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2010 06 - LOINC-ICF
- 1. 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
- 2. Overview • Origins of LOINC – Background, growth, and the LOINC Community • A Proposal for Effective use of ICF with LOINC
- 3. Origins of LOINC The lingua franca of clinical observation exchange
- 4. 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
- 5. Indiana Network for Patient Care
- 6. 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
- 7. 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} What is my patient’s hemoglobin level? 718-7:Hemoglobin:MCnc:Pt:Bld:Qn How fast does my patient usually walk? 41959-8:Walking speed:Vel:1W^mean:^Patient:Qn:Calculated
- 8. Indiana Network for Patient Care HL7 v.2.X Message 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||||||||||||| A A
- 9. A brief digression about data models…
- 10. “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
- 11. “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
- 12. 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
- 13. 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
- 14. The LOINC Community Open, Nimble, Pragmatic
- 15. 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
- 16. 10 new members per day 300+ new members per month
- 18. Downloads: ~1100/month
- 19. US Adoption A few key highlights
- 20. 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
- 21. 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)
- 22. A Proposal for Effective use of ICF and LOINC Making complementary strengths productive
- 23. 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”
- 24. 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
- 25. 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
- 26. 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
- 27. 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
- 28. New Inspiration
- 31. 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
- 32. Proposed ICF Result Package in LOINC ICF classificaBon panel ICF collecBon, populaBon descriptor, observaBon Bme period, other descriptors of the observaBon period 1 to many ICF classificaBon results panel ICF component, any applicable qualifiers, fully-‐qualified ICF item 0 to many ICF supporBng clinical observaBons panel Any supporBng clinical measurements for that ICF classificaBon (direct measures, assessment scores, etc)
- 33. 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 R 1 to N NN-‐N ICF classifica9on results panel R d450 NN-‐N ICF code stem O d450.12 NN-‐N ICF funcBoning classificaBon C 1 – MILD difficulty NN-‐N AcBviBes and parBcipaBon performance qualifier C 2 – MODERATE difficulty NN-‐N AcBviBes and parBcipaBon capacity without assistance qualifier O 0 to N NN-‐N ICF suppor9ng clinical observa9ons panel 59460-‐6 Morse Fall Risk Total 55 0.9 m/sec 4195703 Mean walking speed 24H
- 34. 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
- 35. 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…