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Daniel J. Vreeman, PT, DPT, MScAssociate Research Professor

, Indiana University School of Medicine

Associate Director for Terminology Services, Regenstrief Institute, Inc

@djvreeman

2016

Documents

Clinical LOINC Meeting - Salt Lake City, UT USA

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Overview

1. Origins of a Document Ontology

2. HL7/LOINC Model

3. Evaluation and Ongoing Development

4. Future Directions

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http://loinc.org/slideshows

http://loinc.org/slideshows

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Origins of a DocumentOntology

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Local systems have idiosyncratic names

need a common, controlled vocabulary

OutpatientPain

Note

Dr.SmithsTues

PainClinic

ChronicPain

Clinic

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Document Type Codes

Provide consistent semantics for names of documentsexchanged between systems for any purpose

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.

Display Retrieval Organization Templates

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What is a Document?a collection of information

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an information collection

Title

Sections

Sentences

Sentences

Other content

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Different than a panelenumerated, discrete elements

an information collection

Title

Sections

Sentences

Sentences

Other content

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Clinical Notes

Clinical Note

Aclinicaldocument,producedbycliniciansspontaneouslyorinresponsetoarequestforconsultation.

Clinical Report

Aclinicaldocument,producedinresponsetoanorderforaprocedure.

Formal Document Ontology model and rules

apply to clinical notes, but not (yet) to reports.

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ApproachEmpiric analysis of >2000 documentnames

Mayo, 3M/Intermountain, VA in SLC, VA in Nashville

Find the level of granularity that best

meets exchange use case

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Ultra-specific local

names Dr. Evils Friday Afternoon Pain

Clinic Note

Commonly understoodelements

Outpatient Pain Clinic Note

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Local Codes and Names

Still probably neededCan send both in HL7

Mapping to a standard enables:Interoperability

Aggregation

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Document Ontology Model

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Names are based on

expected informationcontent

NOTdocument format

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Names Based on Content

Same LOINC code for

if information content is the same

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Not Part of the Name

Author nameLocation of service

Date of service

Status (e.g. signed, unsigned)

Security/privacy flags (e.g. protected)

Updates or amendments to a document

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Assume that these other

important attributes wouldbe sent in different fields of

the message (e.g. metadata)

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Domainofthecontentinthedocumente.g. Cardiology, Pediatric Cardiology, Physical Therapy

Subject Matter Domain

Authortraining/professionalclassification(not@subspecialty)e.g. Physician, Nurse, Case Manager, Therapist, Patient

Role

ModestextensionofCMSsdefinition(notequivalenttolocation)e.g. Hospital, Outpatient, Emergency Department

Setting

Serviceoractivityprovidedtopatiente.g. Consultation, History and Physical, Discharge Summary

Type of Service

Generalstructureofthedocumente.g. Note, Letter, Consent

Kind of Document

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Rules for

constructing

namesphoto via Robert S Donovan

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1. Enumerated List

Documentnamesareconstructedfromenumeratedlists of values for each axis.

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2. Document + One Other

NamesneedtospecifyaKind of Documentvalueandatleastone of the other four axes.

Component

Property

Find

System

Scale

Doc

Method

.

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3. Combinations

Combinationsfromwithinanaxisare allowedwheretheyarereasonable(SMD,Service).

Only a few examples currently:

Assessment+Plan note

Treatment plan+summary note

Hematology+Medical oncology

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Example LOINC Names

Component Prop Time System Scale Method

Group counseling note Find Pt Hospital Doc {Author Type}

History and physical note Find Pt {Setting} Doc {Author Type}

Initial evaluation note Find Pt {Setting} Doc Physician

Note Find Pt Outpatient Doc Diabetology

Note Find Pt {Setting} Doc Mental health

{Curly Braces} notation:sendthatcontentasaseparateiteminthemessage(fieldorsegment).

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Find All the Terms

In the LOINC database (and RELMA),all of the terms conforming to the

rules of the ontology are placed in

the DOC.ONTOLOGYclass.

Before LOINC version 2.50, they were (non-intuatively) inthe class DOC.CLINRPT

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LOINC Terms for Sharing Ontology Values

Pro Tip:findthemwiththissearch

http://search.loinc.org/search.zul?query=LOINC+Document+Ontology

http://search.loinc.org/search.zul?query=LOINC+Document+Ontology

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LOINC Accessory FilesSpecial representations of LOINC content

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Accessory Files

LOINC Panels and Forms FileAn export of key panels, survey instruments, and forms in a detailed data structure.

LOINC Document Ontology FileSpecial file for the detailed naming conventions for clinical document titles.

LOINC Multiaxial Hierarchy FileHierarchical organization of LOINC terms based on their axes.

LOINC/IEEE Medical Device Code Mapping FileLinkages between LOINC terms and content from IEEE EMB/11073 standard.

LOINC/RSNA Radiology Playbook FileSpecial file for the detailed naming conventions for radiology procedure titles.

LOINC/SNOMED CT Expression Association and Map SetsDraft status (Technology Preview) file containing a) mappings between LOINC parts and

SNOMED CT concepts and b) SNOMED CT expressions linked to LOINC codes.

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Accessory Files

LOINC Panels and Forms FileAn export of key panels, survey instruments, and forms in a detailed data structure.

LOINC Document Ontology FileSpecial file for the detailed naming conventions for clinical document titles.

LOINC Multiaxial Hierarchy FileHierarchical organization of LOINC terms based on their axes.

LOINC/IEEE Medical Device Code Mapping FileLinkages between LOINC terms and content from IEEE EMB/11073 standard.

LOINC/RSNA Radiology Playbook FileSpecial file for the detailed naming conventions for radiology procedure titles.

LOINC/SNOMED CT Expression Association and Map SetsDraft status (Technology Preview) file containing a) mappings between LOINC parts and

SNOMED CT concepts and b) SNOMED CT expressions linked to LOINC codes.

i h i

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Hierarchy in RELMA

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Document Ontology File

Links all Document Ontology terms to theirconstituent axis values

Axis values given unique Part identifierscategorized by axis

Download from LOINC site

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New (Free) ResourceHL7 Implementation Guide

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Evolution + EvaluationWere not done yet

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Evolution

Ongoing evaluation and evolutionExceptional contributions from Columbia University and the VA

Major Focus: Expanded original SMD values

with ABMS specialty names and iterativediscussion

More ontology additions from submissions

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Development Milestones

2000 06 Document Ontology Task Force

2003 09 First axis values and LOINC codes released

2005 06 Expanded SMD domain

2007 10 Revised axis values approved

2013 06 Special Document Ontology File in releases

2013 12 Major harmonization completed

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Iterative Evaluation

Case StudyNYPH-CUMC

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1. Expanded CDO is better

2. Many local documents map to 1 LOINC

3. Inter-rater reliability was good

Case Study

SMD Role Setting Type Service Kind of Doc Overall DistinctOriginal

CDO

26.7% 99.9% 99.9% 43.5% 100% 23.4%

(n=894)

7.9%

Expanded

CDO

98.6% 100% 100% 99.9% 99.9% 98.5%

(n=935)

39.1%

98.5%

Hyun S, Shapiro JS, Melton G, Schlegel C, Stetson PD, Johnson SB, Bakken S. Iterative evaluation of the Health Level 7--Logical Observation Identifiers Names and Codes Clinical

Document Ontology for representing clinical document names: a case report. J Am Med Inform Assoc. 2009 May-Jun;16(3):395-9.

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Cross-site Mapping Study of DO AxesTerms whose titles specified this axis

SMD Role Setting Type of Service None

West Campus

(n=1644)

67.6% 34.6% 28.9% 59.4% 8.2%

East Campus

(n=1124)

69.1% 56.0% 12.7% 69.0% 7.1%

1. Majority of titles map to at least one axis

2. Sites varied in how they specified titles; createsgranularity issues in cross-site aggregation

Li L, Morrey CP, Baorto D. Cross-mapping clinical notes between hospitals: An application of the LOINC Document Ontology. AMIA Symp Proc; 2011:;777-783.

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The LOINC document ontology modelcan provide a robust representation of

clinical documents. This can beexploited to assist in common namingconventions, finding notes by

traversing the axis categories ofSubject, Setting, Role and Type ofService. However, the granularity of

representation can be an issue inmapping across sites.

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Other Evaluations

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Other Evaluations

Dugas M, Thun S, Frankewitsch T, Heitmann KU.LOINC codes for hospital information systems documentsJ Am Med Inform Assoc. 2009 May-Jun;16(3):400-3.

PMID: 19261942.

Hyrinen K, Mykknen J.

Mapping the Finnish National EHR to the LOINC.Stud Health Technol Inform. 2011;165:161-6.

PMID: 21685603.

Reeves RM, FitzHenry F, Brown SH, et al.

Who said it? Establishing professional attribution among authorsof Veterans' Electronic Health Records.

AMIA Annu Symp Proc. 2012;2012:753-62. Epub 2012 Nov 3.PMID: 23304349.

http://www.ncbi.nlm.nih.gov/pubmed/23304349http://www.ncbi.nlm.nih.gov/pubmed/21685603http://www.ncbi.nlm.nih.gov/pubmed/19261942

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Still ongoing development

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The FutureGreat Scott!

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Future Directions

More v1 and v2 axis value harmonizationIdentifiers for the axis values

Axis definitions

Computable hierarchyExtension to other Kind of Documents

Empiric analysis of document contents

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