Clinical LOINC Meeting | Salt Lake City, UT USA

Documents

Daniel J. Vreeman, PT, DPT, MS

Regenstrief-McDonald Scholar in Data Standards
Indiana University School of Medicine

Director, LOINC and Health Data Standards

@djvreeman Regenstrief Center for Biomedical Informatics

2017
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loinc.org/slideshows
 Overview

1. Origins of a Document Ontology

2. HL7/LOINC Model
3. Evaluation and Ongoing
Development
4. Future Directions

photo via Vernio77

Origins of a Document
Ontology
Local systems have idiosyncratic names

Dr. Smiths
Outpatient Chronic Pain
Tues Pain
Pain Note Clinic
Clinic

need a common, controlled vocabulary

 Document Type Codes
Provide consistent semantics for names of documents
exchanged between systems for any purpose

Display Retrieval Organization Templates

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.
What is a Document?
a collection of information

photo via striatic

 Title
Sections
Sentences
Sentences
Other content

an information collection

Different than a panel

enumerated, discrete elements

photo via karen horton

 Clinical Notes
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.

Formal Document Ontology model and rules

apply to clinical notes, but not (yet) to reports.
 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. Evils 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
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 a LOINC Name
Author name
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)
Subject Matter Domain
Domain of the content in the document
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 CMSs definition (not equivalent to location)
e.g. Hospital, Outpatient, Emergency Department

Type of Service
Service or activity provided to patient
e.g. 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
Names need to specify a Kind of Document value
and at least one of the other four axes.

Component
<Type of Service> <Kind of Document>
Property
Find
System
<Setting>
Scale
Doc
Method
<Subject Matter Domain>.<Role>
 3. Combinations
Combinations from within an axis are allowed
where they are reasonable (SMD, Service).

Only a few examples currently:

Evaluation+Plan note
Plan of care+summary note
Hematology+Medical oncology
 Example LOINC Names
Component Prop Time System Scale Method

Group counseling note Find Pt Hospital Doc {Role}

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

Initial evaluation note Find Pt {Setting} Doc Physician

Note Find Pt Outpatient Doc Diabetology

Note Find Pt {Setting} Doc Mental health

{Curly Braces} notation: send that content as a

separate item in the message (field or segment).
 Find All the Terms
In the LOINC database (and RELMA),
all of the terms conforming to the
rules of the ontology are placed in
the DOC.ONTOLOGY class.

Pro Tip: find them with the search

class:doc.ontology
LOINC Terms for Sharing Ontology Values

Pro Tip: find them with the search LOINC

Document Ontology
LOINC Accessory Files
Special representations of LOINC content
 Accessory Files
LOINC Part File
LOINC Answer File
LOINC Panels and Forms File
LOINC Document Ontology File
LOINC Multiaxial Hierarchy File
LOINC/IEEE Medical Device Code Mapping File
LOINC/RSNA Radiology Playbook File
LOINC/SNOMED CT Expression Association and Map Sets
 Document Ontology File
Links all Document Ontology terms to their
constituent axis values

Axis values given unique Part identifiers

categorized by axis

Download from LOINC site

 Accessory File Format
34130-5 Progress note:Find:Pt:Hospital:Doc:{Role}

LOINC PartNumber PartTypeName PartSequenceOrder PartName

34130-5 LP173418-7 Document.Kind 1 Note

34130-5 LP173213-2 Document.TypeOfService 1 Progress

34130-5 LP173065-6 Document.Setting 1 Hospital

34130-5 LP187187-2 Document.Role 1 {Role}

Enterprise Implementation
Resource (Free)
HL7 Implementation Guide
Used worldwide with
HL7 v2, CDA, and FHIR
Including the ubiquitous Consolidated CDA
Templates for Clinical Notes required in MU
Evolution + Evaluation
Were 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
 Development Milestones

2000 06 Document Ontology Task Force

2003 09 First axis values and LOINC codes released

2005 06 Expanded SMD domain

2007 10 Revised axis values approved

2013 06 Special Document Ontology File in releases

2013 12 Major harmonization completed

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

SMD Role Setting Type of Service None

West Campus 67.6% 34.6% 28.9% 59.4% 8.2%

(n=1644)
East Campus 69.1% 56.0% 12.7% 69.0% 7.1%
(n=1124)

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

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.

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.
 Still ongoing
development

photo via shutterrunner

More Resources
loinc.org/document-ontology
loinc.org/slideshows