2010 06 - LOINC-ICF
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A proposal for interoperable health information exchange with two
Esperantos: ICF and LOINC® ICF and Biomedical Informatics – Part II
Daniel J. Vreeman, PT, DPT, MSc Assistant Research Professor, Indiana University School of Medicine Associate Director of Terminology Services, Regenstrief Institute, Inc
06.24.2010 Copyright © 2010
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Overview • Origins of LOINC
– Background, growth, and the LOINC Community
• A Proposal for Effective use of ICF with LOINC
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Origins of LOINC The lingua franca of clinical observation exchange
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Introduction • Regenstrief’s 35-year history • Indiana Network for Patient Care
– A working HIE for 15 years – 200+ source systems – 10.5 million patients, 3 billion results – Regenstrief: 3rd party convener
• Regenstrief is the 1st WHO collaborating center in medical informatics
• A fundamental challenge – Local systems use idiosyncratic codes
• Vocabulary standards – Provide the lingua franca of information exchange
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Indiana Network for Patient Care
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LOINC Background • Logical Observation Identifiers Names and Codes • Organized by Regenstrief Institute in 1994
– Ongoing support from NLM and Regenstrief
• Covers domain of Clinical Observations – Laboratory Observations (since 1995) – Clinical Observations (since 1996)
• A universal code system that facilitates exchange, pooling, and processing of results
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LOINC’s General Role • If an observation is a question, and the
observation value an answer: – LOINC provides codes for the questions {OBR-4, OBX-3}
718-7:Hemoglobin:MCnc:Pt:Bld:Qn
What is my patient’s hemoglobin level?
41959-8:Walking speed:Vel:1W^mean:^Patient:Qn:Calculated
How fast does my patient usually walk?
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Indiana Network for Patient Care
A
A
MSH|^~\&|HOSPITAL_A|SAMPLE_HOSPITAL_A|||$YearMonthDay||||||||||||||| PID|||$patientId$||$patientName$|||||||||||||||||||| PV1|||||||$attendingDoctor$||$consultingDoctor$|||||||| OBR|1|||44249-1^PHQ-9 Quick Depression Assessment Pnl^LN||$requestDate||||||||| OBX|1|ST|44250-9^Little interest or pleasure in doing thing in last 2W^LN|1|3^More than half the days^LN||||||||||||| OBX|2|ST|44255-8^Feeling down, depressed, or hopeless in last 2W^LN|1|2^Several days||||||||||||| …
OBX|10|ST|44261-6^PHQ-9 Total Score^LN|1|11|||||||||||||
HL7 v.2.X Message
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A brief digression about data models…
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“Flat” Data Model
Patient_ID Provider_ID Date Height Weight Heart_Rate
1111 77777 2010 04 09 183 cm 90.7 kg 74 bpm
2222 77777 2010 04 09 152 cm 49.9 kg 65 bpm
One record per patient
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“Stacked” Data Model Patient_ID Provider_ID Date Observation_Code Observation_Name Value Units
1111 77777 2010 04 09 1234-5 Body Height 183 cm
1111 77777 2010 04 09 2345-6 Body Weight 90.7 kg
1111 77777 2010 04 09 3456-7 Heart Rate 74 bpm
2222 77777 2010 04 09 1234-5 Body Height 152 cm
2222 77777 2010 04 09 2345-6 Body Weight 49.9 kg
2222 77777 2010 04 09 3456-7 Heart Rate 65 bpm
One record per observation
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Laboratory LOINC ― Chemistry ― Allergy Testing
― Urinalysis ― Blood Bank
― Toxicology ― Cell Markers
― Hematology ― Skin Tests
― Microbiology ― Coagulation
― Antibiotic Susceptibilities ― Cytology
― Immunology/Serology ― HLA Antigens
― Molecular Genetics ― Surgical Pathology
― Cell Counts
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Clinical LOINC ― Vital Signs ― EKG
― Hemodynamic Measurements ― Cardiac Ultrasound
― Fluid Intake/Output ― Obstetrical Ultrasound
― Body Measurements ― Discharge Summary
― Emergency Department Variables ― History and Physical
― Respiratory Therapy ― Pathology Findings
― Tumor Registry ― Colonoscopy/Endoscopy
― Ophthalmology Measurements ― Clinical Documents
― Radiology Reports ― Document Sections
― Patient Assessment Instruments
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The LOINC Community Open, Nimble, Pragmatic
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A Highly ‘Open Source’ Model • LOINC (the database) and RELMA (the
mapping program) are available freely worldwide for nearly any purpose
• Much work is done by volunteers • Content additions are end-user driven
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10 new members per day 300+ new members per month
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Translation Efforts
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Downloads: ~1100/month
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US Adoption A few key highlights
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Consolidated Health Informatics
• CHI Goal: – Adopting interoperability standards for all US federal
health agencies
• Adopted LOINC as standard – Laboratory result names (2003) – Laboratory test order names (2006) – Meds: structured product labeling sections (2006) – Federally-required patient assessment instruments
with functioning and disability content (2007) • Same process that adopted ICF as a standard for functioning
and disability domain
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Other Key US Adoptions • eLINCS
– Messaging standard for results delivery from LIS to an EHR
• NAACCR – Volumes II (Data Standards/Dictionary) and V (Path Lab e-Reporting)
• CDISC – Pharmaceutical research specs
• NCQA/HEDIS – Used by 90% of US health plans to measure quality
• HITSP – C80: vital signs, lab results, lab orders, genetic results, other results – IS92: newborn screening – C83: Patient assessment instruments (sections, questions, answers)
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A Proposal for Effective use of ICF and LOINC Making complementary strengths productive
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General Observations • No computer-interpretable version of ICF • Links with other vocabularies (UMLS, SNOMED)
don’t address qualified codes • Several ICF item collections
– Full version, short version, ICF-CY, ICF core sets, more…
• Challenge: ICF classification blends several observation question/answer pairs into 1 code – d410.1302 (changing basic body position) is really 4
“observations”
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Goals • Send a person (or population)’s ICF
classification using same machinery as other health data – To reach ICF’s goals, you need to share data
• Maximize strengths of each terminology (minimize duplication of effort)
• Be informed by real world use – Need some interested parties!
• Facilitate addressing challenges in ICF use – Relationship to standardized assessments and clinical
measures
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Original Option 1 • Simplest Approach: One LOINC code
– NNNN-N:Functioning Classification:Imp:^Patient:Pt:Ord:ICF – Expected “answer” in OBX-5 would be a ICF classification
• Problems with Simplest Approach – Still have blending of question/answer in OBX-5 – No indications of sets
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Original Option 2 • Full LOINC Modeling including panels for
ICF Sets • Example: d420 – Transferring oneself
– N-N:Transferring oneself.Performance:Imp:^Patient:Pt:Ord:ICF – N-N:Transferring oneself.Capacity:Imp:^Patient:Pt:Ord:ICF
– Expected “answers” in OBX-5 would be the ICF qualifiers
0 – No setup or physical help from staff
1 – Setup help only
2 – One person physical assist
3 – Two+ person physical assist
8 – ADL acBvity itself did not occur during enBre 7 days
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Original Option 2 • Problems with this approach
– Labor intensive • Each ICF component + qualifier combination
would be a different LOINC code (assessing different attributes)
• Keeping up with sets would be very difficult
– Some modeling challenges (e.g. anatomy) – Negotiating IP issues
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New Inspiration
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Clinical Genomics Model
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Further Inspiration
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HL7 CDA Framework for Questionnaire Assessments
• Specifies a document package representing the full assessment “form”
• For each observation/answer, enables concurrent transmission of: – Model of Use (LOINC)
• Exact measurement, as on the assessment
– Model of Meaning (SNOMED, ICF) [optional] • Representation of the conceptual assertion in another
(standard) terminology/classification
– Supporting Clinical Observations (LOINC, SNOMED) [optional]
• Data from the EHR that supports the assessment decision
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Proposed ICF Result Package in LOINC
ICF classificaBon panel ICF collecBon, populaBon descriptor, observaBon Bme period, other descriptors of the observaBon period
ICF classificaBon results panel ICF component, any applicable qualifiers, fully-‐qualified ICF item
ICF supporBng clinical observaBons panel Any supporBng clinical measurements for that ICF classificaBon (direct measures, assessment scores, etc)
1 to many
0 to many
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Example ICF Result Package in LOINC
R/O/C Example Answers
NN-‐N ICF classifica9on panel
NN-‐N ICF classificaBon collecBon R Full
NN-‐N PopulaBon descripBon O Clinic population >65 years
NN-‐N DuraBon of observaBon period O Point in time
NN-‐N ICF classifica9on results panel R
NN-‐N ICF code stem R d450
NN-‐N ICF funcBoning classificaBon O d450.12
NN-‐N AcBviBes and parBcipaBon performance qualifier C 1 – MILD difficulty
NN-‐N AcBviBes and parBcipaBon capacity without assistance qualifier
C 2 – MODERATE difficulty
NN-‐N ICF suppor9ng clinical observa9ons panel O
59460-‐6 Morse Fall Risk Total 55
4195703 Mean walking speed 24H 0.9 m/sec
1 to N
0 to N
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Benefits of Nested Model • Uses HL7-LOINC messaging framework while minimizing
redundant modeling • Accommodates ‘meta-data’ about the result package • Flexes to accommodate large or small sets of ICF codes • Enables explicit connection between ICF classification
and supporting clinical data • Accommodates sending alternate identifiers (e.g. UMLS
or SNOMED) for ICF components • Could also use the ICF classification result panel in
another context – nested under a regular clinical observation to convey the
higher level interpretation of that result
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Next Steps • Looking for collaborators with live
systems that have a need to exchange ICF classifications electronically – And want to used established messaging
standards
• Present to Clinical LOINC Committee 7/16/2010
• To infinity and beyond…