Clinical LOINC Meeting | Salt Lake City, UT USA

An Introduction to LOINC

Daniel J. Vreeman, PT, DPT, MS

Regenstrief-McDonald Scholar in Data Standards
Indiana University School of Medicine

Director, LOINC and Health Data Standards

@djvreeman Regenstrief Center for Biomedical Informatics

2017
 Welcome to the
LOINC Community

photo via jamescridland | cc-by

 Workshop Webinar
Interaction
Attendees will be muted for the
workshop but you can still
interact with the LOINC team.

Have a question?
Use the Q&A section of the
webinar and the LOINC team will
respond.

Ask your question here

 meeting.loinc.org

Youll want to download RELMA if you havent already

loinc.org/slideshows
LOINCs superhero
origin story

McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.
 Crash Test Dummies
Informatics Pioneers
40 years of EMR work
Indiana Network for Patient Care
Most comprehensive and longest tenured Health
Information Exchange (HIE) in USA

A neutral 3rd party convener

 The rain forest canopy is a
seamless web through which
arboreal creatures efficiently
move to reach the edible
fruits without any attention
to the individual trees.
McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329. photo via nosha | cc-by-sa
The big problem
 In each case, the goals are stymied
or delayed by the work and
expense of translating the Babel-
like proliferation of different codes
used by different sources for the
same tests even when the sources
comply with existing electronic
message standards.
Forrey AW, McDonald CJ, et al. Logical observation identifier names and codes (LOINC) database: a public use set of codes and names for electronic
reporting of clinical laboratory test results. Clin Chem. 1996 Jan;42(1):81-90. PubMed PMID: 8565239.
Fundamental
challenges:
Local systems have different ways of
identifying the same concept.

Things that look alike arent the same.

The solution
 This problem would not
exist if all laboratories used
the same universal set of
test identifiers when
electronically transmitting
test results.
Forrey AW, McDonald CJ, et al. Logical observation identifier names and codes (LOINC) database: a public use set of codes and names for electronic
reporting of clinical laboratory test results. Clin Chem. 1996 Jan;42(1):81-90. PubMed PMID: 8565239.
The universal standard for
identifying health measurements,
observations, and documents.

Est. 1994
A non-profit research organization in Indianapolis, USA

Established LOINC in 1994

Overall steward and owner of LOINC

Develops and licenses LOINC

A small team that does BIG things
 With the help of many
LOINC Committee
Lab and Clinical

LOINC Community
Submitters
Translators
Advocates
Enthusiasts
And generous financial support
Many sources over the 20+ years of LOINC
AHCPR, ASPE, CDC, CHCF, CMS*, Hartford Foundation, IN
CTSA, Regenstrief Foundation*, Regenstrief Institute,
bioMrieux*, NCATS*, NCRR, NIBIB*, NIDDK*, NLM*,
LOINC User Community*
*active now

Today, the U.S. National Library of Medicine

(NLM) accounts for about 2/3 of our funding.
LOINC makes health data
more portable and
understandable to different
computer systems.
LOINC is free,
but invaluable
The outcome
Systems that
integrate data with
high fidelity
Data when and
where you need it
Computers that
understand the
content and can help
make use of it
We do measurements
LOINC is focused on one piece of
the interoperability puzzle

photo via puuikibeach| cc-by

Laboratory LOINC
Clinical LOINC
 A rich trove of 80,000+ standardized variables
Genetics Lifestyle

21654-9 CFTR gene targeted mutation analysis

24475-6 F2 gene c.20210G>A [Presence] 41950-7 Number of steps in 24 hour Measured

75547-0 Noninvasive prenatal fetal aneuploidy 75296-4 Carbohydrate intake 24 hour Estimated
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
If an observation is a question
and the observation value is
an answer
LOINC provides codes for questions

Where needed, other vocabularies

provide codes for answers
Does my patient have HIV?
48345-3:HIV 1+O+2 Ab [Presence] in Serum or Plasma

Is my HIV patients immune

system responding well to ART?
24467-3:CD3+CD4+ (T4 helper) cells [#/volume] in Blood

photo via nihgov | cc-by

How fast does my
patient usually walk?
41959-8:Walking speed:Vel:1W^mean:^Patient:Qn:Calculated

photo via Ed Yourdon | cc-by-nc-sa

LOINC fits well with
other data standards

photo via Temari 09 | cc-by-nc

Codes for individual observations
Leukocytes [#/volume] in Blood by Automated count
Erythrocytes [#/volume] in Blood by Automated count
Hematocrit [Volume Fraction] of Blood by Automated count

and collections of observations

CBC W Auto Differential panel - Blood
Vital signs, weight and height panel
PHQ-9 quick depression assessment panel
But I love maintaining my
local dictionary, what will
happen to my precious codes?
 Relax

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

Local Code LOINC Code

photo via Julien Haler | cc-by
 One more thing
whats with the pig?
Grown in Indiana
Serving a global community

Data standards are like telephones.

They require a critical mass of users
before they become useful.

~ Clem McDonald, MD (1998)

photo via iboy_daniel| cc-by

Our vision is for
LOINC to be
integrated into every
clinical information
system that shares or
aggregates data.
48,000+ registered users in 176 countries
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
 loinc.org registered users

50,000

45,000

40,000

35,000

30,000

25,000

20,000

15,000

10,000

5,000 6,000 new users per year

0
Translations
into 18 variants
of 12 languages
Adopted as National Standard
Australia Iceland Qatar
Austria India Rwanda
Belgium Italy Saudi Arabia
Brazil Malaysia Slovakia
Canada Mexico Slovenia
Cyprus Mongolia Spain
Estonia The Netherlands Thailand
Finland New Zealand Turkey
France Philippines United States
Germany Portugal
 Large Implementations
SIGA Sade project
7+ Provincial systems in Canada
8+ Regional Health Information Exchanges in
Spain
ePSOS
Assistance publique - Hpitaux de Paris
Hong Kong Hospital Authority
Philippine Health Insurance Corporation
InFSE Project in 5 regions in Italy (LOINC Italia)
Many more...
 A flavor of LOINC
adoption around the world
Members of the Korean National Standards
Committee are developing a LOINC subset
LOINCing in Hong Kong
LOINCing on a street corner near you
Support for LOINC in Ministry of Health Malaysia
Italian law adopting LOINC for identifying lab tests
French law mandating LOINC for identifying
lab tests via IHE XD-LAB profile
Moving standardization upstream
Many IVD manufacturers are identifying the LOINC codes
that match the tests they provide

photo via Fishking_1 | cc-by

Coming soon
Digital Format for
Publication of LOINC for
Vendor IVD Test Results
Adoption in the USA
In USA, major driver of
eHealth standards adoption has
been EHR Incentive Program

a.k.a. Meaningful Use

Blumenthal D, Tavenner M. The "meaningful use" regulation for electronic health records. N Engl J Med. 2010 Aug 5;363(6):501-4. Epub 2010 Jul 13. PubMed PMID:
20647183.
 LOINC adopted for:
1. View, download, transmit data to third party
2. Cancer case reporting to state registry
3. Send/receive electronic lab results in
ambulatory settings
4. Provide a care summary at care transition
5. Provide clinical summaries for patients
6. Submit reportable lab results to public health
Use in Quality Measures
87 mentions of LOINC.
Social, Psychological, and Behavioral Data
Financial resource strain
Education
Stress
Depression
Physical activity
Alcohol use
Social connection and isolation
Exposure to violence
All have specific LOINC codes identified
 LOINC Referenced
Representing Patient Allergic Reactions
Representing Patient Family Health History
Representing Patient Functional Status and/
or Disability
Representing Imaging Diagnostics,
Interventions and Procedures
Representing Laboratory Tests
Nursing
Representing Nursing Assessments
Representing Nursing Interventions
Representing Outcomes for Nursing
Representing Patient Clinical
Problems (i.e., Conditions)
Sex at Birth, Sexual Orientation and
Gender Identity
Representing Patient Gender Identity
Representing Patient Sex (At Birth)
Representing Patient-Identified Sexual
Orientation
Social Determinants
Representing Financial Resource
Strain
Representing Level of Education
Representing Stress
Representing Depression
Representing Physical Activity
Representing Alcohol Use
Representing Social Connection and
Isolation
Representing Exposure to Violence
(Intimate Partner Violence)
Representing Patient Tobacco Use (Smoking
Status)
Representing Patient Vital Signs
CMS Assessment Instruments
Know LOINC?
Get Hired!
My friends think this is cool

photo via DieselDemon | cc-by

 LOINC codes! Oh snap!

Apple Health Export in C-CDA Format

 Many unexpected
successes along the way

photo via heyyu | cc-by-nc-sa

 Everyone loves LOINC

photo via mccaughan

 The LOINC
Distribution
LOINC Table, Accessory Files, and Tools and
Resources for Implementers
Major releases
twice per year
(June and December)

photo via striatic | cc-by

 LOINC Codes Over Time by Release
90,000
LOINC Codes

80,000 Only Lab LOINC Codes

70,000

60,000

50,000

40,000

30,000

20,000
laboratory terms only
10,000

0
83,000 codes
havent you finished yet?
Lots cooking

photo via liber | cc-by

 How is new content
added to the database?
LOINC grows
because YOU ask
 LOINC Table
The main LOINC database content
 One Record Per Term
Cholesterol in LDL [Mass/volume] in Serum
Long Common Name
or Plasma by Direct assay
Short Name LDLc SerPl Direct Assay-mCnc

Class Type Lab

Class Chem

Example Units (local) mg/dL

Example Units mg/dL

Order/Obs Both
LOINC Accessory Files
Special representations of LOINC content
 Accessory Files
LOINC Panels and Forms File
An export of key panels, survey instruments, and forms in a detailed data structure.

LOINC Document Ontology File

Special file for the detailed naming conventions for clinical document titles.

LOINC Multiaxial Hierarchy File

Hierarchical organization of LOINC terms based on their axes.

LOINC/IEEE Medical Device Code Mapping File

Linkages between LOINC terms and content from IEEE EMB/11073 standard.

LOINC/RSNA Radiology Playbook File

Special file for the detailed naming conventions for radiology procedure titles.

LOINC/SNOMED CT Expression Association and Map Sets

Draft status (Technology Preview) file containing a) mappings between LOINC parts and
SNOMED CT concepts and b) SNOMED CT expressions linked to LOINC codes.
Legal Stuff
http://loinc.org/terms-of-use
photo via 917press | cc-by-nc-sa
Just kidding.

Copyright is a good thing for

standards.

Its the licensing you should

pay attention to.
No cost
Worldwide
In perpetuity
Use
Copy
Distribute
Any purpose:
commercial
non-commercial
Encourages
translation into
other languages
CANNOT use any
Licensed Material to
develop or promulgate
a different standard for
orders or observations.
That would defeat
the purpose of
having a standard!
 Read more about
Regenstriefs approach
to licensing LOINC
danielvreeman.com/licensing-loinc
 Tools for
Implementers
photo via Robert S Donovan | cc-by-nc
 A Big Toolbox
RELMA desktop mapping program
Online search app (search.loinc.org)
Community resources
Other reference material
Other LOINC-related software
LForms, FHIR Vocabulary server, etc

Putting the key tools to use is our focus today

What LOINC Essentials covers
LOINC basics

A framework and techniques for picking out the subtle but

important distinctions between LOINC terms

A roadmap and 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
Disclosure
Im the author of the book.

Not a NYT Best Seller.

Net profit going to a special charitable project:

danielvreeman.com/build-a-school
Get some help from
trusted friends
members.loinc.org
 RI Validity Checks
Totally worth the cost

Takes as input
Local test codes, names, units, and mappings

Returns
Spreadsheet highlighting issues detected by the
evaluation process
Sample of Evaluation Rules
Unknown local units
Deprecated LOINC
Discouraged LOINC
Property/units mismatch
Scale/units mismatch
Concentration missing denominator
loinc.org/slideshows