2015 06 - LOINC Introduction

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

Associate Director for Terminology Services, Regenstrief Institute, Inc

@djvreeman

2015

An Introduction to LOINC

Laboratory LOINC Workshop - Indianapolis, IN USA

AcknowledgementsLOINC Development Team

Clem McDonald, Jami Deckard, David Baorto, Katy Holck, Swapna Abhyankar, Theresa Pritchard, Rachel Fuhr, Sara Armson

RELMA Development Team

John Hook, Anandhi Sowmyan, James Dennis

LOINC Committee

Supporters

NLM, Regenstrief Institute, Regenstrief Foundation, APTA, RSNA, the LOINC Premium Members and Donors

Overview

1. Origins and purpose of LOINC

2. The LOINC way

3. LOINC today

4. Overview of implementation resources

photo via Vernio77

Origins of LOINC

McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.

Informatics Pioneers40 years of EMR work

Indiana Network for Patient Care

Regenstrief serves as neutral 3rd party convener

Most comprehensive and longest tenured Health Information Exchange (HIE) in USA

Informatics Pioneers40 years of EMR work


Regenstrief serves as neutral 3rd party convener

Most comprehensive and longest tenured Health Information Exchange (HIE) in USA

Crash Test Dummies

photo via nosha McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.

photo via nosha McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.

The rain forest canopy is a seamless web through which arboreal creatures efficiently

move to reach the edible fruits without any attention

to the individual trees.

In each case, the goals are stymied or delayed by the work and

expense of translating the Babel-like proliferation of different codes used by different sources for the

same tests even when the sources comply with existing electronic

message standards.Forrey AW, McDonald CJ, et al. Logical observation identifier names and codes (LOINC) database: a public use set of codes and names for electronic reporting of clinical laboratory test results. Clin Chem. 1996 Jan;42(1):81-90. PubMed PMID: 8565239.

photo via chadlewis

More than Meets the Eye

Fundamental challenges: Local systems have different ways of identifying the same concept.

Things that look alike arent the same.

This problem would not exist if all laboratories used the same universal set of

test identifiers when electronically transmitting

test results.

Forrey AW, McDonald CJ, et al. Logical observation identifier names and codes (LOINC) database: a public use set of codes and names for electronic reporting of clinical laboratory test results. Clin Chem. 1996 Jan;42(1):81-90. PubMed PMID: 8565239.

LogicalObservationIdentifiersNames andCodes

A universal code system that facilitates exchange, pooling, and processing of clinical data.

Established in 1994 by Regenstrief Institute.

Vocabulary standard for observation identifiers.

LOINC is like a bar code for test data

photo via puuikibeach

WE DO MEASUREMENTS

Laboratory LOINC

Top 10 Lab Domain Overview

Microbiology 10,700Chemistry 9,200Drug/Toxicology 7,200Allergy 3,900Chemistry - Challenge 3,700Serology 2,500Hematology 2,100Antibiotic Susceptibilities 1,700Cell Markers 1,500Molecular Pathology 900

Clinical LOINC

If an observation is a question and the observation value is an answer

LOINC provides codes for questionsWhere needed, other vocabularies provide codes for answers

What is my patients 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

photo via Ed Yourdon


HL7 v2.x Message

MSH|^~\&|HOSPITAL_A|SAMPLE_HOSPITAL_A|||$YearMonthDay||||||||||||||| PID|||$patientId$||$patientName$|||||||||||||||||||| PV1|||||||$attendingDoctor$||$consultingDoctor$|||||||| OBR|1|||012^CBC/Auto Diff^HSPA^57021-8^CBC W Auto Diff^LN||$reqDate||||||||| OBX|2|NM|123^WBC^HSP_A^26464-8^Leukocytes [#/volume] in Blood^LN||10.8|K/MM3|||||F| OBX|3|NM|234^RBC^HSP_A^26453-1^Erythrocytes [#/volume] in Blood^LN||4.82|MIL/MM3|||||F| OBX|4|NM|345^HGB^HSP_A^718-7^Hemoglobin [Mass/volume] in Blood^LN||15.7|GM/DL|||||F| OBX|5|NM|456^HCT^HSP_A^20570-8^Hematocrit [Volume Fraction] of Blood^LN||45|%|||||||F|


HL7 v2.x Message

MSH|^~\&|HOSPITAL_A|SAMPLE_HOSPITAL_A|||$YearMonthDay||||||||||||||| PID|||$patientId$||$patientName$|||||||||||||||||||| PV1|||||||$attendingDoctor$||$consultingDoctor$|||||||| OBR|1|||012^CBC/Auto Diff^HSPA^57021-8^CBC W Auto Diff^LN||$reqDate||||||||| OBX|2|NM|123^WBC^HSP_A^26464-8^Leukocytes [#/volume] in Blood^LN||10.8|K/MM3|||||F| OBX|3|NM|234^RBC^HSP_A^26453-1^Erythrocytes [#/volume] in Blood^LN||4.82|MIL/MM3|||||F| OBX|4|NM|345^HGB^HSP_A^718-7^Hemoglobin [Mass/volume] in Blood^LN||15.7|GM/DL|||||F| OBX|5|NM|456^HCT^HSP_A^20570-8^Hematocrit [Volume Fraction] of Blood^LN||45|%|||||||F|

LocalCode^LocalName^CodeSystem^LOINCcode^LOINCname^CodeSystem


HL7 v2.x Message

Codes for individual observations

Leukocytes [#/volume] in Blood by Automated count

Erythrocytes [#/volume] in Blood by Automated count

Hematocrit [Volume Fraction] of Blood by Automated count

and collections of observations

CBC W Auto Differential panel - Blood

Vital signs, weight and height panel

PHQ-9 quick depression assessment panel

OBX||CE|600-7^Bacteria Bld Cult^LN||56415008^Klebsiella pneumoniae^SCT

Result with a Coded Value



Data type of result (OBX-5) is a coded

element



This code is from LOINC

Code identifying this observation

(what are these results? Bacteria identified by

Blood Culture )


element



This code is from LOINC

Code identifying this observation

(what are these results? Bacteria identified by

Blood Culture )


element

This code is from SNOMED

Code identifying the result (K. pneumoniae)

LOINC fits well with other data standards

photo via Temari 09

The LOINC WayOpen. Nimble. Pragmatic.

Development ApproachWorldwide distribution at no cost

New terms requested by end-users

Welcome all comers

Committees are volunteers

Development ApproachWorldwide distribution at no cost

New terms requested by end-users

Welcome all comers

Committees are volunteers

Its free, but invaluable

Financial SupportMany sources AHCPR, ASPE, CDC, CHCF, CMS, Hartford Foundation, IN CTSA, Regenstrief Foundation*, Regenstrief Institute, NCRR, NIBIB*, NLM*, LOINC User Community* *active now

Today, the U.S. National Library of Medicine (NLM) accounts for about 2/3 of our funding.

Major releases twice per year (June and December)

photo via striatic

010,000

20,000

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70,000

80,000

4/24

/199

5 | 1.

0

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5 | 1.

0a

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5 | 1.

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5 | 1.

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7 | 1.

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| 1.0

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9 | 1.

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| 1.0

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12/0

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07/0

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.27

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.34

06/3

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.36

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.38

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.42

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.44

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.46

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.48

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.50

LOINC Codes

Only Lab LOINC Codes

LOINC Codes Over Time by Release

laboratory terms only

75,000 codeshavent you finished yet?

Lots CookingAlways more lab tests

Genetic testing

Patient reported outcomes

Translational research data

Document titles

Radiology reportsphoto via liber

photo via liber

Deckard J, McDonald CJ, Vreeman DJ. Supporting interoperability of genetic data with LOINC. J Am Med Inform Assoc. 2015 Feb 5. PMID: 25656513.

Legal Stuffhttp://loinc.org/terms-of-use

photo via 917press

Just kidding. Copyright is a good thing for standards.Its the licensing part that is sometimes interesting.

No cost Worldwide In perpetuity

Use Copy Distribute

Any purpose: commercial non-commercial

Encourages translation into other languages

CANNOT use any Licensed Material to develop or promulgate a different standard for orders or observations.

That would defeat the purpose of having a standard!

LOINC in action today

photo via iboy_daniel

Data standards are like telephones. They require a critical mass of users before they become useful.

~ Clem McDonald, MD (1998)

Our vision is for LOINC to be integrated into every clinical information system that shares or aggregates data.

38,300+ registered users in 167 countries

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loinc.org registered users

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loinc.org registered users

6,000 new users per year

LOINC Translators

22 organizations. Currently translations into 18 variants of 12 languages

Vreeman DJ, Chiaravalloti MT, Hook J, McDonald CJ. Enabling international adoption of LOINC through translation. J Biomed Inform. 2012 Aug;45(4):667-73. PMID: 22285984.

Australia

Austria

Belgium

Brazil

Canada

Cyprus

Estonia

Finland

France

Germany

Iceland

India

Malaysia

Mexico

Mongolia

The Netherlands

New Zealand

Philippines

Portugal

Qatar

Rwanda

Saudi Arabia

Slovakia

Slovenia

Spain

Thailand

Turkey

United States

Adopted as National Standard

Large ImplementationsSIGA Sade project

7+ Provincial systems in Canada

8+ Regional Health Information Exchanges in Spain

ePSOS

Assistance publique - Hpitaux de Paris

Hong Kong Hospital Authority

Philippine Health Insurance Corporation

InFSE Project in 5 regions in Italy (LOINC Italia)

Many more...

Other Key AdoptionsMany big labs

All health-related federal agencies in USA

Lots of care organizations

Professional societies

Health information exchange networks

Insurance companies

EHR vendors

Instrument manufacturers (nascent)

For the last few years, the AP-HP has been using the LOINC international

nomenclature Thanks to this catalogue, the AP-HP is able to use the nomenclature in its

treatment processes, whenever biology analyses and test results are

requested.

Vandenbussche PY, Cormont S, Andr C, et al. Implementation and management of a biomedical observation dictionary in a large healthcare information system. J Am Med Inform Assoc. 2013 May 1. PMID: 23635601.


The results of our work validate the choice made to develop a local dictionary

aligned with LOINC.

Members of the Korean National Standards Committee have enthusiastically embraced LOINC

LOINCing in Hong Kong

Some ad hoc LOINCing

Talking about LOINC at the Thai Ministry of Information and Communication Technology

Dr. Case leading some LOINCing in Cyprus

Support for LOINC in Ministry of Health Malaysia

photo via Fishking_1

Upstream standardization. Ask your IVD vendor which LOINC codes

are appropriate for that test.

In USA, major driver of eHealth standards adoption is

EHR Incentive Program

a.k.a. Meaningful Use

Blumenthal D, Tavenner M. The "meaningful use" regulation for electronic health records. N Engl J Med. 2010 Aug 5;363(6):501-4. Epub 2010 Jul 13. PubMed PMID: 20647183.

Stage 1 2011-2012

Data capture and sharing

Stage 2 2014

Advance clinical processes

Stage 3 2016

Improved care outcomes

progressive requirements for data standards

LOINC adopted for: 1. View, download, transmit data to third party 2.Cancer case reporting to state registry 3.Send/receive electronic lab results in

ambulatory settings 4.Provide a care summary at care transition 5.Provide clinical summaries for patients 6.Submit reportable lab results to public health

Lab reporting to EHRs

Use in Quality Measures

LOINC Adopted ForPatient Characteristics

[Non-lab] Diagnostics studies

Patient experience

Family history

Functional status

Health record component

Interventions (that produce an assessment or measured results)

Laboratory tests

Physical exam

Patient preference

Risk evaluation

System resources (healthcare resources)

An Example Quality MeasureNational Committee for Quality Assurance

Diabetes: Hemoglobin A1c Poor Control

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.

Find HbA1c in the EHR with LOINC

Proposed MU3ONC 2015 Standards and Certification Criteria Notice of Proposed Rule Making (NPRM)

March 30, 2015

118 pages. 119 mentions of LOINC.

Need LOINC for these CriteriaComputerized provider order entrylaboratory

Vital signs, body mass index, and growth charts

Clinical Decision Support

Patient-specific education

Social, psychological, and behavioral data

Transitions of care

Incorporate laboratory tests and values/results

Transmission of laboratory test reports

Data portability

Care Plan

Clinical Quality measures - record and export

Clinical Quality measures - import and calculate

View, download, transmit to 3rd party

Transmission to public health agencies - reportable lab tests and values

Transmission to cancer registries

Transmission to public health agencies - antimicrobial use and resistance reporting

Transmission to public health agencies - health care surveys

Consolidated CDA creation performance

Application access to Common Clinical Data Set

Electronic submission of medical documentation

FDA Adoption and Promotion of LOINCJanuary 27, 2015 and May 14, 2015

Know LOINC? Get Hired!June 1, 2015

Many unexpected successes along the way

photo via heyyu

Everyone loves LOINC

photo via mccaughan

The LOINC DistributionLOINC Table, Accessory Files, and Tools and Resources for Implementers

loinc.org/downloads

LOINC TableThe main LOINC database content

One Record Per Term

Long Common Name Cholesterol in LDL [Mass/volume] in Serum or Plasma by Direct assay

Short Name LDLc SerPl Direct Assay-mCnc

Class Type Lab

Class Chem

Example Units (local) mg/dL

Example Units mg/dL

Order/Obs Both

A Rich Encyclopedia

Cells.HPV E6+E7 mRNA/cells [Presence] in Cervix by Flow cytometry (FC)

Most human papilloma virus (HPV) genomes encode for eight major proteins, six "early" (E1, E2, E3, E4, E6, and E7) and two "late" (L1 and L2). The "early" are regulatory in function. E6 and E7 genes in high-risk HPV genotypes are known as oncogenes because of their continuous expression, which leads to disruption of cell-cycle check points and cell genome instability through alteration of cellular p53 and retinoblastoma protein functions. This test identifies cervical cells containing HPV E6 and E7 polycistronic mRNA using in situ hybridization with oligonucleotides specific for the mRNA transcripts. The cells remain intact, and following fixation and permeabilization, the probes enter the cells. The flow cytometer measures two things: 1. Quantification of E6 and E7 mRNA in each cell and 2. The percentage of cells over-expressing E6 and E7 mRNA.

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. Lab terms are organized first by Component, then by System.

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

Tools for Implementers

photo via Robert S Donovan

loinc.org/mailing-lists

search.loinc.org

Alternate Language Search

Everything in Italian!Alternate Language Search

forum.loinc.org

loinc.org/usage

@LOINC@LOINC

loinc.org/slideshows

loinc.org/adopters

loinc.org/adoptersList your organization. Free!

RELMAREgenstrief LOINC Mapping Assistant

RELMA Features

Browse LOINC content

Map local terms to LOINC import/export translate local words to LOINC-speak manual/automated mapping

Search Window

Mapping Screen

22 organizations, 5 countries, 102,000 mappings

Dixon BE, Hook J, Vreeman DJ. Learning From the Crowd in Terminology Mapping: The LOINC Experience. Lab Med. 2015 Spring;46(2):168-74. PMID: 25918199.

LOINC Premium Membership Programmembers.loinc.org

Individual Memberships

Donations (Sponsorships)

Share the love.

Donate to LOINC. members.loinc.org/donate

members.loinc.org/donate

Whats still free?

All the Usual AwesomenessLOINC Table

Accessory Files

RELMA Program

Documentation

Web search app (search.loinc.org)

Participation in the LOINC Community

Access to submit new concepts to LOINC

In closing...

photo via janeandd

photo via gmayster01 on & off ...

Glad youre here to at least get your feet wet...

Jump in!

photo via Justin Ornellas

The Race is On!

Happy LOINCing!photo via ryarwood

photo via milos milosevic

2015 06 - LOINC Introduction

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