Daniel J. Vreeman, PT, DPT, MSc Assistant Research Professor, Regenstrief Institute, Inc.

Associate Director of Terminology Services, Indiana University School of Medicine

Clinical LOINC Meeting | 01/27/2011 Copyright © 2011

Documents

Overview Origins of a Document Ontology HL7/LOINC Model

Evaluation and Ongoing Development Future Directions

Origins of a Document Ontology

Introduction

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 b/w 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

an information collection

Sections Sentences Sentences

Other content

Different than a panel Enumerated, discrete elements

Clinical Notes

Formal Document Ontology model and rules apply to clinical notes, but not (yet) to reports.

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

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

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

Model of Document Names

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

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

Setting • Modest extension of CMS’s definition (not equivalent to location) •  E.g. Inpatient 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

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   Inpa4ent  Hospital   Doc   {Provider}  

Evalua4on  and  management  note   Find   Pt   Outpa4ent   Doc   {Provider}  

Evalua4on  and  management  note   Find   Pt   {Se>ng}   Doc   {Provider}  

History  and  physical  note   Find   Pt   {Se>ng}   Doc   {Provider}  

Ini4al  evalua4on  note   Find   Pt   {Se>ng}   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

Hierarchy in RELMA

Evolution, Evaluation We’re not done yet

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

Expanded original SMD values with ABMS specialty names and iterative discussion

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%

In a separate analysis…

Section headings from nursing documents that could be mapped to existing LOINCs Hyun S, Bakken S. Toward the creation of an ontology for nursing document sections: mapping section names to the LOINC semantic model. AMIA Annu Symp Proc. 2006:364-8.

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

Future Directions

Future Directions More v1 and v2 axis value harmonization Axis definitions Extension to other Kind of Documents Empiric analysis of document contents