LOINC Tutorial Documents

Daniel J. Vreeman, PT, DPT, MSc Assistant Research Professor, Indiana University School of Medicine

Research Scientist, Regenstrief Institute, Inc

Clinical LOINC Meeting

2013 02 14 © 2013 dvreeman@regenstrief.org

http://loinc.org/slideshows

Overview

photo via Vernio77

1.  Origins of a Document Ontology

2.  HL7/LOINC Model

3.  Evaluation and Ongoing Development

4.  Future Directions

Origins of a Document Ontology

Local systems have idiosyncratic names…

…need a common, controlled vocabulary

Outpatient Pain Note

Dr. Smith’s Tues Pain Clinic Note

Chronic Pain Clinic

06/2000 • Document Ontology

Task Force

09/2003 •  First Axis Values and LOINC

Codes 06/2005 •  Expanded SMD Domain

10/2007 • Revised Axis Value

Approval

Ongoing • Harmonization Efforts • New Content Creation

Document Type Codes

Provide consistent semantics for names of documents exchanged between systems

Frazier P, Rossi-Mori A, Dolin RH, Alschuler L, Huff SM. The creation of an ontology of clinical document names. Stud Health Technol Inform. 2001;84(Pt 1):94-8.

Retrieval

Organization

Display Preparation of Templates

What is a Document? a collection of information

photo via striatic

an information collection

Title

Sections Sentences

Sentences

Other content

photo via karen horton

Different than a panel enumerated, discrete elements

Clinical Notes

Formal Document Ontology model and rules apply to clinical notes, but not (yet) to reports. (although non-intuitively they are in CLASS:DOC.CLINRPT)

Clinical Note

A clinical document, produced by clinicians spontaneously or in response to a request for consultation.

Clinical Report

A clinical document, produced in response to an order for a procedure.

Approach Empiric analysis of >2000 document names

Mayo, 3M/Intermountain, VA in SLC, VA in Nashville

Find the level of granularity that best meets exchange use case

Photo via Jeffrey Beall

Ultra-specific local names • Dr. Evil’s Friday Afternoon Pain Clinic Note

Commonly understood elements • Outpatient Pain Clinic Note

Local Codes and Names Still probably needed

Can send both in HL7

Mapping to a standard enables: Interoperability

Aggregation

Document Ontology Model Multi-axial / Poly-hierarchical

Names are based on

expected information content

NOT document format photo via karen horton

Names Based on Content Same LOINC code for…

…if information content is the same

Not Part of the Name Author

Location of service

Date of service

Status (e.g. signed, unsigned)

Security/privacy flags (e.g. protected)

Updates or amendments to a document

Assume that these other important attributes would be sent in different fields of the message (e.g. metadata)

Model of Document Names

Subject Matter Domain • e.g. Cardiology, Pediatric Cardiology, Physical Therapy

Role • Author training/professional classification (not @ subspecialty) • e.g. Physician, Nurse, Case Manager, Therapist, Patient

Setting • Modest extension of CMS’s definition (not equivalent to location) • E.g. Hospital, Outpatient, Emergency Department

Type of Service • Service or activity provided to patient • Eg. Consultation, History and Physical, Discharge Summary

Kind of Document • General structure of the document • E.g. Note, Letter, Consent

Rules for Constructing Names

photo via Robert S Donovan

1. Enumerated List Document names are constructed from enumerated lists of values for each axis.

2. Document + One Other Document name needs specification of a Kind of Document value and at least one of the other four axes.

• <Type of Service> <Kind of Document> Component

• Find Property

• Pt Time

• <Setting> System

• Doc Scale

• <SMD>.<Role> Method

3. Combinations Combinations from within an axis are allowed where they make sense (SMD, Service).

Assessment + Plan

Example LOINC Names Component Prop Time System Scale Method

Group counseling note Find Pt Hospital Doc {Provider}

Evaluation and management note Find Pt Outpatient Doc {Provider}

Evaluation and management note Find Pt {Setting} Doc {Provider}

History and physical note Find Pt {Setting} Doc {Provider}

Initial evaluation note Find Pt {Setting} Doc Physician

{curly braces} notation: send that content as a separate item in the message (field or segment).

Hierarchy Made a 1st pass Component hierarchy

– Based on Type of Service Axis

–  Ignored Kind of Document

Multi-axial hierarchy is auto-generated – Available as a separate download

Custom hierarchies (e.g. context-specific) ones are easily imagined

More on this later…

Hierarchy in RELMA

Evolution, Evaluation We’re not done yet

Evolution Ongoing evaluation and evolution Exceptional contributions from Columbia University and the VA

Major Focus: Expanded original SMD values with ABMS specialty names and iterative discussion

More ontology additions from submissions

Iterative Evaluation Case Study NYPH-CUMC

Case Study

Hyun S, Shapiro JS, Melton G, Schlegel C, Stetson PD, Johnson SB, Bakken S. Iterative evaluation of the Health Level 7--Logical Observation Identifiers Names and Codes Clinical Document Ontology for representing clinical document names: a case report. J Am Med Inform Assoc. 2009 May-Jun;16(3):395-9.

SMD Role Setting Type Service Kind of Doc Overall Distinct Original

CDO

26.7% 99.9% 99.9% 43.5% 100% 23.4%

(n=894)

7.9%

Expanded

CDO

98.6% 100% 100% 99.9% 99.9% 98.5%

(n=935)

39.1%

1.  Expanded CDO is better

2.  Many local documents map to 1 LOINC

3.  Inter-rater reliability was good

Nursing

Hyun S, Shapiro JS, Melton G, Schlegel C, Stetson PD, Johnson SB, Bakken S. Iterative evaluation of the Health Level 7--Logical Observation Identifiers Names and Codes Clinical Document Ontology for representing clinical document names: a case report. J Am Med Inform Assoc. 2009 May-Jun;16(3):395-9.

SMD Role Setting Type Service Kind of Doc Overall Distinct SMD +

CDO

74% 100% 100% 100% 100% 74.5%

(n=94)

33%

Cross-site Mapping Study of DO Axes Terms whose titles specified this axis

Li L, Morrey CP, Baorto D. Cross-mapping clinical notes between hospitals: An application of the LOINC Document Ontology. AMIA Symp Proc; 2011:;777-783.

SMD Role Setting Type of Service None West Campus (n=1644)

67.6% 34.6% 28.9% 59.4% 8.2%

East Campus (n=1124)

69.1% 56.0% 12.7% 69.0% 7.1%

1.  Majority of titles map to at least one axis

2.  Sites varied in how they specified titles; creates granularity issues in cross-site aggregation

Cross-site Mapping to LOINC Using LOINC v2.34

Li L, Morrey CP, Baorto D. Cross-mapping clinical notes between hospitals: An application of the LOINC Document Ontology. AMIA Symp Proc; 2011:;777-783.

Combination of LOINC DO axes (null values allowed)

West Campus mapping rate

East Campus mapping rate

Subject Matter Domain, Type of Service, Role, and Setting

22.3% (n=367) 18.7% (n=210)

Subject Matter Domain, Type of Service, and Role

30.8% (n=506) 22.6% (n=254)

Subject Matter Domain and Type of Service

46.9% (n=771) 39.2% (n=441)

1.  Majority of titles map to at least one axis

2.  Documents assigned LOINC codes were less specified than those in their EHR

The LOINC document ontology model can provide a robust representation of clinical documents. This can be exploited to assist in common naming conventions, finding notes by traversing the axis categories of Subject, Setting, Role and Type of Service. However, the granularity of representation can be an issue in mapping across sites.

“

Case Study German University Hospital

German University Hospital

86 Document Types (1.2 mil documents)

44%

44%

12% Mapped to LOINC

Not specific enough mapping

No LOINC match

Dugas M, Thun S, Frankewitsch T, Heitmann KU. LOINC codes for hospital information systems documents: a case study. J Am Med Inform Assoc. 2009 May-Jun;16(3):400-3.

Used LOINC v2.24 (original DocOnt terms)

German University Hospital

LOINC codes that existed for documents in their set (by volume)

Ongoing Development

A Work-in-Progress

LOINC User’s Guide is definitive source for current policy

Collaboration/discussion Clinical LOINC Meetings

HL7 SDTC

Online

The Future Great Scott!

Future Directions More v1 and v2 axis value harmonization

Identifiers for the axis values

Explicit linkage of DocOnt parts to LOINCs

Axis definitions

Computable hierarchy

Extension to other Kind of Documents

Empiric analysis of document contents

photo via milos milosevic