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Linking Complex Disease and Exposure Data to Established Data Standards

Introduction to
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
Disclosure
I’m the author of the book LOINC Essentials published by Blue Sky Premise, LLC
where I serve as President.

Lots of other funders for data standards work:

U.S. National Library of Medicine


U.S. Food and Drug Administration
U.S. Centers for Medicare and Medicaid Services
National Heart, Lung, and Blood Institute
National Center for Advancing Translational Sciences
American Physical Therapy Association
bioMérieux
Duke University
Radiological Society of North America
LOINC’s superhero
origin story

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

Clinical care, public health reporting, quality


management, clinical and observational research, etc…

photo via pagedooley | cc-by


Connecting Many Data Sources
Social and community determinants

Lifestyle and behavioral

Health history

Patient-generated
EHR
Genetics
Basic science
photo via Heather | cc-by-sa
Problems
Health IT systems often lack
common mechanisms for MO DATA MO PROBLEMS

exchanging data.

Even when they do, they use


different ways of identifying the
same concept.

Only way to overcome these problems is


with data standards
Life without LOINC
CODE NAME
AGTCE Angiotensin Converting Enzyme
5523 ACE SerPl Qn
ACE ACE
22441 AngioTens Conv Enz
99234 ACE (angiotensin)
25284D Angiotensin-1-Converting Enzyme
2737317 ACE (serum)
6881A Angiotensin Converting Enzyme, Ser
3800ACE ANGIOTENSIN CONVERTING ENZYME, S
77934A Angio Convt Enzym
919109 ACE, SERUM
34ACE Angiotensin Con. Enz
ANGCE Angiotensin CE
6621456 Angio. Conv. Enzyme
Standards make
health data more
portable and
understandable to
different computer
systems.
Syntax Standards
Messages, Documents, APIs
HL7v2, C-CDA, FHIR
Also called “technical” standards

Semantic Standards
Vocabulary/code systems
LOINC, SNOMED CT, RxNorm, ATC, ICD, etc
What is LOINC really
all about?
A freely available global standard…
delivered with a rich set of
implementation tools…

used by a diverse global


community…

who propel its continuous


development.
The global standard for
identifying health
measurements,
observations, and
documents.

Est. 1994
Forrey AW, McDonald CJ, DeMoor G, 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. PMID: 8565239.
A big toolbox:
LOINC Table
Accessory Files
RELMA
search.loinc.org
Community resources
Reference material
LForms
FHIR Vocabulary server
…and more!
photo via Robert S Donovan | cc-by-nc
59,000+ registered users from 171 countries

6,000 new users per year


Translations
into 18 variants
of 12 languages
Many kinds of LOINC Users
Referral / reference labs and radiology centers
Health-related federal agencies
Care organizations
Professional societies
Health information exchange networks
Insurance companies
Health IT vendors
Instrument manufacturers
Health app developers
Official national standard in 30+ countries
4
5/ /24
6/ 24 /1
/ 9

100,000

0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
6/23/ 19995
7/ 28 19 5 | 1
9
9/14//19 5 || 1.0.0
12 15 19 95 1 a
4 /2 /1 95 | 1.0b
8/ / 1/ 99 | .0
1229/28/ 19 5 | 1.0 c
/3 19 19 95 1.0d
/ 1 96 96 | 1 e
1
10 /899 | 1 | 1 .0f
/9 /1 6 | .0 .0g
5//199991.0h(2
2 1 9 7h )
LOINC Codes

7/ /12/197 | | 1(3)
8/23/ /1 98 1.0 .0i
6/ 1999 | 1 j- a
2 1 9 9 .0
6/ /4/9999 | | 1 k
1 2 1 .0
Only Lab LOINC Codes

1/3/2 00| 1.0.0ml


1/ 1/ 0 0 m
31 2000 | 1 a
7/ /2 0 | 1 .0n
1/1/2 001 | 2 .00
2/1/2001 | 2.00
2/ 1/ 0 1 | .0
1 2 0 2 1
8/9/2002 | 2.03
9/1/2 002 | 2.04
5/1/2002 | 2.05
10 1/ 0 2 | .0
/ 2 0 2 6
1/1/2002 | 2.07
2/1/2 003 | 2.08
12 1/ 0 3 .0
12/1/2004 || 2.19
/ 2 0 2 0
6/1/2004 | 2.11
12 1/ 0 4 .1
/1 2004 | 2. 2
126/1/2005 | 2.13
/2 /2005 | 2 14
6 1 .
12/21 /2 06 | 2.15
/ /0 | 1
7/03/2006|2.1 6
1/10/ 2007|2.17
07 10 2 07 2. 9
12/06/2008 |2.21
/ / 0 | 2
2/30/2009|2.2 2
6/26/ 2009|2.24
12 15 2 09 2. 6
06/29/2010 |2.27
12/30/2010|2.29
/ /0 | 3
6/30/2010|2.30
12 30 2 11 2. 2
06/30/2011|2.34
12/29/2012 |2.36
06/26/2012|2.38
12/26/2013|2.40
06/22/2013|2.42
12/29/2014|2.44
/ /0 | 4
6/21/2014|2.46
12 24 2 15 2. 8
06/23/2015|2.50
12/23/2016 |2.52
/1 /201 |2 54
5/ 016| .56
20 7 2.5
LOINC Codes Over Time by Release

laboratory terms only

17|2. 8
|2 61
.6
3
LOINC grows
because USERS ask
We do measurements
LOINC is focused on one piece of
the interoperability puzzle

photo via puuikibeach| cc-by


86,500+ standardized variables
Genetics Lifestyle

21654-9 CFTR gene targeted mutation analysis


24475-6 F2 gene c.20210G>A [Presence] 41950-7 Number of steps in 24 hour Measured

75547-0 Noninvasive prenatal fetal aneuploidy 75296-4 Carbohydrate intake 24 hour Estimated
and microdeletion panel based on Plasma cell- 82289-0 Rating of perceived exertion [Score]
free+WBC DNA by Dosage of chromosome-specific
circulating cell free (ccf) DNA 72166-2 Tobacco smoking status NHIS

82245-2 Chromosome region 22q11.2 deletion in 64098-7 Distance walked in 6 minutes


Amniotic fluid or CVS by FISH

Lab and clinical Environmental

82464-9 Mosquito count [#] in Environmental specimen


4548-4 Hgb A1c MFr Bld 67784-9 Individuals below poverty line Neighborhood
8462-4 Diastolic blood pressure 63736-3 Materials to which you were exposed in your
work or daily life
24725-4 Head CT
63805-6 How long did you handle paints or solvents
57021-8 CBC W Auto Differential panel - Blood yourself?

8633-0 QRS duration 67640-3 My teachers believe that I can do well in my


school work
Laboratory LOINC
Clinical LOINC
Codes for individual observations
6690-2 Leukocytes [#/volume] in Blood by Automated count
2339-0 Glucose [Mass/volume] in Blood
29463-7 Body weight
55423-8 Number of steps in unspecified time Pedometer

Codes for collections (panels and documents)


57021-8 CBC W Auto Differential panel - Blood
34565-2 Vital signs, weight and height panel
44249-1 PHQ-9 quick depression assessment panel
36813-4 CT Abdomen and Pelvis W contrast IV
18842-5 Discharge summary
LOINC fits well with
other data standards

photo via Temari 09 | cc-by-nc


Numeric Results
Using Hl7 version 2.x + LOINC

NM (numeric) means the


answer will be a numeric value Result Value
OBX||NM|26453-1^RBC # Bld^LN||4.82|10*6/uL|

Units
{
"resourceType": "Observation",
"id": "body-height",
"meta": {
"profile": [
"http://hl7.org/fhir/StructureDefinition/
vitalsigns"
]
},
"text": {
"status": "generated",
"div": ""
},

Same thing.
"status": "final",
"code": {
"coding": [
{
"system": "http://loinc.org",

Different format.
"code": "8302-2",
"display": "Body height"
}
],
"text": "Body height"
},

Using Hl7 FHIR + LOINC


"subject": {
"reference": "Patient/example"
},
"effectiveDateTime": "1999-07-02",
"valueQuantity": {
"value": 66.899999999999991,
"unit": "in",
"system": "http://unitsofmeasure.org",
"code": "[in_i]"
}
}
Coded Result Values
Using Hl7 version 2.x + LOINC

CE (coded element) Observation Identifier: LN means this code


means the answer is from LOINC
will be coded general health question

OBX||CE|64845-1^In general, would you say your overall health


is [PhenX]^LN||LA8969-3^Poor^LN

Answer Identifier: LN means this LA


answer code is also
Poor (a bad sign!) from LOINC
The LOINC Concept Model
The Fully Specified Name is the key

photo via quinnanya | cc-by-sa


LOINC Term
A representation of a question about a
clinical phenomenon that can be
observed or measured.

Two essential attributes:

LOINC Code
LOINC Fully Specified Name
NOT part of a LOINC Name
Reason for the test (disease it diagnoses)
Testing instrument
Specific details about the specimen
Priority (e.g. STAT)
Where testing was done
Who did the test
Test interpretation
Anything not part of naming the test
Stuff carried in other parts of HL7 message
Anatomy of a LOINC Term
8640-5:Pupil diameter:Len:Pt:Eye.left:Qn:Auto

LOINC Code 8640-5

Component Pupil diameter

Property Len

Timing Pt

System Eye.left

Scale Qn

Method Auto

There are six major LOINC axes


Anatomy of a LOINC Term
64098-7:Walk distance:Len:6M:^Patient:Qn:

LOINC Code 64098-7

Component Walk distance

Property Len

Timing 6M

System ^Patient

Scale Qn

Method

Method is the only optional axis


Advanced panel
attributes in LOINC
For forms, standardized assessment
instruments, etc
LOINC could be a
master question
file and uniform
representation
Standardized Assessments and Collections

Vreeman DJ, McDonald CJ, Huff SM. Representing patient assessments in LOINC®. AMIA Annu Symp Proc. 2010;832-836. PMID: 21347095 .
Vreeman DJ, McDonald CJ, Huff SM. LOINC® - A Universal Catalog of Individual Clinical Observations and Uniform Representation of Enumerated Collections. Int J Funct Inform
Personal Med. 2010;3(4):273-291.
Item-level Attributes
Question Text
Question Source
External Copyright
Terms of Use
Description/Definition
Units of Measure (UCUM)
Data Types
Structured Answer Lists
Answer List Attributes
ID (contains “LL” prefix)
OID
External Link

Answer Item Attributes


ID (contains “LA” prefix)
String
Sequence
Local code
Other standard codes (e.g. SNOMED CT)
Score
Attributes of Items in a Panel Instance
Display name override
Coding instructions
Cardinality
Local code on that form
Skip logic
Answer sequence override
Consistency/validation checks
Images
Context-specific answer list bindings
Pan H, Tryka KA, Vreeman DJ, et al. Using PhenX measures to identify opportunities for cross-study analysis. Hum Mutat. 2012 May;33(5):849-57. doi: 10.1002/humu.
22074. Epub 2012 Apr 3. PubMed PMID: 22415805; PubMed Central PMCID: PMC3780790.
US Government Forms Morse Fall Scale
CARE, MDSv2, MDSv3, OASIS B1, My Mood Monitor
OASIS C, LCDS, IRF-PAI, RFC, US Neonatal Skin Risk Assessment Scale
Surgeon General’s Family Health
Portrait, End Stage Renal Disease Neuro-QOL
forms NIH Stroke Scale
Borderline Symptom List - 23 Item OMAHA
Brief Interview for Mental Status (BIMS) OPTIMAL
CARE long term care hospital (LTCH) PROMIS
Confusion Assessment Method (CAM) PhenX
Core behavioral health terms (SAMHSA) PHQ (9 and 2)
Edinburgh Postnatal Depression Scale Quality Audit Marker (QAM)
FACIT VR 12 and 36
Geriatric Depression Scale (GDS)
HIV Signs and Symptoms Checklist 10,000+ terms in this area
Home Health Care Classification Adding more all the time
howRU
Living with HIV (LIV-HIV)
The LOINC
Distribution
LOINC Table, Accessory Files, and Tools and
Resources for Implementers
Major releases
twice per year
(June and December)

photo via striatic | cc-by


A big toolbox for
Implementers
All available at loinc.org

photo via Robert S Donovan | cc-by-nc


Legal Stuff
http://loinc.org/license
LOINC License
No cost use
Worldwide
In perpetuity
Commercial or noncommercial
purposes
Encourages translation
One major prohibition…
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 Table
The main LOINC database content
One Record Per Term
Cholesterol in LDL [Mass/volume] in Serum
Long Common Name
or Plasma by Direct assay
Short Name LDLc SerPl Direct Assay-mCnc

Class Type Lab

Class Chem

Example UCUM Units mg/dL

Status Active

Order/Obs Both
LOINC Accessory Files
Special representations of LOINC content
Accessory Files
LOINC Part File
LOINC Answer File
LOINC Panels and Forms File
LOINC Document Ontology File
LOINC Multiaxial Hierarchy File
LOINC/IEEE Medical Device Code Mapping File
LOINC/RSNA Radiology Playbook File
LOINC/SNOMED CT Expression Association and Map Sets

Each has a detailed ReadMe and Release Notes


Need a loinc.org account
Need Windows
Need admin privileges
Install RELMA!
RELMA Highlights
Browse LOINC database
Map local codes to LOINC
import/export
translate local words to LOINC-speak
powerful searching capabilities
review all the details about a LOINC term
Maintain your mappings
Submit new LOINC term requests
RELMA Search Screen
search.loinc.org
Happy LOINCing!

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