AMIA 2019 Annual Symposium | Washington, DC USA

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

Daniel J. Vreeman, PT, DPT, MS, FACMI

Senior Clinical Data Standards Lead
RTI International
@djvreeman

Swapna Abhyankar, MD
Interim Director of Content Development and Operations, LOINC
Regenstrief Institute, Inc
@sa_abhyankar © 2019
 High Level Outline

1. An overview of LOINC
2. The LOINC concept model and other
data structures
3. Implementing LOINC

📷 Vernio77 © cc-by-sa
Disclosure

I’m President of Blue Sky Premise, LLC which published the book
LOINC Essentials.

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.
IN THE LOINC COMMUNITY
 Slides available at:
https://danielvreeman.com/amia2019
 Session Objectives
1. Explain the LOINC development process
2. Apply key features of the LOINC concept model in
selecting appropriate codes
3. Design a query using metadata and relationships about
LOINC concepts beyond the concept name
4. Identify and select the key implementation tools
appropriate for their use case
5. Apply best practices for using LOINC

📷 Vernio77 | cc-by-sa
Before we get too far along, you might
be wondering…

What’s with the pig?

 Let’s get a sense of who’s here

📷 Arran Moffat | cc-by

What is your familiarity with LOINC?

! Not much, I’m new

! I’m relatively new
! I’m an advanced LOINCer
What is your clinical background?

! Laboratory professional
! Physician
! Nurse
! Other health professional
! Love working with Health IT / data
What do you want to do with LOINC?

! Data exchange
! Analytics or quality measures
! 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.

Standards Development Organization (SDO) for

two key interoperability standards:
LOINC and UCUM
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
 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
 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
 meerkat meerkat mere cat meerkat

Similar name. Different Meaning.

📷 CaptionTime
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.
Interoperability requires different
kinds of data standards for different Syntax Standards
purposes. Messages, Documents, APIs, CDMs
HL7v2, C-CDA, FHIR, OHDSI

Typically, syntax and semantic Semantic Standards

standards are used together Vocabulary/code systems
LOINC, RxNorm, HPO, ICD,
MONDO, UCUM

No single vocabulary covers it all

 {
"resourceType": "Observation",
"id": "body-height",
"meta": {…},
"text": {…},
"status": "final",
"category": [
{
"coding": […],

LOINC is designed for ],

}
"text": "Vital Signs"

"code": {

Observations (and Orders) "coding": [

{
"system": "http://loinc.org",
"code": "8302-2",
"display": "Body height"
}
],
It works equally well in: },
"text": "Body height"

"subject": {
HL7 v2, CDA, FHIR, CDMs "reference": "Patient/example"
},
"effectiveDateTime": "1999-07-02",
"valueQuantity": {
"value": 66.899999999999991,

Any structure with a key/value (observation, "unit": "in",

"system": "http://unitsofmeasure.org",
"code": "[in_i]"
observation value) data model }
}
 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
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
36813-4 PHQ-9 quick depression assessment panel
55423-8 CT Abdomen and Pelvis W contrast IV

18842-5 Discharge summary

Structured Answer Lists
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.
The LOINC Manifesto
Our Operating System for Open Terminology Development
 86,000+ registered users from 176 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.
Taking a little deeper
LOINC dive
Where to use LOINC codes
Key features of LOINC’s development approach
Where to use LOINC terms
But I LOVE maintaining my local dictionary!
📷 Jonathan McIntosh | cc-by-sa
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
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
HL7 FHIR® US Core Implementation Guide STU 3

Observation.code

Each observation must have a LOINC code, if available, which

tells you what is being measured.

DocumentReference.Type, SmokingStatus Observation.Code, VitalSigns

All bound to value sets of LOINC codes

HL7 FHIR® US Core Implementation Guide STU 3

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
CDISC
Study Data Tabulation Model (SDTM)

As required by FDA beginning 2020

 openEHR,
CIMI, and
other health
data models

© openEHR Foundation | cc-by-sa

 LOINC Development
Our Approach to Making and Distributing LOINC
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
 0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
1.
0
1.
0a
1.
0b
1.
0c
1.
0d
1.
0e
1.
0f
1.
1. 0g
0h
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1. 2)
0h
(3
)
1.
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1. i
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-a
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0m
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00
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00
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01
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29
2.
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34
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2.
LOINC Terms Over Time

44
2.
46
2.
48
2.
50
2.
52
2.
54
2.
56
2.
58
2.
61
2.
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laboratory terms only

2.
64
2.
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2.
66
loinc.org/submissions/stats/
loinc.org/submissions/queue
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

 !
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, HHSN276201400239P,
Agency for Health Care Policy and Research
75N97019C00012
Grants HS 08750 and HS 07719-03
U.S. Food and Drug Administration
Centers for Disease Control and Prevention
Contracts HHSF223201710178P, HHS223201810268P, 75F40119C10140
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
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
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
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
Bhargava A, Kim T, Quine DB, et al. A 20-Year Evaluation of LOINC in the United States’ Largest Integrated Health System. Arch Pathol Lab Med Published Online First: 30 August 2019. doi:10.5858/arpa.2019-0055-OA
U.S. Office of the National Coordinator for Health IT
LOINC Listed For:
Representing Patient Allergic Reactions
Representing Patient Family Health History
Representing Patient Functional Status and Disability
Representing Imaging Diagnostics
Representing Laboratory Tests
Representing Clinical/Nursing Assessments
Representing Outcomes for Nursing
Interoperability Standards Representing Patient Pregnancy Status
Representing Patient Gender Identity
Advisory Representing Patient Sex (At Birth)
Representing Patient-Identified Sexual Orientation
(updated annually) Representing Alcohol Use
Representing Depression
Representing Exposure to Violence
Representing Financial Resource Strain
Representing Level of Education
Representing Physical Activity
Representing Social Connection and Isolation
Representing Stress
ONC’s 2019 ISA Reference Edition Representing Patient Tobacco Use (Smoking Status)
Representing Patient Vital Signs
U.S. Office of the National Coordinator for Health IT

2015 EHR Certification

Criteria

2015 Edition Common Clinical Data Set (CCDS) Reference Document

U.S. Office of the National Coordinator for Health IT

21st Century Cures Act

Notice of Proposed Rulemaking
March 2019

USCDI
API: FHIR, Argonaut Data Query IG v1.0, etc
U.S. Core Data for
Interoperability (USCDI)
USCDI 2019 Version 1

LOINC Listed For:

Assessment and Plan of Treatment
Clinical Notes
Patient Goals
Health Concerns
Laboratory
Vital Signs
U.S. Food & Drug Administration

At present, LOINC is the IVD coding

system that is most widely used by
clinical laboratories and EHRs, and is
the IVD coding standard recommended by
the Office of the National Coordinator
for Health Information Technology
(ONC) in the U.S. Department of Health
and Human Services (HHS) as an
essential part of meaningful use.
LOINC is a partially FDA-recognized
consensus standard, where the
recognition is limited to IVD tests.

GUIDANCE DOCUMENT: LOINC for In Vitro Diagnostic Tests

U.S. Food & Drug Administration

Requiring LOINC for lab test data in studies

starting after 2020 (see Data Standards Catalog)

Strong support of LOINC to identify IVD tests;

helped inspire LIVD*
*also recommended by CLIAC, now under ballot as FHIR IG

Broad vision towards using real-world evidence

in post market surveillance
Recommendations from LOINC Working Group
And so many more…
Collaborations
with other SDOs
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

Innovative and
collaboratively developed
LOINC2HPO effort
coordinated by the
Monarch Initiative.

PMID: 31119199
Live on the HPO website…
 "
Future Work
Create a model for computable LOINC terms, taking advantage of:
Dead Simple OWL Design Patterns
Explicit linkages now defined and published in the LoincParkLink File

Link LOINC Parts with standard open ontologies in corresponding domains

(e.g. ChEBI, Uberon, NCBI Taxonomy etc)

Partner with others who share our Open Terminology ideals and a vision for
Reusable Research Data to deploy a connected set of terminology services
using FHIR.
Q&A
 AMIA Annual Symposium 2019 | Washington, DC USA

LOINC Workshop Part 2:

The LOINC concept model and other attributes,
domain specializations, query syntax, and more!

Swapna Abhyankar, MD
Interim Director of Content Development
& Operations
Part 2 overview
• LOINC concept model
• Other LOINC data structures and ancillary data
• LOINC content domains
• Domain specializations
• Query design
• Q&A
Anatomy of a LOINC term
 LOINC term = LOINC code + LOINC name

80618-2 Zika virus IgM Ab [Units/volume] in Cerebral spinal fluid by

Immunoassay
=
80618-2
+
Zika virus IgM Ab [Units/volume] in Cerebral spinal fluid by Immunoassay
The LOINC code
• Unique, permanent numeric code
• Sequential
• LOINC code value can help determine when code was created
• No intrinsic structure except last character is a mod 10-check digit
• Once officially released, a code is never removed from the LOINC distribution
Each LOINC concept is defined by 6 Parts
Part Description
Component The analyte being measured
Property The dimension of the analyte that is being measured
Time aspect Whether the analyte is measured at a moment in time or over a specific
period of time
System The type of sample
Scale A general classification of the result type, whether quantitative,
qualitative, narrative, etc.
Method How the analyte was measured
*The Method is the only major axis that does not have to be populated for
every LOINC term
Component
The analyte being measured or reported
• Sodium
• HIV 1 p24 antigen
• Body weight
• Diameter.end diastole
• Bispectral index
• Note
• Cytology report
Component subparts
Challenge: a chemical or physiologic stimulus given to a
patient before the analyte is measured (also called a “loading”
or “tolerance” test)
• 2H post 100 g glucose PO
• post exercise
st nd
• 1 specimen/2 specimen
Adjustment: correction of a measured value (rarely used)
• adjusted to pH 7.4
• corrected for nucleated erythrocytes
Sequence when reporting multiple results (even more rare)
Property
The dimension of the analyte that is being measured
• Mass concentration
• Titer
• Presence or Threshold
• Length
• Angle
• Location
• Date
Time aspect
Whether the analyte is measured in a sample taken at a
moment in time or over a specific period of time; for survey
terms this is the “lookback period”
• Point in time
• 24 hours
• 7 days
• 1 year
• Study maximum
• Reporting period
• Lifetime
System
The type of sample/specimen
• Blood
• Serum or Plasma
• Urine
• Synovial fluid
• Mitral valve
• Elbow
• Device
• ^Patient
Super System
The source of the sample if the source is not the patient whose
chart the result is stored in
• ^Fetus
• ^Mother
• ^Father
• ^Family member
• ^Guardian or legally authorized representative
• ^BPU (blood product unit)
• ^Donor
Scale
A general classification of the result type
• Quantitative
• Ordinal (qualitative, can be ordered)
• Nominal (qualitative, cannot be ordered)
• Narrative
• Document
Method
How the analyte was measured or the information was
obtained; for survey terms this is usually the instrument name
• {null} (no method specified)
• Immunoassay
• Sequencing
• X-ray
• Reported
• Observed
• PHQ
• CMS Assessment
 Putting the Parts together
Component Property Time aspect System Scale Method
Sodium SCnc Pt Urine Qn
2955-3 Sodium [Moles/volume] in Urine
Sodium SCnc Pt CSF Qn
2948-8 Sodium [Moles/volume] in Cerebral spinal fluid

Body weight Mass Pt ^Patient Qn

29463-7 Body weight
Body weight Mass Pt ^Fetus Qn US+Estimated from AC
11728-3 Fetal Body weight estimated from Abdominal circumference on US
 LOINC names
• Fully Specified Name (FSN) Sodium: SCnc: Pt: CSF: Qn:
Six axes (“Parts”) separated by a colon
• Long Common Name (LCN) Sodium [Moles/volume] in
Unique*, human-readable, used for display Cerebral spinal fluid
• Shortname
Unique, ≤ 40 characters Sodium CSF-sCnc
• Display Name
Unique*, clinician-friendly Sodium Molar conc (CSF)
(So far, only for Laboratory terms)
• Consumer Name
Not unique, intended for consumer-facing
Sodium, Spinal fluid
applications only; NOT for clinical care
*Truly duplicate concepts will have the same name, but only one term will be have an ACTIVE status; the
duplicates will have a DEPRECATED status and be mapped to their ACTIVE counterparts
Other attributes of a LOINC
term
LOINC term attributes
• Remember, the 6 Parts define a given LOINC concept
• However, each LOINC has lots of other associated information
• Attributes have many different purposes
• To help users understand the meaning of the term
• To organize terms and make them easier to find
• To provide metadata, such as the version in which the concept was first
published or most recently updated
• To provide information surrounding the use of a term, such as copyright
information
 Attribute examples #1
Attribute Description Examples
2
Units Example units of measure associated with mg/dL, kg, cm/s, mm
the result, including submitted units and
UCUM units
Formula The calculation used to determine the result Ejection fraction=[(LV end-diastolic volume-LV end-
systolic volume)/LV end-diastolic volume]*100
Type General classification of the type of 1 (Laboratory), 2 (Clinical), 3 (HIPAA Attachments), 4
observation (Survey)
TypeName Name of the classification Laboratory, Clinical, Attachment, Survey
Class More specific classification within a type Microbiology, Chemistry, Cardiology, Radiology,
PROMIS surveys
Status The state of the term Active, Discouraged, Deprecated, Trial
Order/Obs Whether a term is an order, observation, or Order, Observation, Both
both
 Attribute examples #2
Attribute Description Examples
Related Names Synonyms or other names that are X-ALD (for Lysophosphatidylcholine)
related to a given concept (e.g., f434 (for Malus domestica recombinant)
disease name, allergen code) to help
with searching
Answer list For qualitative results, an enumerated LL1927-4 (for RAST class)
list or pointer to such a list of possible
results
Answer list The binding of an answer list to a term Example, Preferred, Normative
type
Survey The original question text from a In the past 7 days - Stress disturbed my sleep (from
question text validated survey instrument PROMIS sleep item bank)
External Copyright information for terms that COPYRIGHT
rd
copyright link have a 3 party copyright Organization: Kansas City Cardiomyopathy Questionnaire
Copyright: Copyright © 1996-2005 John Spertus, MD, MPH.
Terms of Use: Used with permission.
URL: www.http://cvoutcomes.org/
 Attribute examples #3
Attribute Description
VersionLastChanged The release in which a term was
last changed (or created)
Chngtype How the term changed in the
version last changed
Description Information at both the Part and Stroke volume is the volume of blood pumped from
term level
Examples
2.64, 2.58
ADD, DEL, UND, NAM
one ventricle of the heart during a single beat. It is the
difference between the volume at the end of diastole,
at which point the ventricle is done filling and is at its
maximum volume (also known as maximum end-
diastolic volume), and the end of systole, at which
point the ventricle has finished pumping but has not
yet started filling (also known as minimum end-
systolic volume).
 Attribute values are available in several
places
• In RELMA and http://search.loinc.org:
• On the search screen
• On the details pages
• In the LOINC table
• In various ancillary files, such as
• LoincAnswerListLink
• Linguistic variants
• PanelsAndForms
All of a term’s attributes are on its details page
LOINC content domains…not
just for lab anymore
 LOINC Content Types
Type Name Description
1 Laboratory Concepts from a variety of laboratory domains

2 Clinical All non-laboratory measurements, clinical information, documents, and radiology

and other procedures
3 HIPAA Attachments Concepts that identify the kinds of information communicated between payers
and providers for electronic claims
4 Survey Standardized assessment measures, including government forms and validated
survey instruments
Laboratory term classes
• Allergy • Fertility
• Blood bank • Genetics
• Cell markers • Hematology
• Challenges • HLA
• Chemistry • Microbiology
• Coagulation • Pathology
• Cytology • Serology
• Drug/tox • Urinalysis
Types of lab tests
• Routine testing
• Inpatient hospital lab
• Outpatient lab
• Testing done in providers’ offices
• Tests performed by patients in their homes
• Specialized laboratory testing (“sendout”)
• Newborn screening
• Veterinary
• Public health/Epidemiology
Laboratory – continuously evolving
• Emerging diseases
• Clinical human genetics
• Molecular testing for microorganisms and resistance
mechanisms
• Plasma cell-free DNA
• Veterinary medicine
• Drug tests for synthetic (“designer”) drugs
• New methodologies
Clinical terms
• LOINC type 2 terms include all types of measurements, procedures,
documents, and other clinical information that are not in the
laboratory domain
• Anthropomorphic measurements, Vital signs, History and physical
exam findings
• Procedures such as EKG, Echocardiography, OB ultrasound
• Radiology
• Ophthalmology
• Documents
Patient history examples
Document Ontology examples
Radiology examples
HIPAA Attachments
• Work closely with the HL7 Provider and Payer Information Exchange (PIE)
Working Group, formerly known as “Attachments”
• LOINC codes facilitate the exchange of documentation in support of
electronic claims transactions between payers and providers
• Attachment specifications use LOINC codes to:
• Identify the specific kind of information being communicated in both a request
and response (e.g., a discharge summary or diagnostic imaging report)
• Specify certain optional modifier variables for fulfilling the request for
information (e.g. variables that indicate a modification to the default time
period).
• Identify the attachment (document) type, sections, and sometimes the individual
entries (tests or observations) in structured attachment responses using HL7 CDA
Survey Terms
• LOINC type 4 terms include patient-reported outcomes and provider
completed forms
• Include
• Functional assessments/symptom indexes
• Government required forms
• Behavioral health/Psychiatry/Substance abuse assessments
• Many of the LOINC panel attributes were created for survey panels,
including observation ID in form, override display name, and skip logic
• Other LOINC attributes commonly used in survey terms include
Answer lists, survey question text, and copyright information
Simple survey example
Moderate complexity survey example
Complex survey example
LOINC panels
What is a LOINC “panel”?
• A collector (“parent”) term that contains an enumerated set of
discrete elements (“children”)
• The parent and children are all valid LOINC terms
Panels in LOINC
• We use the word “panel” as a generic concept that is synonymous with
battery, form, data set, etc. in other domains
• Naming conventions
• Most include “panel” in the Component
• If defined by an authoritative body, we tend to use the official name
• If child elements vary on axis values (e.g. Property), the panel term value for that
axis is a dash “-”
• PanelType field in the LOINC table categorizes panel terms as
• Panel (most common): a group of concepts that are ordered/resulted together
• Convenience group: a group of related concepts that serve a common purpose
but would not be ordered/resulted together
• Organizer: groups together subsets of terms in a panel, like headings on a form
PanelType = Panel
PanelType = Convenience group
PanelType = Organizer
What Defines a Panel?
• Panels are defined by the enumeration of child elements
• Conditionality for child elements:
Required (R) – Always expected to be present
Required with alternatives (R-a) – Always expected to be present, but a specific alternate
term may be used (typically a pair)
Optional (O) – May or may not be reported with panel depending on policy or capabilities of
reporting institution
Conditional (C) – Should be included if a specific condition is met (e.g., based on patient age or
diagnosis)
Reflex (Rflx) – Included if it satisfies a reflex condition based on another result in the panel
Null () – Undeclared. Typically used in “convenience” panel or when panel elements vary across
laboratories or hospitals

• We are moving away from specifying conditionality due to the variability across
institutions and impracticality of keeping up with panel definitions, except in certain
situations, e.g., a clinical guidelines, regulations
Attributes Assigned at the Term Level
• Most attributes of a given term apply to the term whether it is on
its own or within a panel
• Units of Measure (UCUM)
• Term description/definition
• Term status
• External Copyright
• Terms of Use
Term-level attributes
Attributes Assigned at the Panel Level
• Some attributes can be assigned to a term within the context of a
panel
• Display name override
• Form coding instructions
• Form context
• Cardinality
• Observation ID in form
• Skip logic
• Override answer list
• Images
 Where to find and view LOINC panels
• LOINC Panel BrowserNEW (https://loinc.org/panels)
• LOINC detail pages in RELMA and https://search.loinc.org
• Show the full panel structure ± details about panel children
• Panels and forms file (https://loinc.org/downloads/accessory-files/)
• Contains the full panel structure for all panels in LOINC
• Use together with the LOINC table, AnswerList file, and LOINCAnswerListLink file
• RELMA “Export full panel structure”
• Export a single panel with all of its attributes from RELMA
• 4 tabs that include all of the information about the panel structure, LOINC terms,
Answer lists, and links between LOINCs and Answer lists included in that panel
A closer look at LOINC
Document Ontology
The Problem
Local systems have idiosyncratic names...

Dr. Smith’s
Outpatient
Silver Spring Pediatrics
Pediatrics
Peds Office Clinic Note
Note
Note
…that make it difficult to exchange and
organize documents across systems
The Solution
A common, controlled vocabulary for
representing clinical documents

Display Retrieval Organization Templates

Frazier P, Rossi-Mori A, Dolin RH, Alschuler L, Huff SM. The creation of an ontology of clinical document names. Stud Health
Technol Inform. 2001;84(Pt 1):94-8.
Names are based on
expected information
content, NOT on document
format
NOT part of a LOINC document name
• Author name
• Location of service
• Date of service
• Status (e.g. signed, unsigned)
• Security/privacy flags (e.g. protected)
• Updates or amendments to a document

Assume that these other important attributes would be sent

in different fields of the message (e.g. metadata)
Document Ontology attributes (axes)
Attribute Description Examples
Kind of General structure of the document; types Note
Document are defined based on the need to define Flowsheet
distinct document headers Report
Type of Characterizes the kind of service or activity Counseling
Service provided to/for the patient Discharge summary
Referral
Setting Where the service was provided Emergency department
Patient’s home
Subject A field of study or a branch of knowledge Psychology
Matter Pediatric cardiology
Domain Physical therapy
Role Profession or occupation Attending
Social worker
Constrained list of values
• Each Document Ontology axis has a
constrained set of values
• Values have been approved by the LOINC
Clinical Committee/Document Ontology
Subcommittee
• Requests for new values in any of the axes
have to be approved by the LOINC
Document Ontology Subcommittee

https://loinc.org/document-
ontology/current-version/
Rules for creating document terms
• Different combinations of values from each axis = unique LOINC
terms
• Terms must have Kind of Document + ≥ 1 other axis value
• Combinations are only created if they make sense clinically
• Can have more than one value within an axis (not common)
• Evaluation+Plan note
• Plan of care+summary note
• Hematology+Medical oncology
Cross-mapping between LOINC Document
Ontology and non-document parts
LOINC non-document part LOINC Document Ontology part
Component Type of Service + Kind of Document
System Setting
Method Subject Matter Domain + Role
Subject Matter Domain.Role
 Putting the Doc Ontology parts together
Component Property Time aspect System Scale Method

Note Find Pt {Setting} Doc Psychiatry.Case manager

83881-3 Psychiatry Case manager Note
Plan of Care note Find Pt {Setting} Doc Child and adolescent
psychiatry
77446-3 Child and adolescent psychiatry Plan of care note
Letter Find Pt Hospital Doc Pediatric surgery
68803-6 Pediatric surgery Hospital Letter
Asthma action plan Find Pt {Setting} Doc {Role}
69981-9 Asthma action plan
The LOINC/RadLex Unified
Model
Unified model overview
• Both the LOINC Radiology and RSNA RadLex Playbook were
designed to represent radiology orderables, results, and their
attributes
• Multi-year collaboration to combine and unify the useful aspects
of both models
• The unified model consists of a set of attributes and sub-
attributes that comprise every term
Attributes and sub-attributes
View Pharmaceutical
View.Aggregation Pharmaceutical.Substance given
View.View type Pharmaceutical.Route
Guidance Anatomy
Guidance for.Presence Anatomic Location.Region imaged
Guidance for.Approach Anatomic Location.Imaging focus
Guidance for.Action Anatomic Location.Laterality.Presence
Guidance for.Object Anatomic Location.Laterality
Reason for Exam Subject
Timing Modality
Maneuver Modality.Modality type
Maneuver.Maneuver type Modality.Modality subtype
View
<View descriptor> <View Aggregation> <View type>

Examples
View descriptor View, Multisection
Aggregation 2, greater than 3 (GT3)
View type AP, lateral, oblique
Guidance
Guidance for <Approach> <Action> of <Object>

Examples
Approach percutaneous, deep
Action aspiration, placement, drainage
Object cyst, catheter, abscess
Reason for exam
Indication or purpose of study

Examples
for shunt patency, for vertebral fracture
Timing
<Timing>
Used with both maneuver and pharmaceutical

Examples
Timing W, WO, WO & W
Maneuver
<Timing> <Maneuver>

Examples
Maneuver type flexion, extension, standing
Pharmaceutical
<Timing> <Pharmaceutical> <Route>

Examples
Pharmaceutical contrast, 18-F FDG
Route IV, PO, via nephrostomy tube,
intra fistula
Anatomy
<Region imaged> “>” <Imaging focus>
laterality attached as appropriate

Examples
Region imaged head, abdomen, lower extremity
Imaging focus brain, clavicle, liver, thigh, ankle
Laterality.Presence true, false
Laterality right, left, bilateral, unspecified
Subject

When study is focused on something other than the patient

Equivalent to Super system in other parts of LOINC

Examples
fetus, surgical specimen
Modality
<Modality>.<Modality subtype>

Examples
Modality XR, CT, MR, NM,
US, PT, MG, RF
Modality subtype angio, densitometry,
spectroscopy, tomography
 Cross-mapping between LOINC radiology and
non-radiology parts
LOINC non-radiology part Unified model attribute (LOINC radiology part)
Component – 1st part View
Guidance
Reason for exam
Component – 2nd part (challenge) Timing + Maneuver
Timing + Pharmaceutical
System Anatomy (Region imaged, Imaging focus, Laterality)
Subject
Method Modality
Relationship of unified model to LOINC and
Playbook concepts

Unified
LOINC model RadLex
RadLex
LOINC non- attributes Playbook
attributes
term radiology (LOINC concept
(RID)
parts radiology (RPID)
parts)
Examples
Content creation and
maintenance
 Ways to submit to LOINC
• RELMA
• Directly through the web or by email
to submissions@loinc.org
• Spreadsheet templates (loinc.org/submissions/new-terms/)
• Basic template
• Lab template
• Form (survey) template
• Radiology template
• Online submission form
 Term creation process
• Initial intake of a submission
• Pre-QA processing
• QA review
• Post-QA processing
• Post-LOINC creation tasks
• Sending Completed Term Report to submitter
• Public distribution of LOINCs
 Maintenance of LOINC
• Just as community requests drive new content creation, the
community also plays a large role in content maintenance
• We rely on LOINC users to tell us about changes that are needed
• We update content for many reasons
• New scientific knowledge
• Nomenclature changes
• Errors or ambiguity in existing concepts
• Updates to existing LOINC terms are only made if the edit does not
change the meaning of the term
• If a term was created incorrectly or its use is no longer
recommended, we will change the status to Deprecated or
Discouraged and define a replacement term
• Available in the MAP_TO table
Phew - we’re almost
done with Part 2!
Are you ready to do
some hands-on
LOINCing?
LOINC Query Design
• Tools
• RELMA
• http://search.loinc.org
• Search based on
• LOINC 6-part concept model
• Other attributes
• Search syntax
• AND (implied)
• OR
• *
• {Attribute}:
Query #1
How do I find all terms added in the latest version of LOINC?

Versionfirstreleased:2.66

Alternatively,
Versionlastchanged:2.66 Chngtype:Add
Query #2
How do I find all terms updated in the latest version of LOINC?

Versionlastchanged:2.66 – Chngtype:Add

(Remember, Versionlastchanged:2.66 Chngtype:Add got

you all terms added in the latest version)
Query #3
How do I find all Radiology terms that are mapped to RadLex Playbook
codes?

Relatedcodes:RPID*

Query #3a
How do I find all terms mapped to RadLex Playbook MR or CT codes?

Relatedcodes:RPID* Method:(CT or MR)

Query #4
How do I find all LOINC terms having to do with Influenza virus testing
in CSF?

Component:Influenza System:CSF

Note 1 – if you search for Component:flu* System:CSF, you will

also get Haemophilus influenzae and Parainfluenza virus terms
Note 2 – if you search for Component:flu* by itself, in addition to
Haemophilus influenzae and Parainfluenza virus, you will also get terms
for Fluoride, Fluconazole, Guidance for aspiration of fluid, and many
more
Query #5
How do I find all terms asking about anxiety that have an answer list?

Component:anxiety Answerlist:true

Note – if you don’t include Component: your search will return any
terms with “anxiety” in any of the Parts or in the Related Names for one
of the Parts
Query #6
How do I find all panels that contain glucose in the name?

Component:glucose Orderobs:order

Alternatively,

Component:glucose panel
Part 3. Implementing LOINC
many tools for implementers
 Part 3 Overivew

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
Key Implementation Resources
Software, API, Documentation, Community
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
 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

RELMA Mapping Screen
 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
https://loinc.org/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
Full Demo of LOINC API
Session S42:

An API for LOINC release content using FHIR Terminology Services

Monday Nov 18, 2019

1:45 PM–3:15 PM

Monroe
 https://loinc.org/guides/micro

FDA-funded development of Guide for

Using LOINC Microbiology Terms

The first in LOINC’s series of Implementation Guides

Coming soon:
Chemistry
Drug/Toxicology
Allergy
Serology/Hematology
Cell Markers
Molecular Pathology

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
 Go upstream
Map more efficiently and consistently

📷 Fishking_1 | cc-by
Reference laboratories have all
mapped their tests to LOINC

Some imaging centers too

https://usdiagnostics.roche.com/en/documentation.html#/q/loinc/s/SCORE_DESC
https://ivdconnectivity.org/livd
 The LOINC term name is key

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

📷 jdhancock | cc-by
LOINC Fully Specified Name
Includes the info necessary to distinguish among clinically
important differences

Defines the essential uniqueness of each term in LOINC

Body height:Len:Pt:^Patient:Qn:
 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!
Which LOINC term is the best match for
Systolic Blood Pressure?

A 8480-6 Systolic blood pressure "

B 8481-4 Systolic blood pressure 1 hour maximum

C 8512-6 Radial artery Systolic blood pressure

D 60984-2 Aorta Systolic blood pressure

Which LOINC term is the best match for
Inpatient Discharge Summary?

A 68823-4 Pediatrics Hospital Discharge summary

B 34105-7 Hospital Discharge summary "

C 84321-9 Physical therapy Outpatient Discharge summary

D 18842-5 Discharge summary

Which LOINC Property is consistent
with the units of measure “mg/dL” ?
A ACnc Aribitrary concentration

B MoM Multiple of the median

C MFr Mass fraction

D MCnc Mass concentration

"
 Which LOINC term is the best match for
LDL Cholesterol (Direct) in mg/dL?

A 57698-3 Lipid panel with direct LDL - Serum or Plasma

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

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

"
D 2089-1 Cholesterol in LDL [Mass/ volume] in Serum or Plasma
 Which LOINC term is the best match for
Cytochrome P450 3A5 (CYP3A5) Genotype (star allele notation)?

CYP3A5 gene product metabolic activity interpretation in Blood or

A 79717-5 Tissue Qualitative by CPIC

CYP3A5 gene c.6986A>G(*3) [Presence] in Blood or Tissue by Molecular

B 72697-6 genetics method

CYP3A4 gene mutations found [Identifier] in Blood or Tissue by

C 81139-8 Molecular genetics method Nominal

D 81140-6
CYP3A5 gene mutations found [Identifier] in Blood or Tissue by
Molecular genetics method Nominal "
 Which LOINC term is the best match for
JAK2 V617F Mutation Analysis, Quantitative (%)?

JAK2 gene targeted mutation analysis in Blood or Tissue by Molecular

A 48726-4 genetics method

B 53761-3
JAK2 gene.p.Val617Phe mutant/Normal in Blood or Tissue by Molecular
genetics method "
JAK2 gene p.Val617Phe [Presence] in Blood or Tissue by Molecular
C 43399-5 genetics method

JAK2 gene p.Val617Phe [Presence] in Bone marrow by Molecular genetics

D 72333-8 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://databrowser.researchallofus.org
https://lhncbc.nlm.nih.gov/project/lhc-forms
 Apple Health Records
Uses Argonaut FHIR Profile

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

https://support.apple.com/en-us/HT208647
FHIR structured
LOINC coded
Searchable with BigQuery:
cloud data warehouse with
built-in machine learning

Eyal Oren
PM, Google
We quantitatively demonstrated the positive impact
of standardizing multi-site laboratory data to
LOINC prior to use in predictive models.

We used our findings to argue for the need for

detailed reporting of data standardization
procedures in predictive modeling, especially in
studies leveraging multi-site datasets extracted
from electronic health records.

Barda AJ, Ruiz VM, Gigliotti T, Tsui FR. An argument for reporting data standardization procedures in multi-site predictive modeling: case study on the impact of LOINC standardization on model performance. JAMIA Open. 2019 Apr;
2(1):197–204. PMCID: PMC6435008
Top 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
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)

 Stay up-to-date
LOINC recommends that users update to the current
version within 90 days of its publication.

📷 Arul Irudayam | by-nd

 $
Why update?
LOINC continues to evolve

Your testing may have changed

Your codes may have changed

Watch changes to codes, names, or units

Your data partners may have updated their codes

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