FHIR DevDays 2017 | Amsterdam, Netherlands

FHIR and LOINC

Daniel J. Vreeman, PT, DPT, MS, FACMI
Regenstrief-McDonald Scholar in Data Standards
Indiana University School of Medicine

Director, LOINC and Health Data Standards

@djvreeman Regenstrief Center for Biomedical Informatics

2017
 FHIR and LOINC go together
like chips and salsa

photo via Marco Verch

 Overview

1. Introduction to LOINC
2. LOINC in the FHIR jungle
3. LOINC specific features in the
FHIR terminology services

photo via Vernio77

Disclosure
Im the author of the book LOINC Essentials published
by Blue Sky Premise, LLC where I serve as President.

Not a NYT Best Seller. Net profit going to a special

charitable project: danielvreeman.com/build-a-school

PI on a contract from bioMrieux for LOINC content

 First, lets get a
sense of whos here

photo via Arran Moffat

What is your familiarity with LOINC?

Not much, Im new

Im relatively new
Im an advanced LONICer
LOINCs superhero
origin story

McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.
 Life without LOINC
CODE NAME
34626D Arterial BP Diastolic
39312D ABP Diastolic
ARTDIASBP Arterial Diastolic BP
nvArtBPS Arterial Blood Pressure Diastolic
DBP DBP
25284D BP (NIBP)
2737317 Diastolic Blood Pressure #1
6881D BP Diastolic
3800DBP BP
77934D BP Manual Diastolic
919109 Diastolic Blood Pressure
DiastBP DiastolicBP
PBPD PRE BLOOD PRESSURE DIASTOLIC
POBPD POST BLOOD PRESSURE DIASTOLIC
MO MONEY MO PROBLEMS
MO DATA MO PROBLEMS
 data
It's like, the more money
we come across
The more problems we see
MO DATA MO PROBLEMS
Problems
Health IT systems often lack
common mechanisms for MO DATA MO PROBLEMS

exchanging data.

Even when they do, they use

different ways of identifying the
same concept.

Only way to overcome these problems is

with data standards
The universal standard for
identifying health measurements,
observations, and documents.

Est. 1994
 LOINC is a rich trove of 84,000+ standardized variables
Genetics Lifestyle

21654-9 CFTR gene targeted mutation analysis

24475-6 F2 gene c.20210G>A [Presence] 41950-7 Number of steps in 24 hour Measured

75547-0 Noninvasive prenatal fetal aneuploidy 75296-4 Carbohydrate intake 24 hour Estimated
and microdeletion panel based on Plasma cell- 82289-0 Rating of perceived exertion [Score]
free+WBC DNA by Dosage of chromosome-specific
circulating cell free (ccf) DNA 72166-2 Tobacco smoking status NHIS

82245-2 Chromosome region 22q11.2 deletion in 64098-7 Distance walked in 6 minutes

Amniotic fluid or CVS by FISH

Lab and clinical Environmental

82464-9 Mosquito count [#] in Environmental specimen

4548-4 Hgb A1c MFr Bld 67784-9 Individuals below poverty line Neighborhood
8462-4 Diastolic blood pressure 63736-3 Materials to which you were exposed in your
work or daily life
24725-4 Head CT
63805-6 How long did you handle paints or solvents
57021-8 CBC W Auto Differential panel - Blood yourself?

8633-0 QRS duration 67640-3 My teachers believe that I can do well in my

school work
No single vocabulary
standard covers it all
Observables (and collections of them): LOINC
Diagnosis, Problems, Organisms, etc: SNOMED CT
Medications: RxNorm, ACT
Reimbursement: National codesets (e.g. CPT)
We do measurements
LOINC is focused on one piece of
the interoperability puzzle

photo via puuikibeach| cc-by

Laboratory LOINC
Clinical LOINC
Designed For Observations
Using Hl7 FHIR + LOINC
Anatomy of a LOINC Term
18262-6:Cholesterol.in LDL:MCnc:Pt:Ser/Plas:Qn:Direct assay

LOINC Code 18262-6

Component Cholesterol.in LDL

Property MCnc

Timing Pt

System Ser/Plas

Scale Qn

Method Direct assay

There are six major LOINC axes

Anatomy of a LOINC Term
8302-2:Body height:Len:Pt:^Patient:Qn:

LOINC Code 8302-2

Component Body height

Property Len

Timing Pt

System ^Patient

Scale Qn

Method

Method is the only optional axis

Codes for individual observations
6690-2 Leukocytes [#/volume] in Blood by Automated count
2339-0 Glucose [Mass/volume] in Blood
29463-7 Body weight
55423-8 Number of steps in unspecified time Pedometer

Codes for collections (panels and documents)

57021-8 CBC W Auto Differential panel - Blood
34565-2 Vital signs, weight and height panel
44249-1 PHQ-9 quick depression assessment panel
36813-4 CT Abdomen and Pelvis W contrast IV
18842-5 Discharge summary
 Structured Answer Lists
Answer List Attributes
ID (contains LL prefix)
OID
External Link

Answer Item Attributes

ID (contains LA prefix)
String
Sequence
Local code
Universal code (SNOMED CT)
Score
Normative => This is it. Dont
mess with it!
 The LOINC Distribution
LOINC Table
LOINC Table Core
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

Each has a detailed ReadMe and Release Notes

Major releases
twice per year
(June and December)

photo via striatic | cc-by

LOINC grows
because USERS ask
 LOINC License
No cost use
Worldwide
In perpetuity
Commercial or noncommercial
purposes
Encourages translation
One major prohibition
CANNOT use any
Licensed Material to
develop or promulgate
a different standard for
orders or observations.
 One more thing
whats with the pig?
 Global Growth
LOINC adoption around the
world
55,000+ registered users from 170 countries

6,000 new users per year

Many kinds of LOINC Users
Referral / reference labs and radiology centers
Health-related federal agencies
Care organizations
Professional societies
Health information exchange networks
Insurance companies
Health IT vendors
Instrument manufacturers
Health app developers
Official national standard in 30+ countries
LOINC in the
FHIR Jungle
Diagnostic Medicine Module
Observation
LOINC is the most widely
used code system for
observations

Heresclassic numeric result

reporting example with
UCUM units
Return hemoglobin
Obs for my patient
http://spark.furore.com/fhir/Observation?
patient=http://spark.furore.com/fhir/Patient/
f001&code=718-7&_format=json
Return patients with
a hemoglobin Obs
http://spark.furore.com/fhir/Patient?
_has:Observation:patient:code=718-7&_format=json

Reverse chaining
Observation
Works just as well for coded
answers like this one where
you may also use LOINC
Answer codes
Profile [Observation]: Genetics

Specific LOINC codes for

each of these more
precisely specified
Observations
Profile [Observation]: Genetics
Profile [Observation]: Vital Signs
Goal
Use LOINC inside the
Goal resource as the
code for target measure
Diagnostic Report
The findings and interpretation of
diagnostic tests.

Some mix of atomic results, images,

textual and coded interpretations,
and formatted representation of
diagnostic reports.

For lab, pathology, radiology, and

other diagnostic services
(cardiology, etc)

LOINC is preferred code set

Imaging Study
vs. Diagnostic Report

Diagnostic Report can point to loinc.org/collaboration/rsna

Imaging Study

Diagnostic Report would typically

be a document in a presented
form and the narrative, with an
imaging study reference and
possibly some key images.

Imaging Study provides

information on a DICOM imaging
study, and the series and imaging
objects in that study.
Foundation Module
Questionnaire
(and Response)
LOINC has a rich data model
for representing collections,
data elements (questions), and
their answers.

10,000+ LOINC terms for

patient reported outcomes
measures
A quick sample of
the LOINC
questionnaire/
assessment
content
 Social, psychological and behavioral Humiliation, Afraid, Rape, and Kick
observations - 2015 Edition Health IT questionnaire
Certification Criteria set HIV Signs and Symptoms Checklist
Adverse Childhood Events howRU
Borderline Symptom List - 23 Item Living with HIV (LIV-HIV)
Brief Interview for Mental Status (BIMS) Morse Fall Scale
Confusion Assessment Method (CAM) My Mood Monitor
Core behavioral health terms (SAMHSA) Neuro-QOL
Edinburgh Postnatal Depression Scale PROMIS
FACIT PhenX
Geriatric Depression Scale (GDS) PHQ
VR 12 and 36

10,000+ patient assessment terms

Adding more all the time
Vreeman DJ, McDonald CJ, Huff SM. Representing patient assessments in LOINC. AMIA Annu Symp Proc. 2010;832-836. PMID: 21347095 .
Vreeman DJ, McDonald CJ, Huff SM. LOINC - A Universal Catalog of Individual Clinical Observations and Uniform Representation of Enumerated Collections. Int J Funct Inform
Personal Med. 2010;3(4):273-291.
Composition
Basic structure that loinc.org/document-ontology

builds FHIR Documents

(immutable bundles with
attested narrative)

LOINC has a rich set of

clinical document type
and section codes (used
extensively in CDA).
DataElement
Individual pieces of data that might
be collected or stored, including
observations requested or
performed and questions on forms

A fair bit of overlap b/w LOINC

attributes and DE definition
(question text, answer list, etc)

LOINC could serve as primary

identifier for many
Security/Privacy Module
Consent
A record of a healthcare
consumers policy choices, which
permits or denies identified
recipient(s) or recipient role(s) to
perform one or more actions within
a given policy context, for specific
purposes and periods of time.

In its Document Ontology, LOINC

provides a set of codes for consent
documents that can be used as the
category codes.
 LOINC-specific
features in FHIR TS
Cool tricks with LOINC via FHIRs Terminology Services
https://www.hl7.org/fhir/loinc.html
URI
http://loinc.org

Codes
LOINC Codes (21176-3)
LOINC Parts (LP31755-9)
LOINC Answer Lists (LL715-4)
LOINC Answer Codes (LA11165-0)

Display Names for LOINC terms

Long Common Name
Short Name (less than 40 characters)
Inactive
ACTIVE=DEPRECATED

Subsumption
Defined by LOINC MultiAxial
Hierarchy
Get info about your
favorite LOINC term
http://test.fhir.org/r3/CodeSystem/$lookup?
system=http://loinc.org&code=39046-8&_format=json
Quick note about
legal stuff
http://loinc.org/license
If you are building value sets (or
other web-accessible artifacts/
documents) that contain LOINC
codes, you must include a
copyright notice (per the license)

<copyright value="This content LOINC is copyright 1995 Regenstrief

Institute, Inc. and the LOINC Committee, and available at no cost
under the license at http://loinc.org/terms-of-use"/>
LOINC Parts
Coded representation of LOINC Fully
Specified Name attributes

Codes have the LP prefix

Represent them in UPPERCASE:
LP15491-1

Some Parts makeup MultiAxial Hierarchy

Other Part uses:

LOINC-specific filter properties
StructureDefinitions
ConceptMap (e.g. Part maps to SNOMED, RadLex, RxNorm)
Get child LOINCs under a Part
from the Multiaxial Hierarchy
A value set with an identifier of "http://loinc.org/vs/[partcode]"

http://test.fhir.org/r3/ValueSet/$expand?
url=http://loinc.org/vs/LP15491-1
LOINC Answer Lists
Value sets of answers for observation
value of ordinal/nominal LOINC terms

Lists are given a code (LL prefix)

LOINC Answer File specifies the binding

strength (Example, Preferred, Normative)

Some lists are intensional, many are

enumerated in LOINC

LOINC Answer strings are given codes

(LA prefix)
Get a LOINC Answer
List value set
http://test.fhir.org/r3/ValueSet/$expand?
url=http://loinc.org/vs/LL378-1&_format=json
LOINC Properties
STATUS
COMPONENT
PROPERTY
TIME_ASPCT
SYSTEM
SCALE_TYP
METHOD_TYP
CLASS
CLASSTYPE 1=Lab, 2=Clinical, 3=Claims Attachments, 4=Surveys

ORDER_OBS Order, Observation, Both

Building Value Sets
Based on LOINC
Properties
Include:
Component of Body height
Property of Len
System of ^Patient

Exclude:
None

Include special circumstances like post-partum, standing, etc

http://localhost:10000/vocab/ValueSet/test-
vs6/$expand?_format=json
Include:
Component of Glucose
Property of MCnc
System of Bld*

Exclude:
System of Bld.dot or BldC
http://localhost:10000/vocab/ValueSet/test-
vs5/$expand?_format=json
Include:
Method of Sports Medicine
Scale of Doc

Exclude:
None
http://localhost:10000/vocab/ValueSet/test-
vs7/$expand?_format=json
Work in Progress:
Canonical representation of LOINC as a
FHIR Code System

photo via Arul Irudayam | by-nd

https://loinc.org/fhir/loinc.xml
 Take home lesson:
When clinical data is coded with LOINC
codes and made accessible by FHIR,
diverse IT applications can understand
and interact with it for the benefit of
many in the health ecosystem.

photo via IMLS DCC | cc-by