LOINC Conference Winter 2017 | Indianapolis, IN USA

FHIR and LOINC

Daniel J. Vreeman, PT, DPT, MS, FACMI
Regenstrief-McDonald Scholar in Data Standards
Indiana University School of Medicine

Director, LOINC and Health Data Standards

@djvreeman Regenstrief Center for Biomedical Informatics

2017
 FHIR and LOINC go together
like chips and salsa

photo via Marco Verch

 Overview

1. Introduction to FHIR
2. LOINC in the FHIR jungle
3. LOINC specific features in the
FHIR terminology services

photo via Vernio77

What is FHIR?
Fast
Healthcare
Interoperable
Resources
The Latest (and Hottest) HL7 Standard
 HL7 Strategy (2017 09)
Strategic Goal (#3)
Establish FHIR as the primary standard for global health data
interoperability.

Strategic Objectives (subset)

Increase understanding of FHIR usage and value of usage worldwide
Demonstrate the value of FHIR in enabling interoperability
Ensure resources are most effectively focused to enhance FHIR
Resources are the Building Blocks
Defined, structured data elements

Mapped to formal definitions (RIM, ISO 11179)

Can be represented in multiple syntaxes: JSON, XML,

RDF

Native support for Extensions (every element in a

resource can be extended)

May include human-readable narrative

 FHIR Support Four
Interoperability Paradigms
REST
Documents
Messages
Service
(Data Storage perhaps coming too)
 REST
What got people really excited
about FHIR was a restful API

Leverages HTTP
GET, POST, etc

Predefined operations
Create, Read, Update, Delete
Also: History, Read Version, Search, Validate, etc
Regardless of the
paradigm, the
content is the same
This is one thing that makes FHIR special

A lab system can send a test result as a message to a FHIR

repository where it can be packaged as summary document to a
national exchange and read via REST client app by a mobile device.
FHIR Spec is Organized into Modules
 The Spec is Bootstrapped
StructureDefinition is a resource
that defines a FHIR structure.
Describes data element definitions and rules of usage,
and also extensions and constraints on resources and
data types.

Also contains value set references that specify the

allowed codes for a particular element.
Testing and Conformance Built in
A testing framework is established within
the spec itself
TestScript resource for natural language and computable test
cases
Lots of public test servers available

CapabilityStatement resource
Describes the capabilities of a client and server: a statement of
features, rules, and behaviors of a FHIR system
A Maturity Model is Built in Too
Resource Maturity Definition
0 Draft
1 + No build warnings
+ Successfully exchanged/tested b/w 3 systems
2
(connectathon)
3 + Verified by WG; formally balloted
4 + Scope tested; formal publication; multiple projects
+ Published 2+ release cycles; 5+ independent
5
production deployments
6 Normative

Community consultation for breaking

changes for anything 4+
Resources by Maturity
 Profiling
A FHIR Profile defines a statement
of use for one or more resources

May include constraints, extensions,

terminology bindings, etc
What makes FHIR so special?
 In fact, nearly every notable name
in the electronic health record
market has something to say
about how FHIR will transform
the current health IT landscape,
and they are pouring plenty of
resources into attracting third-
party talent to the cause.

https://healthitanalytics.com/news/4-basics-to-know-about-the-role-of-fhir-in-interoperability
Eyal Oren (Product Manager, Google Brain) keynote at FHIR DevDays 2017
5 reasons FHIR is special:
Implementation focus (balance modeling rigor and practicality)

Foundation in modern web standards (XML, JSON, HTTP,

OAuth, etc)

Open License (literally, public domain CC0)

Innovations in consensus building and standards development

But the biggest reason is that FHIR is also

A vibrant, open, collaborative, respectful,
well-orchestrated COMMUNITY
LOINC in the
FHIR Jungle
Diagnostic Medicine Module
Observation
LOINC is the most widely
used code system for
observations

Heresclassic numeric result

reporting example with
UCUM units
Return hemoglobin
Observation for my patient
http://spark.furore.com/fhir/Observation?
patient=http://spark.furore.com/fhir/Patient/
f001&code=718-7&_format=json
Return patients with a
hemoglobin Observation
http://spark.furore.com/fhir/Patient?
_has:Observation:patient:code=718-7&_format=json

Reverse chaining
Observation
Works just as well for coded
answers like this one where
you may also use LOINC
Answer codes
Profile [Observation]: Genetics

Specific LOINC codes for

each of these more
precisely specified
Observations
Profile [Observation]: Genetics
Profile [Observation]: Vital Signs
Goal
Use LOINC inside the
Goal resource as the code
for target measure
Diagnostic Report
The findings and interpretation of
diagnostic tests.

Some mix of atomic results, images,

textual and coded interpretations,
and formatted representation of
diagnostic reports.

For lab, pathology, radiology, and

other diagnostic services
(cardiology, etc)

LOINC is preferred code set

Imaging Study
vs. Diagnostic Report

Diagnostic Report can point to loinc.org/collaboration/rsna

Imaging Study

Diagnostic Report would typically

be a document in a presented
form and the narrative, with an
imaging study reference and
possibly some key images.

Imaging Study provides

information on a DICOM
imaging study, and the series and
imaging objects in that study.
Foundation Module
Questionnaire
(and Response)
LOINC has a rich data model
for representing collections,
data elements (questions), and
their answers.

10,000+ LOINC terms for

patient reported outcomes
measures
Composition
Basic structure that loinc.org/document-ontology

builds FHIR Documents

(immutable bundles with
attested narrative)

LOINC has a rich set of

clinical document type
and section codes (used
extensively in CDA).
DataElement
Individual pieces of data that might
be collected or stored, including
observations requested or
performed and questions on forms

A fair bit of overlap b/w LOINC

attributes and DE definition
(question text, answer list, etc)

LOINC could serve as primary

identifier for many
Security/Privacy Module
Consent
A record of a healthcare
consumers policy choices, which
permits or denies identified
recipient(s) or recipient role(s) to
perform one or more actions within
a given policy context, for specific
purposes and periods of time.

In its Document Ontology, LOINC

provides a set of codes for consent
documents that can be used as the
category codes.
A small sample of
LOINC-powered
FHIR innovations
 LOINC-specific
features in FHIR TS
Cool tricks with LOINC via FHIRs Terminology Services
FHIR Spec is Organized into Modules
FHIR Terminology
Services with LOINC
enable an exciting set of
capabilities that were
much harder before!
https://www.hl7.org/fhir/loinc.html
URI
http://loinc.org

Codes
LOINC Codes (21176-3)
LOINC Parts (LP31755-9)
LOINC Answer Lists (LL715-4)
LOINC Answer Codes (LA11165-0)

Display Names for LOINC terms

Long Common Name
Short Name (less than 40 characters)
Quick note about
legal stuff
http://loinc.org/license
If you are building value sets (or
other web-accessible artifacts/
documents) that contain LOINC
codes, you must include a
copyright notice (per the license)

<copyright value="This content LOINC is copyright 1995 Regenstrief

Institute, Inc. and the LOINC Committee, and available at no cost
under the license at http://loinc.org/terms-of-use"/>
Get info about your
favorite LOINC term
http://test.fhir.org/r3/CodeSystem/$lookup?
system=http://loinc.org&code=39046-8&_format=json
LOINC Parts
Coded representation of LOINC Fully
Specified Name attributes

Codes have the LP prefix

Represent them in UPPERCASE:
LP15491-1

Some Parts makeup MultiAxial Hierarchy

Other Part uses:

LOINC-specific filter properties
StructureDefinitions
ConceptMap (e.g. Part maps to SNOMED, RadLex, RxNorm)
Get child LOINCs under a Part
from the Multiaxial Hierarchy
A value set with an identifier of "http://loinc.org/vs/[partcode]"

http://test.fhir.org/r3/ValueSet/$expand?
url=http://loinc.org/vs/LP15491-1
LOINC Answer Lists
Value sets of answers for observation
value of ordinal/nominal LOINC terms

Lists are given a code (LL prefix)

LOINC Answer File specifies the binding

strength (Example, Preferred, Normative)

Some lists are intensional, many are

enumerated in LOINC

LOINC Answer strings are given codes

(LA prefix)
Get a LOINC Answer
List value set
http://test.fhir.org/r3/ValueSet/$expand?
url=http://loinc.org/vs/LL378-1&_format=json
LOINC Properties
STATUS
COMPONENT
PROPERTY
TIME_ASPCT
SYSTEM
SCALE_TYP
METHOD_TYP
CLASS
CLASSTYPE 1=Lab, 2=Clinical, 3=Claims Attachments, 4=Surveys

ORDER_OBS Order, Observation, Both

Building Value Sets
Based on LOINC
Properties
Include:
Component of Body height
Property of Len
System of ^Patient

Exclude:
None

Include special circumstances like post-partum, standing, etc

http://localhost:10000/vocab/ValueSet/test-
vs6/$expand?_format=json
Include:
Component of Glucose
Property of MCnc
System of Bld*

Exclude:
System of Bld.dot or BldC
http://localhost:10000/vocab/ValueSet/test-
vs5/$expand?_format=json
Include:
Method of Sports Medicine
Scale of Doc

Exclude:
None
http://localhost:10000/vocab/ValueSet/test-
vs7/$expand?_format=json
Work in Progress:
Canonical representation of LOINC as a
FHIR Code System

photo via Arul Irudayam | by-nd

https://loinc.org/fhir/loinc.xml
 Take home lesson:
When clinical data is coded with LOINC
codes and made accessible by FHIR,
diverse IT applications can understand
and interact with it for the benefit of
many in the health ecosystem.

photo via IMLS DCC | cc-by