Daniel J. Vreeman, PT, DPT, MScAssociate Research Professor, Indiana University School of Medicine

Associate Director for Terminology Services, Regenstrief Institute, Inc

© 2015

Documents

Clinical LOINC Meeting

2015 02 12

Overview

1. Origins of a Document Ontology

2. HL7/LOINC Model

3. Evaluation and Ongoing Development

4. Future Directions

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http://loinc.org/slideshows

Origins of a Document Ontology

Local systems have idiosyncratic names

…need a common, controlled vocabulary

Outpatient Pain Note

Dr. Smith’s Tues Pain Clinic

Chronic Pain Clinic

Development Milestones

2000 06 Document Ontology Task Force

2003 09 First axis values and LOINC codes released

2005 06 Expanded SMD domain

2007 10 Revised axis values approved

2013 06 Special Document Ontology File in releases

2013 12 Major harmonization completed

Document Type CodesProvide consistent semantics for names of documents exchanged between systems for any purpose

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.

Display Retrieval Organization Templates

What is a Document?a collection of information

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an information collection

Title

Sections

Sentences

Sentences

Other content

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Different than a panel enumerated, discrete elements

an information collection

Title

Sections

Sentences

Sentences

Other content

Clinical NotesClinical Note

A clinical document, produced by clinicians spontaneously or in response to a request for consultation.

Clinical Report

A clinical document, produced in response to an order for a procedure.

Formal Document Ontology model and rules apply to clinical notes, but not (yet) to reports.

ApproachEmpiric analysis of >2000 document names

Mayo, 3M/Intermountain, VA in SLC, VA in Nashville

Find the level of granularity that best meets exchange use case

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Ultra-specific local names • Dr. Evil’s Friday Afternoon Pain

Clinic Note

Commonly understood elements • Outpatient Pain Clinic Note

Local Codes and NamesStill probably needed

Can send both in HL7

Mapping to a standard enables: Interoperability

Aggregation

Document Ontology Model

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Names are based on

expected information content

NOT document format

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Names Based on ContentSame LOINC code for…

…if information content is the same

Not Part of the NameAuthor name

Location of service

Date of service

Status (e.g. signed, unsigned)

Security/privacy flags (e.g. protected)

Updates or amendments to a document

Assume that these other important attributes would be sent in different fields of the message (e.g. metadata)

Domain of the content in the document e.g. Cardiology, Pediatric Cardiology, Physical Therapy

Subject Matter Domain

Author training/professional classification (not @ subspecialty) e.g. Physician, Nurse, Case Manager, Therapist, Patient

Role

Modest extension of CMS’s definition (not equivalent to location) e.g. Hospital, Outpatient, Emergency Department

Setting

Service or activity provided to patient e.g. Consultation, History and Physical, Discharge Summary

Type of Service

General structure of the document e.g. Note, Letter, Consent

Kind of Document

Rules for constructing names

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1. Enumerated ListDocument names are constructed from enumerated lists of values for each axis.

2. Document + One Other

Names need to specify a Kind of Document value and at least one of the other four axes.

Component

<Type of Service> <Kind of Document>

Property

Find

System

<Setting>

Scale

Doc

Method

<Subject Matter Domain>.<Role>

3. Combinations

Combinations from within an axis are allowed where they are reasonable (SMD, Service).

Only a few examples currently:

Assessment+Plan note

Treatment plan+summary note

Hematology+Medical oncology

Example LOINC NamesComponent Prop Time System Scale Method

Group counseling note Find Pt Hospital Doc {Author Type}

History and physical note Find Pt {Setting} Doc {Author Type}

Initial evaluation note Find Pt {Setting} Doc Physician

Note Find Pt Outpatient Doc Diabetology

Note Find Pt {Setting} Doc Mental health

{Curly Braces} notation: send that content as a separate item in the message (field or segment).

Find All the Terms

In the LOINC database (and RELMA), all of the terms conforming to the rules of the ontology are placed in the DOC.ONTOLOGY class.

Before  LOINC  version  2.50,  they  were  (non-­intuatively)  in  the  class  DOC.CLINRPT

LOINC Terms for Sharing Ontology Values

Pro Tip: find them with this search

http://search.loinc.org/search.zul?query=LOINC+Document+Ontology

LOINC Accessory FilesSpecial representations of LOINC content

Accessory FilesLOINC Panels and Forms File

An export of key panels, survey instruments, and forms in a detailed data structure.

LOINC Multiaxial Hierarchy File Hierarchical organization of LOINC terms based on their axes. DocOnt terms are organized by Component (Type of Service)

LOINC Document Ontology File Special file for the detailed naming conventions for clinical document titles (e.g. Discharge Summary, Progress Note, etc).

Accessory FilesLOINC Panels and Forms File

An export of key panels, survey instruments, and forms in a detailed data structure.

LOINC Multiaxial Hierarchy File Hierarchical organization of LOINC terms based on their axes. DocOnt terms are organized by Component (Type of Service)

LOINC Document Ontology File Special file for the detailed naming conventions for clinical document titles (e.g. Discharge Summary, Progress Note, etc).

Hierarchy in RELMA

Document Ontology FileLinks all Document Ontology terms to their constituent axis values

Axis values given unique Part identifiers categorized by axis

Download from LOINC site

New (Free) ResourceHL7 Implementation Guide

Evolution + EvaluationWe’re not done yet

EvolutionOngoing evaluation and evolution Exceptional contributions from Columbia University and the VA

Major Focus: Expanded original SMD values with ABMS specialty names and iterative discussion

More ontology additions from submissions

Iterative Evaluation Case StudyNYPH-CUMC

1. Expanded CDO is better

2. Many local documents map to 1 LOINC

3. Inter-rater reliability was good

Case StudySMD Role Setting Type Service Kind of Doc Overall Distinct

Original CDO

26.7% 99.9% 99.9% 43.5% 100% 23.4% (n=894)

7.9%

Expanded CDO

98.6% 100% 100% 99.9% 99.9% 98.5% (n=935)

39.1%

98.5%

Hyun S, Shapiro JS, Melton G, Schlegel C, Stetson PD, Johnson SB, Bakken S. Iterative evaluation of the Health Level 7--Logical Observation Identifiers Names and Codes Clinical Document Ontology for representing clinical document names: a case report. J Am Med Inform Assoc. 2009 May-Jun;16(3):395-9.

Cross-site Mapping Study of DO AxesTerms whose titles specified this axis

SMD Role Setting Type of Service None

West Campus (n=1644)

67.6% 34.6% 28.9% 59.4% 8.2%

East Campus (n=1124)

69.1% 56.0% 12.7% 69.0% 7.1%

1. Majority of titles map to at least one axis 2. Sites varied in how they specified titles; creates

granularity issues in cross-site aggregation

Li L, Morrey CP, Baorto D. Cross-mapping clinical notes between hospitals: An application of the LOINC Document Ontology. AMIA Symp Proc; 2011:;777-783.

The LOINC document ontology model can provide a robust representation of clinical documents. This can be exploited to assist in common naming conventions, finding notes by traversing the axis categories of Subject, Setting, Role and Type of Service. However, the granularity of representation can be an issue in mapping across sites.

“

Other Evaluations

Other EvaluationsDugas M, Thun S, Frankewitsch T, Heitmann KU.

LOINC codes for hospital information systems documents J Am Med Inform Assoc. 2009 May-Jun;16(3):400-3. PMID: 19261942.

Häyrinen K, Mykkänen J.

Mapping the Finnish National EHR to the LOINC. Stud Health Technol Inform. 2011;165:161-6. PMID: 21685603.

Reeves RM, FitzHenry F, Brown SH, et al. Who said it? Establishing professional attribution among authors of Veterans' Electronic Health Records. AMIA Annu Symp Proc. 2012;2012:753-62. Epub 2012 Nov 3. PMID: 23304349.

Still ongoing development…

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The FutureGreat Scott!

Future DirectionsMore v1 and v2 axis value harmonization

Identifiers for the axis values

Axis definitions

Computable hierarchy

Extension to other Kind of Documents

Empiric analysis of document contents

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