LOINC®Panels, Forms, and Patient Assessment Instruments

08.13.2009

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

Research Scientist | Regenstrief Institute, Inc

Copyright © 2009

Clinical LOINC Tutorial

Overview• Background• Standard Panels in LOINC• Enhanced Panel Model for Patient

Assessment Instruments• Current Projects • Challenges Along the Way

Brief Timeline• 2000 – First panels in LOINC• 2000 – Original Model Extension for Standardized Assessment

Measures (Braden, etc)– Bakken, S, Cimino, JJ, Haskell, R, Kukafka, R, Matsumoto, C, Chan, GK, and Huff, SM (2000).

Evaluation of the clinical LOINC (Logical Observation Identifiers, Names, and Codes) semantic structure as a terminology model for standardized assessment measures. J Am Med Inform Assoc 7(6):529-38.

• 2000 – Initial surveys stored in LOINC (HIV, HHC, etc)

• 2002 – Proposed extension for Assessment Instruments– White, TM and Hauan, MJ (2002). Extending the LOINC conceptual schema to support standardized assessment instruments. J Am Med

Inform Assoc 9(6):586-99.

• 2005 – Dissection of OASIS in LOINC – Choi, J, Jenkins, ML, Cimino, JJ, White, TM, and Bakken, S (2005).

Toward semantic interoperability in home health care: formally representing OASIS items for integration into a concept-oriented terminology. J Am Med Inform Assoc 12(4):410-7.

• 2006 – Initial work with MDS/OASIS (LOINC v2.17)• 2006 – More discussions about data model, APSE/CHI interest• 2006 – CHI/NCVHS Endorsement of LOINC as standard for

federally-required assessment instruments (quest/ans)

Standard Panels in LOINC

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 identified 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 finding and thus should be

assumed to be negative, absent, or not present if panel result does not include data for this element.

Example Panel

Example Panel with Nesting

Clinical Panels

Patient Assessment Instruments

Iterative Enhancement of the Panel Model

Introduction• Initial modeling (circa 2000) required modest

extensions to the LOINC axes– E.g. for System to include aggregate units like “family”, and Method

to distinguish among reported and observed findings

• 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

What’s in the Master Question File?

• Question (item) name/text– Exact question text, form-specific 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

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

• Separates the form structure, question details, the rendered version (paper or screen), and the program that manages it

• Can easily reuse observations (and attributes) in different forms/sets

Panels/Forms Available as Separate Download

http://loinc.org/downloads

Rules for Display of Items1. 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]

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.

3. COMPONENT. This is the default display

Pain Presence. Ask resident: “Have you had pain or hurting at any time in the last 7 days?”

Item label = “Body Mass Index (BMI)”LOINC Component = “Body mass index”

Rules for Display of Items

• LOINC is developing/evolving other display names– Short Name– Long Common Name– Consumer Name

• May be useful in some contexts, but our current practice is to capture the exact form display with previous rules

• Some of the original surveys in LOINC may not yet follow the model

Structured Answer Lists• Many items in surveys have highly specialized, fixed

answer lists– Often the answer lists define the meaning of the question– Few are represented by existing codes in reference terminologies

• LOINC has created answer codes where needed– Have “LA” prefix and a mod-10 check digit– Are unique by lexical string (ignoring capitalization)– Intentionally do NOT distinguish based on context-specific meaning

• In some cases, the answer list is identified with a Regenstrief-assigned OID (for HL7 CDA use)

• Answer list shows sequence, but not bound by it• Store local codes for items and have place to store

universal code (e.g. SNOMED) – not yet populated

Current Projects and Directions

ASPE as Key Supporter

• ASPE (Jennie Harvell) has championed use of HIT standards for assessment instruments in many venues

• Initial Reports– Making the "Minimum Data Set" Compliant with Health Information Technology Standards– Standardizing the MDS with LOINC® and Vocabulary Matches

Consolidated Health Informatics Initiative

• CHI Goal:– Adopts a portfolio of existing health information

interoperability standards (health vocabulary and messaging) enabling all agencies in the federal health enterprise to “speak the same language”

• In 2006, adopted LOINC as standard:– Laboratory test order names– Medications: Structured Product Labeling Sections

Consolidated Health Informatics Initiative

• In 2007, CHI adopted LOINC as standard for federally-required assessments:– questions and answers– assessment forms that include functioning

and disability content

• Jennie Harvell (ASPE) Co-chaired

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 Classification• howRU• OMAHA• PHQ (9 and 2)

Find them in RELMA

Current RI/LOINC Efforts

• ASPE-funded effort to create LOINC® representation of new instrument versions– MDSv3 (done)– OASIS-C (this fall)

• CMS-funded effort to create LOINC® representation of new CARE instrument– Make recommendations on legacy instruments– Interoperability recommendations

HL7 CDA Implementation Guide

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

ChallengesCorralling the Creativity

Intellectual Property Issues

• Must negotiate separate agreements with each copyright/IP holder

• Many instruments are fiercely 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)

Modeling

• Despite many instruments now in LOINC, reuse of items has been minimal– E.g. extremely few of same items b/w MDSv2

and MDSv3– MDSv3 has greater similarity to CARE, but the

lookback period is different (7D vs 2D)

• Lament the seemingly trivial differences between the CMS-required instruments

Original PHQ-9

CARE

MDSv3

MDSv2

MDSv3

OASIS

CARE

Incongruity with HL7 Information Model

• Items for things that could go in PID, etc• Flat data model vs stacked

– Every ‘Check all that apply’ stored as separate yes/no item

• “Unknown” or “unable to determine” as answer choices vs flavors of null

• In general, CMS has not been thinking in terms of interoperable data exchange– Resistant to getting involved in SDO processes like

balloting

Many Yes/No Diseases

Always New Challenges

• How to label/store definitional text vs text giving examples– Rashes – e.g. intertrigo, eczema, drug rash, heat rash…

• Answer list sequences– Same answers across instruments but different order

• Skip logic shown at level of answer– Current strategy is to aggregate up to question level