2009 08 13 - clinical loinc tutorial - introductions and foundations
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Outline for All Tutorials
• LOINC Introduction and Foundation
• Documents
• Assessment Instruments and Survey Instruments
• Radiology and Imaging
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Outline
• LOINC background and goals
• LOINC structure and content– Clinical LOINC– Examples
• Attachments
• Context specific hierarchies
• Collections
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Important facts
• LOINC 2.27 (June 2009) contains 55,056 codes– 40,302 Lab LOINC codes– 10,773 Clinical LOINC codes– 1,354 Claims Attachment codes– 2,629 Survey codes
• LOINC is protected by copyright, but is licensed Free for Use
• Download files and tools from Regenstrief Web Site– www.regenstrief.org/loinc/loinc.htm– Reference manual, submission database, RELMA
• RELMA – a tool for mapping local codes to LOINC
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Coverage
• Laboratory LOINC– All laboratory categories including genetic
testing , veterinary medicine testing
• Clinical LOINC– Many routine measures, parts of H+P, EKG,
Cardiac echoes, OB ultrasound, Nursing survey instruments, Much more
• HIPAA attachments – (Content managed by HL7)
• Survey Questions– Skilled nursing facility Minimum Data Set (MDS)
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The Messaging Paradigm
SystemSystemAA
SystemSystemAA
SystemSystemBB
SystemSystemBB
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Segment
HL7 Result Message (ORU)
Data Field
Component
MSH|^~\&|||||19981105131523||ORU^R01|PID|||100928782^9^M11||Smith^John^J|OBR||||Z0063-0^BP^LN|OBX||CE|8361-4^POSITION^LN||SIT^Sitting|OBX||NM|8479-8^SBP^LN||138|mmHg|
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Status
A code that identifies the units of numerical data
in OBX-5
A code that identifies the
datatypeof OBX-5
A code
that identifies the data in
OBX-5(Temp
Reading)
OBX-5: Data
OBX: a name-value pair approach
OBX||NM|11289-6^^LN||38|C^^ISO+|||||F
Other data fields include: date of observation, identity of provider giving observation, normal ranges, abnormal flags
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The code isfrom SNOMED
The code isfrom LOINC
OBX-5: Data
A code for Group O
A code that identifies the datatype as a
coded element
OBX: with a coded value
A code that identifies the data in
OBX-5(ABO Blood Group)
OBX||CE|883-9^Blood Group^LN||58460004^Group O^SCT|
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So we are all using HL7, what is the problem?
You and I may know that these are similar results, but our computers will not.
• Site 1:OBX|1|CE|SysBP^Systolic BP||132||mmHg|
• Site 2:OBX|1|CE|SBP^Systolic BP||132||mmHg|
• Site 3:OBX|1|CE|BP^Systolic BP||132/70||mmHg|
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• Site 1:OBX|1|CE|8479-8^SysBP^LN||132||mmHg|
• Site 2:OBX|1|CE|8479-8^SBP^LN||132||mmHg|
• Site 3:OBX|1|CE|8479-8^Systolic BP^LN||132/70||mmHg|
The Goal
Agree on a universal coding system for clinical observations.
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How terminologies fit into the model
• LOINC – attributes/observables
• SNOMED CT – findings/values (mostly) and observables (some)
• First Data Bank - values
• RxNORM - values
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Focus of LOINC
• Value for ‘Observation Identifier’ (Seq. #3) of OBX– Or the name of the observation in other standards, such
as ASTM or DICOM
• Individual result names first, then panels– Panels are built based on the tests they contain– Panels can contain other panels
• Name should facilitate automated or manual matching (fully specified)– Create local labels as needed– Standard LOINC short names
• One common identifier for tests that are ‘clinically’ the same
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Brief History of LOINC
• Logical Observation Identifier Names and Codes
• Organized by Clement McDonald, 1994
• Supported by Regenstrief Institute and NLM
• Create a universal language for observation identifiers
• Laboratory observations were created first
• Creation of clinical observations began in 1996
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Approach
• Collect result names and descriptions– IHC, VA, Regenstrief, Mayo Clinic, 3M, Vendors
• Formulate a model to represent the individual pieces of information in the name– Avoid strategies that lead to “combinatorial explosion”
• Create “fully specified names”
• Adjust model as needed– Do any distinct entities have the same name?– Do any entities that are the same have different names?
• Repeat the process until no more adjustments are needed
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LOINC makes names for things in use
• We do not make all possible permutations that the six axes would allow (no blind cross products)
• We try to only make names and codes for things that are real (exist in someone’s system)
• We do make names that allow both atomic (post coordinated) and molecular (pre coordinated) styles– Some people wish we would be more prescriptive– Name everything, let others dictate usage
• We do object to violations of the HL7 model– No names that include post coordinated fields from other
parts of the HL7 message (status, priority, user role)
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Two LOINC committees
• Laboratory LOINC– Clem McDonald, Chair– All aspects of tests/measurements done on specimens
• Chemistry, Hematology, Microbiology, Histology, Cytology, etc.
• Clinical LOINC– Stan Huff, Chair– All aspects of tests/measurements on a patient
• Vital signs, Hemodynamic measurements, Physical findings, Radiology, Ultrasound, etc.
• Both committees meet at least 2-3 times each year
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Current and Former Clinical LOINC Members
James Barthel , Dean Bidgood, Bruce Bray, Bill Francis, Alan Golichowski, Daniel Vreeman, Karl Hammermeister, Anders Thurin, Barry Gordon, Warren Williams, James Campbell, Jim Cimino, Sue Bakken, Pat Wilson, Stan Huff, Doug Martin, Clem McDonald, Dan
Pollock, Angelo Rossi Mori, Susan Matney, Jeff Suico, Wayne Tracy, Pavla Frazier, Pat
Wilson, Lee Min Lau, Shawn Shakib, Bill Karitis, Thomas White, Steven Steindel,
Elizabeth King, Loren Stevenson, Sundak Ganesan, Ted Klein, Vivian Auld
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Clinical LOINC Subject Areas
• Vital Signs
• Hemodynamics
• Fluid Intake/Output
• Body Measurements
• Operative Notes
• Emergency Department
• Respiratory Therapy
• Documents (collections)
• Standard survey instruments
• EKG (ECG)
• Cardiac Ultrasound
• Obstetrical Ultrasound
• Discharge Summary
• History & Physical
• Pathology Findings
• Colonoscopy/Endoscopy
• Radiology reports
• Clinical Documents
• Tumor Registry
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LOINC Mascot
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Outline
• LOINC background and goals
• LOINC structure and content– Clinical LOINC– Examples
• Attachments
• Context specific hierarchies
• Collections
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LOINC codes are created systematically using a six axis model
<component> : <property> :<component> : <property> :<timing> : <system> :<timing> : <system> :<scale> : <scale> : <method><method>
General Form of Clinical LOINC Names
The first 5 parts are mandatory, but method is optional. Subparts of the six axes are created as
needed in specific subject areas.
8331-1 Body Temperature :TEMP :PT :MOUTH :QN
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Summary of the six primary axes (clinical)• Component
– Ejection fraction, heart beats, cardiac output, circumference
• Kind of property– Angle, area, length, mass, pressure, temperature
• Timing– Point in time, study minimum, maximum in 8 hours
• System– Head of fetus, tricuspid valve, ventilator setting
• Scale– Quantitative, ordinal, nominal (coded), narrative
• Method– Stated, measured, estimated, ultrasound, spirometry
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Component
The substance or entity that is measured, evaluated, or observed.
• RR INTERVAL• ORIFICE (OF A HEART VALVE)• EJECTION FRACTION• HEART BEATS• BREATHS• CARDIAC OUTPUT• SEGMENTAL WALL MOTION• PROSTHETIC VALVE TYPE• FLUID INTAKE
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Subtypes – period as a separator
• CAPACITY.VITAL.FORCED• GRADIENT.MAX (as across a valve)• INTERNAL DIAMETER.MINOR
AXIS.SYSTOLE• BIRTHS.TERM• GLASGOW SCORE.VERBAL• R' WAVE AMPLITUDE.LEAD II• ST SEGMENT AXIS.HORIZONTAL PLANE• PHYSICAL FINDINGS.SENSATION• CALORIE INTAKE.TOTAL• TIDAL VOLUME MAX.SETTING
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Challenge/Pre condition - ^ as a separator
• FLUID OUTPUT.URINE ^ POST VOID• FRACTIONAL COLLAPSE ^ INSPIRATION• BREATHS ^ AT MAX VOLUNTARY
VENTILATION• RR INTERVAL ^ AT TRICUSPID FLOW
MEASUREMENT• GAS FLOW.MIN ^ PRE THERAPY• FLOW ^ AT 25-75% OF FORCED EXPIRATION• INTRAVASCULAR DIASTOLIC ^ STANDING• NEONATAL APGAR ^ 5M POST BIRTH• MULTISECTION ^ WITH ANESTHESIA• BODY WEIGHT ^ WITH CLOTHES
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Adjustments - ^ ^ as a separator
• DIFFUSION CAPACITY.CARBON MONOXIDE ^ ^ ADJUSTED FOR HEMOGLOBIN
• DIFFUSION CAPACITY ^ ^ ADJUSTED TO BODY CONDITIONS
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Kind of Property
• TYPE – selection of subtype (nominal items)• PRID – presence or identified (nominal items)• TIME – duration of time• COLOR – color• ANGLE – degrees of arch• APER – appearance• AREA - area• ELPOT – voltage• LEN – length• MASS – mass• MRAT – mass rate (gm/hr)• PRES – pressure• TEMP – temperature• FCN – function (of a body part or system)
The characteristic or attribute of the component thatis measured, evaluated, or observed.
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Timing
• PT - at a point in time
• STDY^MIN – minimum over the period of a study
• 24H - a twenty four hour shift
• 10H^MEAN – mean value for a ten hour period
• 8H^MAX – maximum value in an eight hour period
The interval of time over which the observationor measurement was made.
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System
• YOLK SAC^FETUS• UPPER GI TRACT• TRICUSPID VALVE^PATIENT• TRICUSPID VALVE^FETUS• SYNOVIAL SPACE• HEART.VENTRICLE.RIGHT• VENTILATOR• ARTERIAL SYSTEM• BLADDER• EYE.LEFT
The system (context) or body part aboutwhich the observation was made.
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Patient, Control, or Donor (as part of system)
• CONTROL
• PATIENT
• DONOR
• BABY
• FETUS
Non-patient values for this axis should be used with care, or combinatorial explosion could result
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Scale
• QN - quantitative– 4, 7.4, 1:8
• ORD - ordinal, the answers can be ranked– +/-, 1+, 2+, 3+ ….– mild, moderate, severe
• NOM - nominal, answers are unranked– Stool appearance– Chest tube type
• NAR - answer is a paragraph of text
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Method
• STATED – reported verbally
• MEASURED – actually observed
• CALCULATED – numeric calculation
• US – ultrasound
• EKG – electrocardiogram
• ESTIMATED – an educated guess at the real value
• HELIUM REBREATHING – helium rebreathing
• SPIROMETRY – spirometry
• MANUAL – done by hand
• AUTOMATED – used an instrument
Procedure used to make the measurement or observation. Only used when it makes an important distinction in sensitivity or specificity.
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Putting it all togetherCode Component Prop TIME System Scale Method
8302-2 BODY HGHT LEN PT ^PATIENT QN
3140-1 BODY SURF AREA PT ^PATIENT QN DERIVED
8331-1 BODY TEMP TEMP PT MOUTH QN
8319-6 BODY TEMP TEMP 12H^MIN XXX QN
8629-8 Q WAVE DPT ELPOT PT HEART QN EKG
8632-2 QRS AXIS ANGLE PT HEART QN EKG
8642-1 PUPIL DIA LEN PT EYE.RIGHT QN AUTO
21611-9 AGE TIME PT ^PATIENT QN EST
21612-7 AGE TIME PT ^PATIENT QN REPORT
19867-1 CAPACITY.VITAL VOL PT RESP SYS QN
9279-1 BREATHS NRAT PT RESP SYS QN
11882-8 GENDER FIND PT ^FETUS NOM US
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More complex examples
9273-4 NEONATAL APGAR^2M POST BIRTH FCN PT^PATIENT ORD
9192-6 FLUID OUTPUT.URINE VRAT 24H URINARY TRACT QN
11892-7 GESTATIONAL AGE TIME PT ^FETUSQN US.ESTIMATED FROM AC.HADLOCK84
10105-5 ST SLOPE.LEAD V6 ELPOTRAT PT HEARTQN EKG
8431-9 INTRACHAMBER SYSTOLIC PRES PTHEART.VENTRICLE.LEFT.OUTFLOW TRACT QN
8283-4 CIRCUMFERENCE.MAX LEN PTCALF.RIGHT QN
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Outline
• LOINC background and goals
• LOINC structure and content– Clinical LOINC– Examples
• Attachments
• Context specific hierarchies
• Collections
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HL7 & the Claims Attachment Recommendation
• HIPAA Legislation was passed in Aug 1996
• Extended debate– Different motivations for payers and providers
• Initial proposal to use X12 messages, HL7 Version 2 messages, LOINC
• Notice of proposed rule making (NPRM) in Sept 2005– X12 messages– HL7 CDA Release 1 standard (probably will now be R2)
• XML based standard for transmitting documents– LOINC codes
• No final rule yet
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Unsolicited Attachment
Yes
No
X12N 837+
X12N 275Additional Information
Provider Payer
Deliver aservice
Sufficient toPay?
Submits a claimwith SupportingDocumentation
Pay the claimDeny the
claim
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Request for Additional Information
No
Yes
X12N 837
X12N 277Request for
Additional information
X12N 275Additional Information
Provider Payer
Deliver aservice
Need moreinfo to pay?
Providersubmits a
claim
Requestadditional
documentation
Assemblesupporting
documentation
Pay the claim
Sufficient toPay?
Yes
Deny theclaim
No
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Organizations & Documents
X12 277 Transaction
12748-1
9832-1
X12 275 Transaction
HL7 CDA R1
15748-3
7832-8
20118-5
4332-7
12748-1
9832-1
ASC X12 &ASC X12 & Subcommittee Subcommittee
X12NX12N
X12 X12 Trans.Trans.Sets Sets
277, 275277, 275
TG2 Impl.TG2 Impl.Guides Guides 277, 275277, 275
Health Level Seven
HL7 CDA R 1
HL7 Claims
AttachmentsImpl.
Guide
LOINC Consortium
LOINCCodes
LOINCAttachment
Booklets
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Attachment Types Selected for HIPAA
• Attachment types ultimately selected for development and HIPAA recommendation:
1. Ambulance
2. Emergency Department
3. Rehabilitative Services
4. Lab Results
5. Medications
6. Clinical Notes
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CDA: Semi- or fully-structured HIPAA Claims Attachments
Autoadjudicate
<section><caption>
<caption_cd V="8709-8"/>Skin</caption><paragraph>
<content>Erythematous rash, palmar surface,left index finger.
<observation_media><observation_media.valueMT="image/jpeg">
<REF V="rash.jpeg"/>
</observation_media.value></observation_media></content>
</paragraph></section>
Provider Payer
Transcription*
Scanned Paper or Document Imaging*
Level 3 CPR
<section><caption>
<caption_cd V="8709-8"/>Skin</caption><paragraph>
<content>Erythematous rash, palmar surface,left index finger.
<observation_media><observation_media.valueMT="image/jpeg">
<REF V="rash.jpeg"/>
</observation_media.value></observation_media></content>
</paragraph></section>
Image + XML
Semistructured
Structured and coded
Specific XML forms*
<section><caption>
<caption_cd V="8709-8"/>Skin</caption><paragraph>
<content>Erythematous rash, palmar surface,left index finger.
<observation_media><observation_media.valueMT="image/jpeg">
<REF V="rash.jpeg"/>
</observation_media.value></observation_media></content>
</paragraph></section>
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Outline
• LOINC background and goals
• LOINC structure and content– Clinical LOINC– Examples
• Attachments
• Context specific hierarchies
• Collections
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Use cases for Context Specific Hierarchies
• Roll-up in decision support– Body weight– Body height– Blood pressure
• Basis for queries– “All surgery notes”– “All head x-ray reports”– “All hematology lab results”
• Control of data access– Tabs for document types
• Radiology– (by body region) – Head, neck, chest, abdomen, …– (by modality) – X-ray, CT, Ultrasound, Scans, …
• Documents– (by subject) – cardiology, ob-gyn, heme-onc, surgery, internal medicine, …– (by setting) – inpatient, ambulatory, home care, SNF, …
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Consultation Note Example
• 11488-4 Consultation note Find Pt {Setting} Doc {Provider}
• 34100-8 Consultation note Find Pt Critical care unit Doc {Provider}
• 34101-6 Consultation note Find Pt Outpatient Doc {Provider}
• 34101-6 Consultation note Find Pt Outpatient Doc General medicine
• 34749-2 Consultation note Find Pt Outpatient Doc Anesthesia
• 34104-0 Consultation note Find Pt Hospital Doc {Provider}
• 34102-4 Consultation note Find Pt Hospital Doc Psychiatry
• NewCD Consultation note Find Pt {Setting} Doc Internal medicine
• 34764-1 Consultation note Find Pt {Setting} Doc General Medicine
• 34776-5 Consultation note Find Pt {Setting} Doc Gerontology
• 34781-5 Consultation note Find Pt {Setting} Doc Infect. Disease
• 34795-5 Consultation note Find Pt {Setting} Doc Nephrology
• 34797-1 Consultation note Find Pt {Setting} Doc Neurology
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Outline
• LOINC background and goals
• LOINC structure and content– Clinical LOINC– Examples
• Attachments
• Context specific hierarchies
• Collections
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Issues related to “collections”
• Two “kinds” of items within LOINC– Individual measurements/observations/data elements– Collections of measurements/observations/data elements
• Different codes for orders versus results?
• Different codes for narrative vs nominal?– Medication history – paragraph versus coded list– Want to have a single code to get all medication history
• Two kinds of “collections” but different things– Panels (known explicit content)
• Vital Signs, ABGs, CBC, Chem 7 panel (known explicit content)– Documents (vague or abstract content)
• Operative note, discharge summary, consult
• Bone marrow exam – text table of discreet data
• Separate codes for: rtf, Word, pdf, scanned images?
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Proposed stragegy
• For individual measurements– Continue to create codes that distinguish between character
identifiers, strings, codes, dates, numbers– Create generic parents as needed, relate parent to children
using new hierarchies
• For collections– Continue to distinguish panels (explicit list of contained
elements) from documents (ill defined or vague contents)– For documents, do not make distinct names based on
narrative, nominal, pdf, Word, scanned image
• Use the same codes for orders as for results– Just a code for “hematocrit”, no code for “hematocrit order”
or “hematocrit result”– Use context to complete the meaning
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Literature References
• McDonald CJ, Huff SM, etal. LOINC® a universal standard for identifying laboratory observations – a 5-year Update. Clinical Chemistry, 2003
• Huff SM, Rocha RA, McDonald CJ, De Moor GJE, etal. Development of the LOINC® (Logical Observation Identifier Names and Codes) Vocabulary. Journal of American Medical Informatics Association, 1998, 5:276-292.
• Dolin RH, Huff SM, Rocha RA, Spackman KA, Campbell, KE. Evaluation of a “Lexically Assign, Logically Refine”Strategy for Semi-Automated Integration of Overlapping Terminologies. Journal of American Medical Informatics Association, 1998, 5:203-213.
• Forrey AW, McDonald CJ, DeMoor G, Huff SM , Leavelle D, Leland Fiers DT, Charles L, Griffin B, Stalling F, Tullis A, Hutchins K, Baenziger J. Logical Observation Identifier Names and Codes (LOINC) Database: A public use set of codes and names for electronic reporting of clinical laboratory test results. Clinical Chemistry, 1995.