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Scientific Data Resources Forum | Health Care Systems Research Network (HCSRN)

LOINC
A Vital Tool for Electronic Exchange of Clinical Data

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
Welcome to the
LOINC Community

📷 jamescridland | cc-by
Slides available at:
danielvreeman.com/hcsrn
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.
!
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
High Level Outline

1. Superhero origin story


2. A shallow LOINC dive
3. Implementing LOINC

📷 Vernio77 | cc-by-sa
The Superhero Origin Story
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
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
Syntax Standards
Solving this problem Messages, Documents, APIs, CDMs
HL7v2, C-CDA, FHIR, VDW

requires different kinds Semantic Standards


of data standards Vocabulary/code systems
LOINC, RxNorm, HPO, ICD,
MONDO, UCUM
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.


No single vocabulary
standard covers it all
Observables (and collections of them): LOINC
Units of measure: UCUM
Problems, Organisms, Conditions, etc: SNOMED CT, ICD, HPO
Medications: RxNorm, ACT
Reimbursement: National codesets (e.g. CPT)
{
"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 89,000+ 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
78,000+ 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.
Taking a little deeper
LOINC dive
LOINC’s content scope
Where to use LOINC codes
Key features of LOINC’s development approach
High Level LOINC Landscape
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
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


Structured Answer Lists

LOINC Answer Lists LOINC Answers


ID (contains “LL” prefix) ID (contains “LA” prefix)
Can be defined as enumerated or pointers String-based, not truly “concept” based
Contains extra attributes about the package Have some mappings to external codes (e.g. SNOMED CT)
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

Radiology Procedures
Wonderful collaboration with RSNA [PMID: 29850823]
5,800 terms with rich metadata
loinc.org/radiology

📷 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 and patient reported outcome terms
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
LOINC Development
We’ll focus on the key features

📷 jurvetson | cc-by
Guiding Principles
Openness
Accessibility
Growth
Pragmatics
Agility
Diligence
Respect

Read more in our draft LOINC Manifesto


LOINC Distribution
Major releases twice per year
Rich collection release artifacts
Implementation tools
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
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 Radiology


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
(
1. 2)
0h
(3
)
LOINC Terms

1.
0
1. i
0j
-a
1.
0k
1.
0
Only Lab LOINC Terms

1. l
0m
1.
0m
a
1.
0n
1.
00
2.
00
2.
01
2.
03
2.
04
2.
05
2.
06
2.
07
2.
08
2.
09
2.
10
2.
11
2.
12
2.
13
LOINC Terms Over Time

2.
14
2.
15
2.
16
2.
17
2.
19
2.
21
2.
22
2.
24
2.
26
2.
27
2.
29
2.
30
2.
32
2.
34
2.
36
2.
38
2.
4
2.
42
2.
44
2.
46
2.
48
2.
50
2.
52
2.
54
2.
56
2.
58
2.
61
2.
63
2.
laboratory terms only

64
2.
65
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
Implementing LOINC
many tools for implementers
Many resources
loinc.org/downloads

“Raw” release artifacts


Online and desktop browser (RELMA)
API (via FHIR)
Documentation
Community resources

Most require a free loinc.org account


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 Linguistic Variants
LOINC Group File New!

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
https://search.loinc.org
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
https://loinc.org/fhir
Current U.S. Landscape
Brief Summary of LOINC Adoptions
Many forces converging on the need for
interoperable health data

21st Century Cures with TEFCA/USCDI (and ISA)


“Promoting Interoperability” and related programs ( superseding “Meaningful Use”)
Value-based healthcare
Precision medicine
Population health
Care coordination
Quality measurement
Person-centered care
Innovation
Population-based research
ONC CMS
Interoperability Standards Embraced LOINC as standard
Advisory vocabulary for PAC
EHR Certification Criteria

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

LOINC for lab data in 2020


Support for LOINC by IVD vendors Research Networks
HCSRN, PCoreNet, OHDSI, etc
Ideas for Leveraging LOINC
in Population Research
In good company…
https://databrowser.researchallofus.org
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
Add clarity to other VDW
domains by linking to LOINC
See: ONC’s 2019 ISA Reference Edition
Patient Allergic Reactions Alcohol Use
Patient Family Health History Depression
Patient Functional Status and/or Disability Exposure to Violence (Intimate Partner Violence)
Imaging Diagnostics, Interventions and Procedures Financial Resource Strain
Laboratory Tests Level of Education
Clinical/Nursing Assessments Physical Activity
Outcomes for Nursing Social Connection and Isolation
Patient Pregnancy Status Stress
Patient Gender Identity Patient Tobacco Use (Smoking Status)
Patient Sex (At Birth) Patient Vital Signs
Patient-Identified Sexual Orientation
True even if your data
structure is “flat”
Vital Signs, Social History, etc

versus “stacked” Labs, Procedures


For analytical
purposes, you may
want to group
results from
several LOINCs.
Wait…what!?!
loinc.org/groups
Go upstream
Mapping is more efficient and consistent with help
from lab test manufacturers

📷 Fishking_1 | cc-by
https://ivdconnectivity.org/livd/
https://usdiagnostics.roche.com/en/documentation.html#/q/loinc/s/SCORE_DESC
Bonus Tip
LOINC can augment your QA
LOINC Property -> Units mismatch
LOINC System (Specimen) -> SPECIMEN_SOURCE
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.
Happy LOINCing!
Q & A