibition
zone
• Difhicult
for
some
systems
to
implement
OBX
sub
IDs
and
links
back
to
parent
culture
battery
54. Panels
(Batteries)
in
LOINC
• Panel
term
linked
to
enumerated
child
elements
– Child
elements
can
be
panels
themselves
(nesting)
• Panel
term
names
(under
discussion)
– Component
often
have
“panel”,
include
authoritative
source
– Property
typically
“-‐”
because
child
elements
will
vary
– Scale
typically
“-‐”
because
child
elements
will
vary
– Class
PANEL.*
• Child
elements
linked
and
identihied
as:
– Required
(R)
Element
always
reported
with
panel
– Optional
(O)
Element
may
not
be
reported
depending
on
institutional
policies
or
capabilities
– Conditional
(C)
Element
is
a
key
hinding
and
thus
should
be
assumed
to
be
negative,
absent,
or
not
present
if
panel
result
does
not
include
data
for
this
element.
59. Introduction
• Survey
instruments
have
psychometric
properties
• Question
meaning
tightly
coupled
with
answers
• With
experience
in
modeling
instruments
from
various
domains,
we
uncovered
additional
relevant
attributes
to
store
General Aim: LOINC could serve as the
“master question file” in this domain
60. What’s
in
the
Master
Question
File?
• Question
(item)
name/text
– Exact
question
text,
form-‐specihic
display
name
• Data
type
• Description
and/or
help
text
• For
numeric
values:
units
of
measure,
range
checks
• For
categorical
results:
answers
in
an
answer
list
• Required
item
(Y/N)
• Cardinality
(more
than
one
answer
allowed)
• Copyright
and
terms-‐of-‐use
notices
• Skip
logic
• Consistency/data
integrity
logic
• …
and
more
64. Advantages
of
the
Master
Catalog
• Single
database
(LOINC)
contains
the
details
about
individual
observations
and
sets
– In
the
database,
all
forms
(sets)
look
the
same
– Automatic
standardization
– Data
collection
and
other
programs
can
be
built
upon
a
common
data
model
• Can
easily
reuse
observations
(and
attributes)
in
different
forms/sets
65. Rules
for
Display
of
Items
1. SURVEY_QUEST_TEXT
(if
populated).
Used
when
item
is
asked
as
a
question.
Sometimes
the
item
has
a
label
and
a
question,
so
we
store
both
as
[label].[question
text]
Pain Presence. Ask resident: “Have you had pain or hurting at
any time in the last 7 days?”
2. DISPLAY_NAME_FOR_FORM
(if
populated).
Provides
an
override
display
linked
to
the
instance
of
the
LOINC
in
a
particular
form.
Allows
for
presentation
variation
that
doesn’t
affect
meaning
and
for
where
the
LOINC
naming
conventions
require
some
difference
b/w
the
item
and
the
LOINC
Component.
Item label = “Body Mass Index (BMI)”
LOINC Component = “Body mass index”
3. COMPONENT.
This
is
the
default
display
66. Currently
in
LOINC
• US
Government
Forms
– CARE,
MDSv2,
MDSv3,
OASIS,
RFC
– US
Surgeon
General’s
Family
Health
Portrait
• Geriatric
Depression
Scale
• HIV
Signs
and
Symptoms
Checklist
• Home
Health
Care
Classihication
• howRU
• OMAHA
• PHQ
(9
and
2)
67. Many
Other
Potential
Opportunities
• Mental
health
instruments
• Lots
of
other
commonly-‐used
instruments
(SF-‐36,
etc)
• AHRQ
Common
Framework
forms
• CDC
case
report
forms
• PhenX
protocols
for
clinical
research
trials
68. Intellectual
Property
Issues
• Must
negotiate
separate
agreements
with
each
copyright/IP
holder
• Many
instruments
are
hiercely
protected
– Protection
against
change
and
attribution
are
understandable
– Some
want
royalties
– Commercial
use
in
LOINC’s
context
is
tricky
• Even
more
complicated
when
several
instruments
included
in
larger
CMS
ones
(MDS,
CARE,
etc)
69. RELMA®
Regenstrief
LOINC
Mapping
Assistant
(some
screen
shots
from
v4.2
that
will
be
out
soon)
70. RELMA
• Browse
LOINC
– Restrict
based
on
hierarchies
– Flexible
searching
• Map
local
codes
to
LOINC
– Start
with
local
codes
from
master
hile
or
HL7
messages
• Include
sample
data,
units,
categories
• Mass
translations
• Propose
new
LOINC
codes
based
on
old
ones
• Export
mapped
terms
87. Setting
Search
Limits
in
RELMA
• Narrows
search
to
subsets
of
LOINC
terms
– Reduces
number
of
candidate
terms
• Component
attribute
can
be
further
restricted
by
number
of
words
• Tree
structure
allows
for
hierarchical
constraints
96. Context
Specihic
Hierarchies
• Generic
data
model
to
allow
local
dehinition
of
LOINC
code
hierarchies
• Template
data
base
is
provided
with
RELMA
• CONTEXT_SPECIFIC_HIERARCHY_TEMPLATE.mdb
• Or
download
from
LOINC
website
• Described
in
detail
in
RELMA
User’s
Manual
• Hierarchies
can
be
displayed
(only)
in
RELMA
• Codes
may
come
from
multiple
code
systems
• May
share
community
contributed
hierarchies
on
LOINC
website
and/or
incorporate
into
main
LOINC
distribution
The Regenstrief Institute has over 30 years of experience aggregating, storing, and processing electronic health information. The original Regenstrief Medical Record system developed in the early 70’s now forms the core of a community and state-wide health information exchange called the INPC. Currently, more than 100 different source systems contribute data to the INPC, including data from all 5 major health systems in Indianapolis. A fundamental challenge for us and others who integrate data within and among systems is that local systems have idiosyncratic ways of identifying similar concepts. In response to this challenge, Regenstrief investigators pioneered the development of LOINC, a universal code system for laboratory and other clinical observations. When local system terms are mapped to a common vocabulary like LOINC, LOINC can serve as the lingua franca for information exchange, as it does in our network. As we continue integrating sources into the INPC and distributing their content throughout the network, we hope to combat the common problem of important clinical results like lab tests and radiology being unavailable when and where they are needed.
In response to this challenge, Regenstrief investigators pioneered the development of LOINC, a universal code system for laboratory and other clinical observations. When local system terms are mapped to LOINC, LOINC can serve as the lingua franca for information exchange, as it does in our network. As these sources are integrated and their content distributed throughout the network, we hope to combat the common problem that clinical data are often unavailable when and where they are needed.
Total PHQ-9 Score of 11 = Moderate Depression
Total PHQ-9 Score of 11 = Moderate Depression
Highlight Code from rest of name Normal results vary, but in general are: Male: 13.8 to 17.2 gm/dL Female: 12.1 to 15.1 gm/dL
2001-2004:Slope = 600 2004-2007:Slope = 2200
LOINC Axes What a Challenge Is.
co
Example properties: mass rate (MRAT) – g/24h, substance rate (SRAT) – mol/24h
