MedInfo 2019 | Lyon, France

Introduction to LOINC
The global vocabulary for identifying health measurements,
observations, and documents

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

© 2018 © 2019
IN THE LOINC COMMUNITY
Slides available at:
danielvreeman.com/medinfo2019
Disclosure
I’m President of Blue Sky Premise, LLC which published the book LOINC
Essentials.

I’m PI on contracts from bioMérieux and BD for LOINC content

development (and many federal and non-profit funding sources for LOINC).

This material contains content from LOINC® (http://loinc.org). The LOINC Table, LOINC Table Core, LOINC Panels and
Forms File, LOINC Answer File, LOINC Part File, LOINC Group File, LOINC Document Ontology File, LOINC Hierarchies,
LOINC Linguistic Variants File, LOINC/RSNA Radiology Playbook, and LOINC/IEEE Medical Device Code Mapping Table are
copyright © 1995-2018, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC)
Committee and is available at no cost under the license at http://loinc.org/license.
 High Level Outline

1. Overview of LOINC
2. The LOINC Concept Model and other
Data Structures
3. Implementing LOINC

📷 Vernio77 | cc-by-sa
Before we jump in,
you might be wondering…

what’s with the pig?

 Let’s get a sense of who’s here

📷 Arran Moffat | cc-by

 https://danielvreeman.com/poll

What is your familiarity with LOINC?

Not much, I’m new

I’m relatively new
I’m an advanced LOINCer
 https://danielvreeman.com/poll

What is your clinical background?

Laboratory professional
Physician
Nurse
Other health professional
Just love working with Health IT / data
 https://danielvreeman.com/poll

What do you want to do with LOINC?

Data exchange
Analytics or quality metrics
App design or decision support
Research
Other
The Superhero Origin Story
A non-profit research organization with a mission to
connect and innovate for better health.

We envision a world where better information

empowers people to end disease and realize true health.
The industrialist pioneer of automatic dishwashers sought to
apply technological and engineering advances to medicine.

Samuel Nathan Regenstrief

Est. Regenstrief Foundation and Institute in 1969
Clem McDonald, MD in the Regenstrief computer terminal room
Circa 1974

McDonald CJ. Protocol-based computer reminders, the quality of care

and the non-perfectability of man. N Engl J Med 1976;295:1351–5
Connecting Many Data Sources

Social and community determinants

Lifestyle and behavioral
Health history
Patient-generated
EHR/clinical
Genetics
Basic science
Reality:
patients move faster and further
than their health information
We want seamless
data flows for…
Informing clinical care (everywhere)
Population health analytics / registry
Electronic quality measure analysis
Observational/epidemiological research
Interoperability
Why is it so hard?
 Interoperability is ultimately
about people who want (their
health IT systems) to work
together and understand
each other
📷 scarlatti2004_images | cc-by-sa
 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
Solving this problem requires different
kinds of data standards
Syntax Standards
Messages, Documents, APIs, CDMs
Regenstrief is the SDO home for two key HL7v2, C-CDA, FHIR

interoperability standards:
LOINC and UCUM Semantic Standards
Vocabulary/code systems
LOINC, RxNorm, HPO, ICD,
We actively participate in the MONDO, UCUM

development (and use) of many others

 Est. 1994

The universal standard for identifying health

measurements, observations, and documents.

Terms have the specificity to distinguish between

clinically important differences.
📷 puuikibeach | cc-by
LOINC is a freely available global standard

delivered with a rich set of implementation tools…

used by a diverse global community…

who propel its continuous development.

LOINC makes health data
more portable and
understandable to different
computer systems.
 {
"resourceType": "Observation",
"id": "body-height",
"meta": {…},
"text": {…},
"status": "final",
"category": [
{

LOINC is designed for

"coding": […],
"text": "Vital Signs"
}
],

Observations (and Orders)

"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8302-2",
"display": "Body height"
}

It works equally well in: ],

"text": "Body height"
},

HL7 v2, CDA, FHIR, CDMs

"subject": {
"reference": "Patient/example"
},
"effectiveDateTime": "1999-07-02",
"valueQuantity": {
"value": 66.899999999999991,
Any structure with a key/value(observation, "unit": "in",
"system": "http://unitsofmeasure.org",
observation value) data model "code": "[in_i]"
}
}
 LOINC is a rich trove of 91,000+ standardized variables
Genetics Lifestyle

21654-9 CFTR gene targeted mutation analysis

41950-7 Number of steps in 24 hour Measured
24475-6 F2 gene c.20210G>A [Presence]
75296-4 Carbohydrate intake 24 hour Estimated
75547-0 Noninvasive prenatal fetal aneuploidy
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

📷 glasgowamateur | cc-by-sa
📷 unamid-photo | cc-by-nd
LOINC Distribution
Major releases twice per year
Rich collection release artifacts
Documentation
Online and desktop browser, API (via FHIR)
Codes for individual observations
6690-2 Leukocytes [#/volume] in Blood by Automated
2339-0 count
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
Structured Answer Lists
 82,000+ registered users from 175 countries

🌐 loinc.org/atlas
Today, there are hundreds of
millions of patients with billions
of discrete results stored in
systems around the world that
are coded with LOINC.
 LOINC Development
Our Approach to Making and Distributing LOINC
The LOINC Manifesto
Our Operating System
We imagine a world where
people experience optimal
health catalyzed by a
seamless network of health
information systems.
Our mission is to develop and
advance the adoption of open data
standards that enable efficient
transmission, understanding, and
use of health data.
Our Approach:

We learn.
As individuals and as a collective community, we apply
a learning mindset to every aspect of our work.
Guiding Principles
Openness
Accessibility
Growth
Pragmatics
Agility
Diligence
Respect

Read more in the Manifesto for Open Terminology Development

LOINC License
No cost use
Worldwide
In perpetuity
Commercial or noncommercial
Encourages translation
One major prohibition…
CANNOT use any Licensed
Material to develop or
promulgate a different standard
for orders or observations.
Read more about
Regenstrief’s approach
to licensing LOINC
danielvreeman.com/licensing-loinc
 !
Financial Support for LOINC
Regenstrief Institute Grant 1R24ES028479-01
Regenstrief Foundation Research Triangle Institute International via CMS
U.S. National Library of Medicine Contract 0-312-0209853
Contracts NO1-LM-4-3510, N01-LM-6-3546, N01-LM-9-3517, and John A. Hartford Foundation
HHSN276200800006C, HHSN276201400138P,
Agency for Health Care Policy and Research
HHSN276201400239P
Grants HS 08750 and HS 07719-03
U.S. Food and Drug Administration
Centers for Disease Control and Prevention
Contracts HHSF223201710178P, HHS223201810268P
Grant and Contracts R13/CCR517099 and H75/CCH520501
American Physical Therapy Association
Centers for Medicare and Medicaid Services
BD
Contract HHSM-500-2016-00040C
bioMérieux
National Center for Advancing Translational Sciences
Indiana Clinical and Translational Sciences Institute
Grant 3UL1TR001108-04S1
California Healthcare Foundation
National Institute of Diabetes and Digestive and Kidney Diseases
Radiological Society of North America through the National Institute of
Biomedical Imaging and Bioengineering Contract HHSN275201600752P
Contract HHSN268201500247A Office of the National Coordinator for Health IT
AHIMA Foundation Grant 90AX0021/01-00
Contract FORE-ASPE-2007-5 Members of the LOINC Community who have made donations or
became Premium Members
Research Triangle Institute International via NIEHS

🌐 loinc.org/funding-support
 This is the LOINC Team
(they rock)

! loinc.org/team
LOINC Committee
Advisory body to Regenstrief that sets naming conventions and
development policies.

Open, international membership (individuals, orgs, etc).

Comprised of 3 composite committees by domain:

Laboratory Clinical LOINC/RadLex

 Major releases twice
per year
(June and December)

📷 striatic | cc-by
 0
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LOINC Terms Over Time

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laboratory terms only

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Vocabulary standards grow
because USERS ask
(broad user community drives new content)

Medicine keeps evolving

If we’re missing content, just ask: loinc.org/submissions
loinc.org/submissions/stats/
loinc.org/submissions/queue
A tiny taste of
LOINC usage…
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
France

Public Health Code for Practice of

Laboratory Medicine in France
Adopts the French specification of IHE XD-LAB profile, including HL7
CDA for format and structure and LOINC for lab test identification

https://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000031922237&categorieLien=id

http://esante.gouv.fr/sites/default/files/CI-SIS_CONTENU_VOLET-CR-BIOLOGIE_v1.2.0.0.pdf
Netherlands

Nictiz
Many national projects are using LOINC

Nationwide surveillance network for bacterial typing and antibiotic resistance

National laboratory code list (selected by NVKC and NVMM societies)
National special test registry (WieDoetWat-database)

Nictiz is a LOINC Premium Member

https://www.rivm.nl/Documenten_en_publicaties/Algemeen_Actueel/Nieuwsberichten/2018/Vijf_labs_operationeel_bij_Eenheid_van_Taal_in_antibioticaresistentie

http://www.cchi.gov.sa/en/Projects/SHIP/Pages/Dictionary.aspx
Austria

National Patient Health Record

(ELGA)
Uses LOINC for laboratory tests, documents, and sections

LOINC value set for laboratory tests is maintained and updated in

coordination with the laboratory community

Seerainer C, Sabutsch SW. eHealth Terminology Management in Austria. Stud Health Technol Inform. 2016;228:426-30. PubMed PMID: 27577418.
International Collaborations

International Patient Summary (IPS)

A non-exhaustive patient summary, specialty-agnostic, condition-
independent, but readily usable by clinicians for the cross-border
unscheduled care of a patient.

Coordinated with the IPS project mandated to CEN TC 251 by the

European Commission.

Uses LOINC for:

Document type, sections, lab results, other clinical observations, and radiology reports

http://international-patient-summary.net
Turkey

Turkish Ministry of Health

General Directorate of Health Services mandates LOINC

for lab results in public, university, and private facilities

Maintain a Turkish translation of LOINC and mapping to national billing

codes (plus online search/mapping tool).

http://www.cchi.gov.sa/en/Projects/SHIP/Pages/Dictionary.aspx
Malaysia

Ministry of Health
National Health Informatics Committee and Ministry pathologists
adopted LOINC for lab data standardization (in LIS’s)

Malaysian Health Data Warehouse national analytics project

https://myhdw.moh.gov.my/public/documents/20186/169489/MyHDW+2015-2016/86b7603a-eab4-40c0-aa94-35ded673838d

https://myhdw.moh.gov.my/public/home
Canada

Canada Health Infoway

Curate pCLOCD subset of LOINC codes (incl fr-CA translation)

Province-wide lab data repositories throughout the country

Clinical Data Repositories using document and other LOINC terms

https://www.ehealthontario.on.ca/en/

https://infocentral.infoway-inforoute.ca/en/standards/international/loinc
USA

ONC CMS
Interoperability Standards Advisory Embraced LOINC as standard vocabulary for
EHR Certification Criteria PAC

Argonaut Project CDC

Lab reporting, case reporting, immunization
messaging, National EMS Info System, National
FDA Trauma Data Standards, vital statistics, etc

LOINC for lab data in 2020

Support for LOINC by IVD vendors Research Networks
HCSRN, PCoreNet, OHDSI, etc
And so many more…
Where to use LOINC terms
If your system stores a
“master file” or dictionary of
Observations or Orders,
use LOINC there as an index
Same idea with other
Common Data Models
PCORnet
OHDSI
Mini-Sentinel
 Using LOINC in HL7 version 2.x

NM (numeric) means the

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

LOINC Units
 Relax…
You can still use local terms too

OBX||NM|123^RBC^MyHosp^26453-1^RBC # Bld^LN||4.82|10*6/uL
Local term LOINC term

📷 Julien Haler | cc-by

Many Active Collaborations
HL7
IEEE
CDISC
IICC
DICOM

SNOMED International
RSNA
Monarch Initiative (HPO, MONDO, etc)
Using LOINC and SNOMED CT Together
Collaboration agreement endorses using both
IHTSDO endorses the use of LOINC Codes for representation of orders and
observations in countries where LOINC has been adopted.

How?
LOINC provides codes that represent the names of information items (e.g.
questions) and SNOMED CT provides codes that may represent nominal and
ordinal values (e.g. answers) for these named information items.
Using LOINC and SNOMED CT
In an HL7 version 2 message

CE (coded
element) answer Observation: LOINC

OBX||CE|625-4^Bacteria Stl Cult^LN||5933001^Clostridium

difficile (organism)^SCT|

Result Value:
SNOMED CT
HL7 v2 Lab Standards Quartet: LRI, LOI, ELR, eDOS
Observation Identifier (OBX-3) and Universal Service ID (OBR-4)
LOINC shall be used as the standard coding system for this field if an appropriate LOINC code exists,
i.e., the LOINC concept is available in the LOINC database, accurately represents the observation, and has
a status that allows its use…If a local coding system is in use, a local code should also be sent to help
with identification of coding issues. When no valid LOINC exists the local code may be the only code sent.

Producer’s Obs ID (OM1-2), Other Obs ID (OM1-7) Obs in an ordered

test (OM5-2), Clinical Info Request (OMC-4)
The laboratory’s local test code and coding system shall be used to identify the orderable test in its
electronic Directory of Services. LOINC shall be used as the standard alternate vocabulary to identify
an orderable test. The performing laboratory makes the determination of an applicable LOINC order
code. When no applicable LOINC code exists, the local code may be the only code defined in the eDOS.

📷 beatlesmania11 | cc-by
Argonaut Project FHIR IG / US Core IG
Data element query of the ONC Common Clinical Data Set and Document query

Observation.code

Each observation must have a LOINC code, if available. Other

(e.g. local) codes allowed if no suitable LOINC exists

DocumentReference.Type, SmokingStatus Observation.Code, VitalSigns

All bound to value sets of LOINC codes
C-CDA 2.1
Result Observation

Other uses
All Document type codes
All Section codes
Vital sign observations
ADL result type
Food and Nutrition and anthropometric variables
Skin and wound measurements
Key IHE Profiles with
LOINC support
Laboratory Analytical Workflow (LAW)
Laboratory Testing Workflow (LTW)
Laboratory Code Sets Distribution (LCSD)

Sharing Laboratory Reports (XD-LAB)

Cross-Enterprise Document Sharing (XDS*)
CDISC
Study Data Tabulation Model (SDTM)

As required by FDA beginning 2020

 openEHR,
CIMI, and
other health
data models

© openEHR Foundation | cc-by-sa

Q&A
Part 2: The LOINC
Concept Model
Taking a little deeper LOINC dive
 Part 2 Overview
1. Primary LOINC naming model
2. Additional term attributes
3. High level view of LOINC content domains
4. Advanced naming models and data
structures
5. Query design
📷 Vernio77 | 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
 LOINC Code
18262-6

The unique, permanent identifier that serves as a

computer processable representation of a LOINC Term

Sequential hints at relative age

Penultimate dash
Final character is Mod-10 check digit
Carries no intrinsic meaning
Once released, never removed
LOINC Names
Julius Winfield Erving II
The Doctor
Dr. J
 Official LOINC Name Types
Fully-Specified Name (FSN)
Mapping

Long Common Name (LCN)

Primary display name

Short Name
Column header, old-school systems with character limits

Display Name
New provider-friendly display name (rules are still under development)

Consumer Name
New consumer-friendly display name (rules are still under development…stay tuned)
 Example LOINC Names
Fully-Specified Name (FSN)
Urea nitrogen:MCnc:Pt:Ser/Plas:Qn:

Long Common Name (LCN)

Urea nitrogen [Mass/volume] in Serum or Plasma

Short Name
BUN SerPl-mCnc

Display Name
Urea nitrogen [Mass/Vol]

Consumer Name
Urea Nitrogen (BUN), Blood
 LOINC Fully Specified Name
Includes the info necessary to distinguish among
clinically important differences

Defines the essential uniqueness of each term in LOINC

Recommended name to help you choose the right

LOINC term
 Anatomy of a LOINC FSN
18262-6 Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay

Component Cholesterol.in LDL

Property MCnc

Timing Pt

System Ser/Plas

Scale Qn

Method Direct assay

There are six major LOINC name axes

 "
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 that is not part of naming the test
 The LOINC fully specified term
name is key for mapping local
terms to LOINC

📷 quinnanya | cc-by-sa
 Component
The substance or entity that is measured,
evaluated, or observed

Examples
Component
Sodium
Glucose
Brucella sp. identified
HIV 1 p24 antigen
Cytomegalovirus antibody
Body weight

Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay

 Property
The characteristic or attribute of the analyte that is
measured, evaluated, or observed.

Examples
LOINC Abbreviation Property Example units
MCnc Mass concentration mg/dL
SCnc Substance concentration umol/L
MCnt Mass content mg/g
CCnc Catalytic concentration U/L
Prid Presence or identity

Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay

 Timing
The interval of time over which the observation was made

Examples
LOINC Abbreviation Time Aspect
Pt Point in time
12H 12 hour collection
24H 24 hour collection
7D 7 days (look back period)

Tip: If Timing != Pt, Property is often a “Rate”

Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay
 System
The system (context) or specimen type upon which the
observation was made.

Examples
LOINC Abbreviation System
Bld Whole blood
Ser/Plas Serum or plasma
Tiss Tissue
Unknown, unspecified in the test name, and/
XXX
or specified in another part of the message

*See LOINC Users’ Guide for further discussion

Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay
📷 AlishaV | cc-by
 Scale
A classification of the result type

Examples
LOINC Abbreviation Scale
Qn Quantitative * can have operators
Ord Ordinal
Nom Nominal
Nar Narrative
Doc Document

Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay

📷 puuikibeach | cc-by
 Method
A classification of how the analyte was measured or the
information was obtained

Method is an optional axis. Only needed if interpretation affected.

different normal ranges, test sensitivities, etc
Specified at a generic level

LOINC Abbreviation Method

IA Immunoassay
LC/MS/MS Liquid Chromatography-Tandem Mass
Molgen Spectrometry
Molecular genetics
CT Computed tomography
Estimated Estimated
Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay
📷 dfataustralianaid | cc-by
 LOINC Part File
LOINC Parts are coded representations of LOINC name attribute values

18262-6 Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay

Attribute Part Number Part LinkTypeName

Component LP15491-1 Cholesterol.in LDL Primary

Property LP6827-2 MCnc Primary

Timing LP6960-1 Pt Primary

System LP7576-4 Ser/Plas Primary

Scale LP7753-9 Qn Primary

Method LP6230-9 Direct assay Primary

See the “Enriched Linkages between LOINC terms and LOINC Parts” documentation in the LOINC Part File
Additional Term Attributes
LOINC Table (See Appendix A in LOINC Users Guide)
Attribute Description Examples

Example units of measure that

Units mg/dL, kg, cm/s, mm2
could be used with this term

Ejection fraction=[(LV end-diastolic

Calculation used to determine the
Formula volume-LV end-systolic volume)/LV end-
result
diastolic volume]*100

Microbiology, Chemistry, Cardiology,

General domain category (single
Class Radiology,
hierarchy)
PROMIS surveys

Status Current state of the term Active, Deprecated, Trial, Discouraged

Term represents an orderable,

Order/Observation observable, or both
Order, Observation, Both
Attribute Description Examples

Synonyms or other names related to

X-ALD (for Lysophosphatidylcholine)
Related Names this term (e.g., disease name,
f434 (for Malus domestica recombinant)
allergen code)

Copyright © 2006-2016 National

Copyright attribution for terms
External Copyright Institutes of Health and Northwestern
with a third party copyright
University. Used with permission.

Version First LOINC release where this term was

2.66, 2.54
Released first published

Version Last LOINC release where this term was

2.66, 2.54
Changed last edited (or first released)

Categorizes panel terms as

Panel Type "Convenience group", "Organizer", Panel, Organizer, Convenience Group
or "Panel"
A Rich Encyclopedia of Descriptions
91672-6 ABCB1 gene targeted mutation analysis in Blood or Tissue by
Molecular genetics method
High Level LOINC Domain
Landscape
LOINC is famous for lab test content,
but you still might not know about…

Newborn screening
Full set of terms, included in HL7 IG Lab Results Interface (LRI)

Genetic reporting
2000+ tests, including collections for structured reporting of simple variants, structural and copy number variants, complex variants,
and pharmacogenomic studies. [PMID: 25656513] See HL7 LRI and the developing FHIR CG IG.

Orders
Not only single tests, but 1,000+ order panels and a consensus-vetted list of 1,500 order codes covering 95% of common volume. See
loinc.org/usage/orders

Public health
Close work with CDC on emerging diseases and reportable conditions
Clinical Notes and Documents
2,700+ terms with a specialized structure
loinc.org/document-ontology
34123-0 Preoperative evaluation and management note:Find:Pt:Hospital:Doc:Anesthesiology

Subject Matter Domain Anesthesiology

Role {Role}

Setting Hospital

Type of Service Preoperative evaluation and management

Kind of Document Note

 Radiology Procedures PMID: 29850823

5,800 terms with rich metadata. Wonderful collaboration with RSNA.

loinc.org/radiology

36813-4 CT Abdomen and Pelvis W contrast IV

Modality CT
Anatomic Location Abdomen, Pelvis
View
Timing W
Manuever
Pharmaceutical Contrast IV
Reason for Exam
Guidance
Subject
📷 unamid-photo | cc-by-nd
Broad collection of other clinical variables
Vital signs
CDC’s vital statistics forms (birth, death, etc)
CMS’s patient assessment instruments
Nursing Assessments
Physical Therapy National Outcomes Database
NEMSIS and NTDS
ESRD variables
Chronic kidney disease management
Ophthalmology variables
Medical device measurements via IEEE 11073
ECG, PFT, spirometry, etc
10,000+ assessment terms
and growing…
Social, psychological and behavioral observations - 2015 Edition Geriatric Depression Scale (GDS)
Health IT Certification Criteria set
Humiliation, Afraid, Rape, and Kick questionnaire
Adverse Childhood Events
HIV Signs and Symptoms Checklist
ADAPTABLE patient report item set
howRU
Borderline Symptom List - 23 Item
International Physical Activity Questionnaire
Brief Interview for Mental Status (BIMS)
Living with HIV (LIV-HIV)
Comprehensive Behavior Health Screen
Morse Fall Scale
Confusion Assessment Method (CAM)
My Mood Monitor
Core behavioral health terms (SAMHSA)
Neuro-QOL
Edinburgh Postnatal Depression Scale
PROMIS (e.g. Social Isolation item bank)
Everyday Cognition
PhenX (eg. Social Environments domain)
Exercise Vital Sign
PHQ
FACIT
VR 12 and 36
 Advanced LOINC Naming
Models and Data Structures
Information Collections
Panels and Documents
Panels "
A “collector” parent term linked to an enumerated set of child elements


Each child element is a LOINC term too (and can nest)

Panel is a generic concept synonymous with battery, form, data set, etc.
Panels "
Naming conventions
Most have panel in the Component
If defined by an authoritative body, we tend to use the official name
If children vary on axis values (e.g. Property), the panel term will have a dash “-” for that axis

Categorized in PanelType attribute of LOINC Table as

Panel Concepts that are ordered/resulted together

Concepts grouped for a common use, but that would

Convenience Group
not be ordered/resulted together

Concepts forming a subset of terms in a panel,

Organizer
such as a section (heading) on a form
Panel
Convenience Group
 Panel
Organizer

Organizer
Many term attributes apply everywhere

Attribute Description Examples

Example units of measure that

Units mg/dL, kg, cm/s, mm2
could be used with this term

Ejection fraction=[(LV end-diastolic

Calculation used to determine the
Formula volume-LV end-systolic volume)/LV end-
result
diastolic volume]*100

Status Current state of the term Active, Deprecated, Trial, Discouraged

Copyright © 2006-2016 National

Copyright attribution for terms
External Copyright with a third party copyright
Institutes of Health and Northwestern
University. Used with permission.
Other attributes apply in the context of a panel
Attribute Description

Display Name Override Form-specific display text

Form Coding Instructions Instruction text for users completing the form

Cardinality Item cardinality

Skip Logic Form skip logic (currently only a text representation)

Override Answer List Form-specific answer list

Images Visual image related to item

Documents
#
In LOINC, a document is simply an information collection

Explicit contents are not prescribed (unlike panels)

Content could be structured (e.g. CDA) , or unstructured (plain text)

Names are based on expected information content, not format

$%&'!
Same LOINC term if information content is the same
Clinical Notes #
LOINC Document Ontology

Names are constructed from enumerated

allowed values for each axis

Each axis value has been approved by the

LOINC Document Ontology Subcommitee

Structure is published in LOINC Users Guide

(alpha OWL version coming soon)
LOINC Document Ontology File
34797-1 Neurology Consult note

PartSequence
LoincNumber PartNumber PartTypeName PartName
Order

34797-1 LP173418-7 Document.Kind 1 Note

34797-1 LP173110-0 Document.TypeOfService 1 Consultation

34797-1 LP173061-5 Document.Setting 1 {Setting}

34797-1 LP172964-1 Document.SubjectMatterDomain 1 Neurology

Radiology Procedures (
The LOINC/RSNA Radiology Playbook is long term collaboration
that unified two terminologies for radiology procedures

A detailed model for specialized radiology attributes with

attribute values coded as LOINC Parts and RadLex IDs
 LOINC/RSNA Radiology Playbook:
Main Ideas
Jointly developed, unified standard terminology for radiology procedures

Regenstrief’s terminology experience + RSNA’s domain expertise

Unify, don’t just do mappings (eternal work)

LOINC codes as the primary identifiers for procedures in the unified terminology, attribute
values linked to RadLex

Distribute the standard at no cost worldwide

📷 didmyself | cc-by-nc-sa
Definitive documentation
published as User Guide
Radiology Procedure Naming Model
Modality Maneuver
Modality.Modality Type Maneuver.Maneuver Type
Modality.Modality Subtype
Pharmaceutical
Anatomic Location Pharmaceutical.Substance Given
Anatomic Location.Region Imaged Pharmaceutical.Route
Anatomic Location.Imaging Focus
Anatomic Location.Laterality.Presence Reason for Exam
Anatomic Location.Laterality
Guidance
View Guidance for.Presence
View.Aggregation Guidance for.Approach
View.View Type Guidance for.Action

 Guidance for.Object
Timing

Subject
LOINC/RSNA Radiology Playbook Version 2.66
June 2019

Current Status

6,000+ Radiology procedure terms

Over 42,000 attribute value relationships linking more than 1,000

LOINC Parts to RadLex clinical terms.

995 LOINC terms are mapped to unique RPID concepts

New requests welcome!

LOINC/RSNA Radiology Playbook File
37667-3 XR Ankle - Right AP and Lateral

Part Type Part Name

Rad.Modality.Modality type XR
Rad.Anatomic Location.Region Imaged Lower extremity
Rad.Anatomic Location.Imaging Focus Ankle
Rad.Anatomic Location.Laterality.Presence TRUE
Rad.Anatomic Location.Laterality Right
Rad.View.Aggregation Views
Rad.View.View type AP
Rad.View.View type Lateral
 LOINC/RSNA Radiology Playbook File
LOINC LOINCLongCommonName PartNumber PartType PartName PartSeqOrder RID PreferredName RPID LongName

CT Abdomen and Pelvis W RID103 CT Abdomen/Pelvis w IV

36813-4 LP200067-9 Rad.Modality.Modality type CT A computed tomography RPID145
contrast IV 21 Contrast

CT Abdomen and Pelvis W Rad.Pharmaceutical.Substanc RID115 CT Abdomen/Pelvis w IV

36813-4 LP200085-1 Contrast A Contrast agent RPID145
contrast IV e Given 82 Contrast

CT Abdomen and Pelvis W RID498 CT Abdomen/Pelvis w IV

36813-4 LP200088-5 Rad.Timing W A W RPID145
contrast IV 53 Contrast

CT Abdomen and Pelvis W RID111 CT Abdomen/Pelvis w IV

36813-4 LP200078-6 Rad.Pharmaceutical.Route IV A intravenous RPID145
contrast IV 60 Contrast

CT Abdomen and Pelvis W Rad.Anatomic CT Abdomen/Pelvis w IV

36813-4 LP199956-6 Abdomen A.A RID56 Abdomen RPID145
contrast IV Location.Region Imaged Contrast

CT Abdomen and Pelvis W Rad.Anatomic RID250 CT Abdomen/Pelvis w IV

36813-4 LP199998-8 Pelvis A.B Pelvis RPID145
contrast IV Location.Region Imaged 7 Contrast
Query Design Using
LOINC Metadata
https://search.loinc.org
https://search.loinc.org
Key Search
Syntax Features
danielvreeman.com/search-syntax/
Let’s find all terms added in the
last LOINC release (2.66)
VersionFirstReleased:2.66
Find all terms about
Cytomegalovirus testing in CSF
Component:cytomegalovirus System:CSF
Find all panel terms with glucose
in the name
Component:glucose OrderObs:order
Component:glucose PanelType:panel
Find all terms for variables about
anxiety with an answer list
Component:anxiety AnswerList:true
Find AFP tests in Amniotic Fluid
reported in IU/mL
afp amniotic ExUCUMUnits:IU/mL
Component:alpha-1-fetoprotein amniotic ExUCUMUnits:IU/mL
 )

Ok, now let’s use the data files…

LOINC Document Ontology File #
Let’s find all the Consult document terms,
regardless of setting, subject matter domain, etc.
LoincNumber PartNumber PartTypeName PartSequenceOrder PartName

11488-4 LP173110-0 Document.TypeOfService 1 Consultation

34099-2 LP173110-0 Document.TypeOfService 1 Consultation

34100-8 LP173110-0 Document.TypeOfService 1 Consultation

34101-6 LP173110-0 Document.TypeOfService 1 Consultation

…
 LOINC/RSNA Radiology Playbook File
(
Find all Liver studies, regardless of modality, etc.
LoincNumber LongCommonName PartNumber PartTypeName PartNam
RF Guidance for transjugular biopsy
e
24718-9 LP199933-5 Rad.Anatomic Location.Imaging Focus Liver
of Liver-- W contrast IV
24811-2 CT Guidance for fluid aspiration of LP199933-5 Rad.Anatomic Location.Imaging Focus Liver
Liver
24812-0 CT Guidance for biopsy of Liver LP199933-5 Rad.Anatomic Location.Imaging Focus Liver

24813-8 CT Guidance for core needle biopsy of LP199933-5 Rad.Anatomic Location.Imaging Focus Liver
Liver
24814-6 CT Liver LP199933-5 Rad.Anatomic Location.Imaging Focus Liver

24815-3 CT Liver W contrast IV LP199933-5 Rad.Anatomic Location.Imaging Focus Liver

24816-1 US Guidance for biopsy of Liver LP199933-5 Rad.Anatomic Location.Imaging Focus Liver

…
Q&A
 Part 3:
Implementing LOINC
many tools for implementers
 Part 3 Overview

1. Overview of key resources

2. General approach to mapping
3. What is possible when you’re done
4. Best practices and recommendations

📷 Vernio77 | cc-by-sa
Many free resources
“Raw” release artifacts
Online and desktop browser (RELMA)
API (via FHIR)
Documentation
Community resources
Most require a free loinc.org account
My favorite LOINC easter egg…
loinc.org/86944-6
loinc.org/{any LOINC term, Part, Answer List, Group}
https://loinc.org/downloads/loinc/

Formats for
importing into
Health IT
applications
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
LOINC Display Name File
LOINC Consumer Name File
LOINC Linguistic Variants
LOINC Group File

Each has a detailed ReadMe and Release Notes

LOINC Groups
loinc.org/groups
A flexible, computable tool for rolling up groups of LOINC codes that can
be considered equivalent for a particular purpose
An example…
Lower level groups rolled up
into defining sets called
Parent Groups
https://loinc.org/groups/community/
RELMA: the gold standard mapping tool

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 mappings
Submit new LOINC term requests
RELMA Search Screen
 Loading local
codes into RELMA

📷 john_fielding | cc-by
Creating your source file
for mapping to LOINC
danielvreeman.com/source-file

a sample section from LOINC Essentials

 Observation Source File
Basic Format

Panel Code Panel Description Test Code Test Description Units Tag

GLUCWB GLUCOSE WHOLE BLOOD GLUCWB GLUCOSE WHOLE BLOOD MG/DL chem

BGART BLD GAS ART PCO2 PCO2 MMHG chem

BGART BLD GAS ART PH PH chem

BGART BLD GAS ART PO2 PO2 MMHG chem

CBCDF CBC+DIFF HCT HEMATOCRIT % hem

CBCDF CBC+DIFF HGB HEMOGLOBIN G/DL hem

 The Mapping Screen
Working Set Navigation Local Term and Mapping Detail

Search Results Grid

 Export Options
File -> Export Local Terms and Their LOINC Mappings to
Delimited File

Choose Term File

Choose Format

Choose Stuff
 Oh no, roadblock!
Can’t install RELMA?

📷 brizo_the_scot | cc-by
https://search.loinc.org
Other Implementation Resources
API, Documentation, Community
https://loinc.org/fhir
Enhanced LOINC features now available in HAPI FHIR
Get info about your favorite
LOINC term
https://fhir.loinc.org/CodeSystem/$lookup?system=http://
loinc.org&code=4544-3
Every Answer List is available as a ValueSet
Get a particular Answer List as a ValueSet
https://fhir.loinc.org/ValueSet/?
url=http://loinc.org/vs/LL1162-8

And every Group is available as a ValueSet

Get a particular LOINC Group as a ValueSet

https://fhir.loinc.org/ValueSet/?
url=http://loinc.org/vs/LG32848-0
Get the LOINC to IEEE
Mapping
https://fhir.loinc.org/ConceptMap/?url=http://loinc.org/cm/
loinc-to-ieee-device-codes
 https://loinc.org/guides/micro

FDA-funded development of
Guide for Using LOINC
Microbiology Terms

Our first (but hopefully not last) “Implementation Guide”

Grant HHSF223201710178P and HHS223201810268P from U.S. Food and Drug Administration
What LOINC Essentials covers…
LOINC basics

A framework and techniques for picking out the subtle but important
distinctions between LOINC terms

Step by step guidance for mapping with RELMA

Best practices in LOINC mapping and how to set yourself up for success in
the long run
This tutorial is based on content from the book
Many ways to learn more and
participate in LOINC Community

Mailing list
User Forum
In-person LOINC Conferences
Special Topics Workgroups
Committees
General Approach to Mapping
 The LOINC term name is key

📷 quinnanya | cc-by-sa
 Scan LOINC axes to notice the
differences needing closer inspection

📷 jdhancock | cc-by
 Local tests names are:
Notoriously short
Lacking info needed for mapping

Don’t make assumptions, but…

Use all available contextual clues

📷 paurian | cc-by
 #
For qualitative tests, use
LOINC Answer Lists to
inform your mapping
Mapping Exercise
Your turn!
 https://danielvreeman.com/poll

Which LOINC term is the best match for

Systolic Blood Pressure?

8480-6 Systolic blood pressure

8481-4 Systolic blood pressure 1 hour maximum

8512-6 Radial artery Systolic blood pressure

60984-2 Aorta Systolic blood pressure

 https://danielvreeman.com/poll

Which LOINC term is the best match for

Inpatient Discharge Summary?

68823-4 Pediatrics Hospital Discharge summary

34105-7 Hospital Discharge summary

84321-9 Physical therapy Outpatient Discharge summary

18842-5 Discharge summary

 https://danielvreeman.com/poll

Which LOINC Property is consistent with the

units of measure “mg/dL”?

ACnc (aribitrary concentration)

MoM (multiple of the median)
MFr (mass fraction)
MCnc (mass concentration)
 https://danielvreeman.com/poll

Which LOINC term is the best match for

LDL Cholesterol (Direct) in mg/dL?
57698-3 Lipid panel with direct LDL - Serum or Plasma

69419-0 Cholesterol in LDL [Moles/volume] in Serum or Plasma by Direct assay

18262-6 Cholesterol in LDL [Mass/volume] in Serum or Plasma by Direct assay

2089-1 Cholesterol in LDL [Mass/ volume] in Serum or Plasma

 https://danielvreeman.com/poll

Which LOINC term is the best match for

Cytochrome P450 3A5 (CYP3A5) Genotype (star allele notation)?

79717-5 CYP3A5 gene product metabolic activity interpretation in Blood

or Tissue Qualitative by CPIC
72697-6 CYP3A5 gene c.6986A>G(*3) [Presence] in Blood or Tissue by
Molecular genetics method
81139-8 CYP3A4 gene mutations found [Identifier] in Blood or Tissue by
Molecular genetics method Nominal
81140-6 CYP3A5 gene mutations found [Identifier] in Blood or Tissue by
Molecular genetics method Nominal
 https://danielvreeman.com/poll

Which LOINC term is best match for

JAK2 V617F Mutation Analysis, Quantitative (%)?

JAK2 gene targeted mutation analysis in Blood or Tissue by

48726-4
Molecular genetics method Narrative
JAK2 gene.p.Val617Phe mutant/Normal in Blood or Tissue by
53761-3
Molecular genetics method
JAK2 gene p.Val617Phe [Presence] in Blood or Tissue by
43399-5
Molecular genetics method
JAK2 gene p.Val617Phe [Presence] in Bone marrow by Molecular
72333-8
genetics method
 Collect once. Use many.
Clinical care, public health reporting, quality management, clinical and
epidemiological research, etc…

📷 pagedooley | cc-by
75856-5
#Falls in past 1Y

66247-8
Sit to stand [30 sec]

8454-1
DBP - standing

8460-8
SBP - standing
If this, then that…

If {# Falls in last year} > 0

Then
initiate {gait, strength, balance evaluation}
Reporting / Analytics
% patients 65 years of age and older who were screened for future fall risk

75856-5 Number of falls in the past 12 months [Reported]

59460-6 Fall risk total [Morse Fall Scale]

66247-8 Sit to stand 30 seconds

52552-7 Falls in the past year [CMS Assessment]

83280-8 Has the patient had any falls since admission [CMS Assessment]

71949-2 Falls Behavioral Scale for Older People [FaB]

…
Same data for…
Informing clinical care
Population health analytics / registry
Electronic quality measure analysis
Observational/epidemiological research
A sample of LOINC-powered
informatics innovations
https://lhncbc.nlm.nih.gov/project/lhc-forms
 Based on the Argonaut
FHIR Profile
(which requires LOINC for observations)

https://www.apple.com/healthcare/health-records/

https://support.apple.com/en-us/HT208647
https://www.apple.com/healthcare/health-records/

https://support.apple.com/en-us/HT208647
Top 3 Tips for Using LOINC
Key principles for smart LOINCing
 Not all juice is worth the squeeze
What do you really need to standardize?

Pareto principle
A few tests account for most volume
70% of tests take 30% of mapping time

Vreeman DJ, Finnell JT, Overhage JM. A rationale for parsimonious laboratory term mapping by frequency. AMIA Annu Symp Proc. 2007 Oct 11:771-5. PMID: 18693941.
📷 elwillo | cc-by http://www.himss.org/news/interoperability-not-all-juice-worth-squeeze-0
 Go upstream
Map more efficiently and consistently

📷 Fishking_1 | cc-by
Trust, but verify
Don’t make assumptions…

No Specimen? Don’t guess.

Validate missing information in SOPs, package
inserts, or consulting experts

Got to have units (Qn) or look at sample answers (Ql)

Bonus Tip
 Bonus Tip:
Stay up to date

📷 Arul Irudayam | by-nd

LOINC recommends that
users update to the current
version within 90 days of its
publication.
 Identify Replacement Terms
Tools -> Find Local Terms Mapped to Deprecated LOINCs

Map when ready

Review commentary

Check the alternatives

 $
Other Updates to Your Terms

Your testing may have changed

Your codes may have changed

Watch changes to codes, names, or units
A journey, not a destination.

Across many INPC institutions, in

2 years after go live we saw half
as many new local terms appear as
what we started with.
Vreeman DJ, Stark M, Tomashefski GL, Phillips DR, Dexter PR. Embracing change in a health information exchange. AMIA Annu Symp Proc. 2008 Nov 6:768-72. PMID: 18999242
Take home lesson:
When clinical data is coded with LOINC, diverse IT
applications can understand and interact with it for
the benefit of many in the health ecosystem.

It’s your turn: begin.

Happy LOINCing!
Q&A