Clinical LOINC® Tutorial Panels, Forms, and Patient Assessments

Clinical LOINC Meeting

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

Overview •  Background •  Standard Panels in LOINC •  Enhanced Panel Model for Patient

Assessment Instruments •  Current Projects •  Lessons Learned

Standard Panels in LOINC Enumerated child elements

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.

Example Panel

Example Panel with Nesting

Clinical Panels

Patient Assessments in LOINC Iterative enhancements of the panel model

Upcoming AMIA 2010 Paper

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

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

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)

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

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

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

Panels/Forms Available as Separate Download

http://loinc.org/downloads

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]

•  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.

•  COMPONENT. This is the default display

Pain Presence. Ask resident: “Have you had pain or hurting at any time in the last 7 days?”

Item label = “Body Mass Index (BMI)” LOINC Component = “Body mass index”

Successes and Current Projects

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)

Find them in RELMA

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

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)

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

Challenges and Lessons Learned Corralling the Creativity

Lesson 1 Variation Abounds

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

Original PHQ-9

CARE

MDSv3

MDSv2

MDSv3

OASIS

CARE

Lesson 2 Starting from a uniform data model may bring clarity

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

Many Yes/No Diseases

Lesson 3 IP issues present large challenges

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

Lesson 4 Always new challenges

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