2. Overview
• Background
• Standard Panels in LOINC
• Enhanced Panel Model for Patient
Assessment Instruments
• Current Projects
• Challenges Along the Way
3. Brief Timeline
• 2000 – First panels in LOINC
• 2000 – Original Model Extension for Standardized Assessment
Measures (Braden, etc)
– Bakken, S, Cimino, JJ, Haskell, R, Kukafka, R, Matsumoto, C, Chan, GK, and Huff, SM (2000).
Evaluation of the clinical LOINC (Logical Observation Identifiers, Names, and Codes) semantic structure as a terminology model for standard
J Am Med Inform Assoc 7(6):529-38.
• 2000 – Initial surveys stored in LOINC (HIV, HHC, etc)
• 2002 – Proposed extension for Assessment Instruments
– White, TM and Hauan, MJ (2002). Extending the LOINC conceptual schema to support standardized assessment instruments. J Am Med
Inform Assoc 9(6):586-99.
• 2005 – Dissection of OASIS in LOINC
– Choi, J, Jenkins, ML, Cimino, JJ, White, TM, and Bakken, S (2005).
Toward semantic interoperability in home health care: formally representing OASIS items for integration into a concept-oriented terminolo
J Am Med Inform Assoc 12(4):410-7.
• 2006 – Initial work with MDS/OASIS (LOINC v2.17)
• 2006 – More discussions about data model, APSE/CHI interest
• 2006 – CHI/NCVHS Endorsement of LOINC as standard for
federally-required assessment instruments (quest/ans)
5. 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.
10. Introduction
• Initial modeling (circa 2000) required modest
extensions to the LOINC axes
– E.g. for System to include aggregate units like “family”, and Method
to distinguish among reported and observed findings
• Survey instruments have psychometric properties
• Question meaning tightly coupled with answers
• With experience in modeling instruments from
various domains, we uncovered additional
relevant attributes to store
General Aim: LOINC could serve as the
“master question file” in this domain
11. What’s in the Master Question File?
• Question (item) name/text
– Exact question text, form-specific display name
• Data type
• Description and/or help text
• For numeric values: units of measure, range checks
• For categorical results: answers in an answer list
• Required item (Y/N)
• Cardinality (more than one answer allowed)
• Copyright and terms-of-use notices
• Skip logic
• Consistency/data integrity logic
• … and more
12.
13.
14.
15.
16. 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
19. Rules for Display of Items
1. 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?”
2. 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”
3. COMPONENT. This is the default display
20. Rules for Display of Items
• LOINC is developing/evolving other display
names
– Short Name
– Long Common Name
– Consumer Name
• May be useful in some contexts, but our
current practice is to capture the exact form
display with previous rules
• Some of the original surveys in LOINC may
not yet follow the model
21. Structured Answer Lists
• Many items in surveys 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)
• Answer list shows sequence, but not bound by it
• Store local codes for items and have place to store
universal code (e.g. SNOMED) – not yet populated
23. 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 Tech
– Standardizing the MDS with LOINC® and Vocabulary Matches
24. Consolidated Health Informatics Initiative
• CHI Goal:
– Adopts a portfolio of existing health information
interoperability standards (health vocabulary and
messaging) enabling all agencies in the federal
health enterprise to “speak the same language”
• In 2006, adopted LOINC as standard:
– Laboratory test order names
– Medications: Structured Product Labeling Sections
25. Consolidated Health Informatics Initiative
• In 2007, CHI adopted LOINC as standard
for federally-required assessments:
– questions and answers
– assessment forms that include functioning
and disability content
• Jennie Harvell (ASPE) Co-chaired
26. Currently in LOINC
• US Government Forms
– CARE, MDSv2, MDSv3, OASIS, RFC
– US Surgeon General’s Family Health Portrait
• Geriatric Depression Scale
• HIV Signs and Symptoms Checklist
• Home Health Care Classification
• howRU
• OMAHA
• PHQ (9 and 2)
28. Current RI/LOINC Efforts
• ASPE-funded effort to create LOINC®
representation of new instrument versions
– MDSv3 (done)
– OASIS-C (this fall)
• CMS-funded effort to create LOINC®
representation of new CARE instrument
– Make recommendations on legacy instruments
– Interoperability recommendations
30. Many Other Potential Opportunities
• Mental health instruments
• Lots of other commonly-used
instruments (SF-36, etc)
• AHRQ Common Framework forms
• CDC case report forms
• PhenX protocols for clinical research
trials
32. Intellectual Property Issues
• Must negotiate separate agreements with each
copyright/IP holder
• Many instruments are fiercely protected
– 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)
33. Modeling
• 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)
• Lament the seemingly trivial differences
between the CMS-required instruments
36. Incongruity with HL7 Information 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
• “Unknown” or “unable to determine” as answer
choices vs flavors of null
• In general, CMS has not been thinking in terms of
interoperable data exchange
– Resistant to getting involved in SDO processes like
balloting
38. Always New Challenges
• How to label/store definitional text vs text
giving examples
– Rashes – e.g. intertrigo, eczema, drug rash, heat rash…
• 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
