1. Clinical LOINC Meeting
Clinical LOINC® Tutorial
Panels, Forms, and Patient Assessments
Daniel J. Vreeman, PT, DPT, MSc
Assistant Research Professor, Indiana University School of Medicine
Associate Director of Terminology Services, Regenstrief Institute, Inc
07.15.2010 Copyright © 2010

2. Overview
• Background
• Standard Panels in LOINC
• Enhanced Panel Model for Patient
Assessment Instruments
• Current Projects
• Lessons Learned

3. Standard Panels in LOINC
Enumerated child elements

4. Panels (Batteries) in LOINC
• Panel term linked to enumerated child elements
– Child elements can be panels themselves (nesting)
• Panel term names (under discussion)
– Component often have “panel”, include authoritative source
– Property typically “-” because child elements will vary
– Scale typically “-” because child elements will vary
– Class PANEL.*
• Child elements linked and identified as:
– Required (R) Element always reported with panel
– Optional (O) Element may not be reported depending on
institutional policies or capabilities
– Conditional (C) Element is a key finding and thus should be
assumed to be negative, absent, or not present if
panel result does not include data for this
element.

5. Example Panel

6. Example Panel with Nesting

7. Clinical Panels

8. Patient Assessments in
LOINC
Iterative enhancements of the panel model

9. Upcoming AMIA 2010 Paper

10. Introduction
• Patient assessments are widely used to measure a broad
range of health attributes
– Functional status, depression, health-related quality of life, etc
– Survey instruments, questionnaires, assessment forms, etc
• Observations from patient assessments (whether
clinician-observed or self-report) are in many respects
very similar to other kinds of clinical observations
• Survey instruments have psychometric properties
• Question meaning tightly coupled with answers
General Aim: LOINC could serve as a “master question file”
and provide a uniform representation

11. Approach
• Iterative refinement of the base panel model as
we added new content
– Kept uncovering new wrinkles
• Collaborated with many people
– Tom White, CHI Functioning and Disability
workgroup, APSE, AHIMA, CMS, RTI, HL7, HITSP, and
others
• Represent the full assessment content with
attributes at three levels
– Individual item, answer list, panel-specific item
instance

12. Attributes of Assessment Items
• Question (item) name/text
– Exact question text, form-specific display name
• Data type
• Definition/description
• For numeric values: units of measure, range checks
• For categorical results: answers in an answer list
• Copyright and terms-of-use notices
• HL7 field sub-id
• HL7 data types (v2 and v3)

13. Structured Answer Lists
• Many items have highly specialized, fixed answer lists
– Often the answer lists define the meaning of the question
– Few are represented by existing codes in reference terminologies
• LOINC has created answer codes where needed
– Have “LA” prefix and a mod-10 check digit
– Are unique by lexical string (ignoring capitalization)
– Intentionally do NOT distinguish based on context-specific meaning
• In some cases, the answer list is identified with a
Regenstrief-assigned OID (for HL7 CDA use)
– Identify lists as “normative” vs “example”
• Answer list shows sequence, but not bound by it
• Store local codes for items and have place to store
universal code (e.g. SNOMED) if we’re able

14. Attributes of Items in a Panel Instance
• Some non-defining attributes of an item vary by panel
– Vary across instruments or different forms of the same
assessment
• Represented at the level of the item instance in a panel
– Display name override (e.g. “BMI” vs “Body Mass Index”)
– Cardinality
– Observation ID in form (local code)
– Skip logic
– Data type in form
– Answer sequence override
– Consistency/validation checks
– Relevance equation
– Coding instructions

19. Advantages of the Master Catalog
• Single database (LOINC) contains the details
about individual observations and sets
– In the database, all forms (sets) look the same
– Automatic standardization
• Separates the form structure, question details,
the rendered version (paper or screen), and the
program that manages it
• Can easily reuse observations (and attributes)
in different forms/sets

20. Panels/Forms Available as
Separate Download
http://loinc.org/downloads

21. Rules for Display of Items
• SURVEY_QUEST_TEXT (if populated). Used when item is asked as
a question. Sometimes the item has a label and a question, so we
store both as [label].[question text]
Pain Presence. Ask resident: “Have you had pain or hurting at
any time in the last 7 days?”
• DISPLAY_NAME_FOR_FORM (if populated). Provides an override
display linked to the instance of the LOINC in a particular form.
Allows for presentation variation that doesn’t affect meaning and
for where the LOINC naming conventions require some difference
b/w the item and the LOINC Component.
Item label = “Body Mass Index (BMI)”
LOINC Component = “Body mass index”
• COMPONENT. This is the default display

22. Successes and Current
Projects

23. Currently in LOINC
• US Government Forms
– CARE, MDSv2, MDSv3, OASIS B1, OASIS C RFC
– US Surgeon General’s Family Health Portrait
• Brief Interview for Mental Status (BIMS)
• Confusion Assessment Method (CAM)
• Geriatric Depression Scale (GDS)
• HIV Signs and Symptoms Checklist
• Home Health Care Classification
• howRU
• Living with HIV (LIV-HIV)
• Morse Fall Scale
• OMAHA
• PHQ (9 and 2)
• Quality Audit Marker (QAM)

24. Find them in RELMA

25. ASPE as Key Supporter
• ASPE (Jennie Harvell) has championed use of
HIT standards for assessment instruments in
many venues
• Initial Reports
– Making the "Minimum Data Set" Compliant with
Health Information Technology Standards
– Standardizing the MDS with LOINC® and Vocabulary
Matches

26. 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)

29. Many Other Opportunities
• PhenX Measures
• PROMIS
• Neuropsychological testing instruments (APA)
• Lots of other commonly-used instruments
(SF-36, etc)
• CDC case report and other forms
• National physical therapy outcomes database
measures

30. Challenges and Lessons
Learned
Corralling the Creativity

31. Lesson 1
Variation Abounds

32. Variation Abounds
• Despite many instruments now in LOINC,
reuse of items has been minimal
– E.g. extremely few of same items b/w MDSv2
and MDSv3
– MDSv3 has greater similarity to CARE, but the
lookback period is different (7D vs 2D)
• We noticed differences that might have
been avoided
• Urge developers to weigh the cost of
losing comparability before inventing

33. Original PHQ-9
CARE
MDSv3

34. MDSv2
MDSv3
OASIS
CARE

35. Lesson 2
Starting from a uniform data model may bring clarity

36. A Uniform Data Model Would Help
• We usually started from paper forms, though some instruments had
their own software and data structures
• Forced to reconcile many potential discrepancies
– “Unknown”/“unable to determine” as answer choices vs flavors of null
– How do you store “Other specified ______”
– Units of measure implied?
– Which text is the item and which is “help”
• Incongruence with the HL7+LOINC model
– Items for things that could go in PID, etc
– Flat data model vs stacked
– Every ‘Check all that apply’ stored as separate yes/no item
• Interoperable data exchange standards haven’t been in the minds
of survey developers
• Starting with the LOINC model may elucidate hidden challenges

37. Many Yes/No Diseases

38. Lesson 3
IP issues present large challenges

39. Intellectual Property Issues
• Must negotiate separate agreements with each
copyright/IP holder for inclusion in LOINC
• Many instruments have difficult restrictions
– Protection against change and attribution are understandable
– Some want royalties
– Commercial use in LOINC’s context is tricky
• Even more complicated when several instruments
included in larger CMS ones (MDS, CARE, etc)
• Funders should require developers to avoid such
restrictive licenses

40. Lesson 4
Always new challenges

41. Always New Challenges
• Answer list sequences
– Same answers across instruments but different order
• Skip logic shown at level of answer
– Current strategy is to aggregate up to question level
• Items with pictures
• Computer-adaptive testing coefficients and
attributes