A proposal for interoperable health information exchange with two

Esperantos: ICF and LOINC® ICF and Biomedical Informatics – Part II

Daniel J. Vreeman, PT, DPT, MSc Assistant Research Professor, Indiana University School of Medicine Associate Director of Terminology Services, Regenstrief Institute, Inc

06.24.2010 Copyright © 2010

Overview •  Origins of LOINC

– Background, growth, and the LOINC Community

•  A Proposal for Effective use of ICF with LOINC

Origins of LOINC The lingua franca of clinical observation exchange

Introduction •  Regenstrief’s 35-year history •  Indiana Network for Patient Care

–  A working HIE for 15 years –  200+ source systems –  10.5 million patients, 3 billion results –  Regenstrief: 3rd party convener

•  Regenstrief is the 1st WHO collaborating center in medical informatics

•  A fundamental challenge –  Local systems use idiosyncratic codes

•  Vocabulary standards –  Provide the lingua franca of information exchange

Indiana Network for Patient Care

LOINC Background •  Logical Observation Identifiers Names and Codes •  Organized by Regenstrief Institute in 1994

–  Ongoing support from NLM and Regenstrief

•  Covers domain of Clinical Observations –  Laboratory Observations (since 1995) –  Clinical Observations (since 1996)

•  A universal code system that facilitates exchange, pooling, and processing of results

LOINC’s General Role •  If an observation is a question, and the

observation value an answer: –  LOINC provides codes for the questions {OBR-4, OBX-3}

718-7:Hemoglobin:MCnc:Pt:Bld:Qn

What is my patient’s hemoglobin level?

41959-8:Walking speed:Vel:1W^mean:^Patient:Qn:Calculated

How fast does my patient usually walk?

Indiana Network for Patient Care

A  

A  

MSH|^~\&|HOSPITAL_A|SAMPLE_HOSPITAL_A|||$YearMonthDay||||||||||||||| PID|||$patientId$||$patientName$|||||||||||||||||||| PV1|||||||$attendingDoctor$||$consultingDoctor$|||||||| OBR|1|||44249-1^PHQ-9 Quick Depression Assessment Pnl^LN||$requestDate||||||||| OBX|1|ST|44250-9^Little interest or pleasure in doing thing in last 2W^LN|1|3^More than half the days^LN||||||||||||| OBX|2|ST|44255-8^Feeling down, depressed, or hopeless in last 2W^LN|1|2^Several days||||||||||||| …

OBX|10|ST|44261-6^PHQ-9 Total Score^LN|1|11|||||||||||||

HL7 v.2.X Message

A brief digression about data models…

“Flat” Data Model

Patient_ID Provider_ID Date Height Weight Heart_Rate

1111 77777 2010 04 09 183 cm 90.7 kg 74 bpm

2222 77777 2010 04 09 152 cm 49.9 kg 65 bpm

One record per patient

“Stacked” Data Model Patient_ID Provider_ID Date Observation_Code Observation_Name Value Units

1111 77777 2010 04 09 1234-5 Body Height 183 cm

1111 77777 2010 04 09 2345-6 Body Weight 90.7 kg

1111 77777 2010 04 09 3456-7 Heart Rate 74 bpm

2222 77777 2010 04 09 1234-5 Body Height 152 cm

2222 77777 2010 04 09 2345-6 Body Weight 49.9 kg

2222 77777 2010 04 09 3456-7 Heart Rate 65 bpm

One record per observation

Laboratory LOINC ― Chemistry ― Allergy Testing

― Urinalysis ― Blood Bank

― Toxicology ― Cell Markers

― Hematology ― Skin Tests

― Microbiology ― Coagulation

― Antibiotic Susceptibilities ― Cytology

― Immunology/Serology ― HLA Antigens

― Molecular Genetics ― Surgical Pathology

― Cell Counts

Clinical LOINC ― Vital Signs ― EKG

― Hemodynamic Measurements ― Cardiac Ultrasound

― Fluid Intake/Output ― Obstetrical Ultrasound

― Body Measurements ― Discharge Summary

― Emergency Department Variables ― History and Physical

― Respiratory Therapy ― Pathology Findings

― Tumor Registry ― Colonoscopy/Endoscopy

― Ophthalmology Measurements ― Clinical Documents

― Radiology Reports ― Document Sections

― Patient Assessment Instruments

The LOINC Community Open, Nimble, Pragmatic

A Highly ‘Open Source’ Model •  LOINC (the database) and RELMA (the

mapping program) are available freely worldwide for nearly any purpose

•  Much work is done by volunteers •  Content additions are end-user driven

10 new members per day 300+ new members per month

Translation Efforts

Downloads: ~1100/month

US Adoption A few key highlights

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) •  Same process that adopted ICF as a standard for functioning

and disability domain

Other Key US Adoptions •  eLINCS

–  Messaging standard for results delivery from LIS to an EHR

•  NAACCR –  Volumes II (Data Standards/Dictionary) and V (Path Lab e-Reporting)

•  CDISC –  Pharmaceutical research specs

•  NCQA/HEDIS –  Used by 90% of US health plans to measure quality

•  HITSP –  C80: vital signs, lab results, lab orders, genetic results, other results –  IS92: newborn screening –  C83: Patient assessment instruments (sections, questions, answers)

A Proposal for Effective use of ICF and LOINC Making complementary strengths productive

General Observations •  No computer-interpretable version of ICF •  Links with other vocabularies (UMLS, SNOMED)

don’t address qualified codes •  Several ICF item collections

–  Full version, short version, ICF-CY, ICF core sets, more…

•  Challenge: ICF classification blends several observation question/answer pairs into 1 code –  d410.1302 (changing basic body position) is really 4

“observations”

Goals •  Send a person (or population)’s ICF

classification using same machinery as other health data –  To reach ICF’s goals, you need to share data

•  Maximize strengths of each terminology (minimize duplication of effort)

•  Be informed by real world use –  Need some interested parties!

•  Facilitate addressing challenges in ICF use –  Relationship to standardized assessments and clinical

measures

Original Option 1 •  Simplest Approach: One LOINC code

–  NNNN-N:Functioning Classification:Imp:^Patient:Pt:Ord:ICF –  Expected “answer” in OBX-5 would be a ICF classification

•  Problems with Simplest Approach –  Still have blending of question/answer in OBX-5 –  No indications of sets

Original Option 2 •  Full LOINC Modeling including panels for

ICF Sets •  Example: d420 – Transferring oneself

–  N-N:Transferring oneself.Performance:Imp:^Patient:Pt:Ord:ICF –  N-N:Transferring oneself.Capacity:Imp:^Patient:Pt:Ord:ICF

–  Expected “answers” in OBX-5 would be the ICF qualifiers

0  –  No  setup  or  physical  help  from  staff  

1  –  Setup  help  only  

2  –  One  person  physical  assist  

3  –  Two+  person  physical  assist  

8  –  ADL  acBvity  itself  did  not  occur  during  enBre  7  days  

Original Option 2 •  Problems with this approach

– Labor intensive •  Each ICF component + qualifier combination

would be a different LOINC code (assessing different attributes)

•  Keeping up with sets would be very difficult

– Some modeling challenges (e.g. anatomy) – Negotiating IP issues

New Inspiration

Clinical Genomics Model

Further Inspiration

HL7 CDA Framework for Questionnaire Assessments

•  Specifies a document package representing the full assessment “form”

•  For each observation/answer, enables concurrent transmission of: –  Model of Use (LOINC)

•  Exact measurement, as on the assessment

–  Model of Meaning (SNOMED, ICF) [optional] •  Representation of the conceptual assertion in another

(standard) terminology/classification

–  Supporting Clinical Observations (LOINC, SNOMED) [optional]

•  Data from the EHR that supports the assessment decision

Proposed ICF Result Package in LOINC

ICF  classificaBon  panel    ICF  collecBon,  populaBon  descriptor,  observaBon  Bme  period,  other  descriptors    of  the  observaBon  period  

ICF  classificaBon  results  panel    ICF  component,  any  applicable  qualifiers,  fully-­‐qualified  ICF  item  

ICF  supporBng  clinical  observaBons  panel    Any  supporBng  clinical  measurements  for  that  ICF    classificaBon  (direct  measures,  assessment  scores,  etc)  

1 to many

0 to many

Example ICF Result Package in LOINC

R/O/C   Example  Answers  

NN-­‐N          ICF  classifica9on  panel  

NN-­‐N          ICF  classificaBon  collecBon   R Full

NN-­‐N          PopulaBon  descripBon   O Clinic population >65 years

NN-­‐N          DuraBon  of  observaBon  period   O Point in time

NN-­‐N          ICF  classifica9on  results  panel             R

NN-­‐N          ICF  code  stem   R d450

NN-­‐N          ICF  funcBoning  classificaBon   O d450.12

NN-­‐N          AcBviBes  and  parBcipaBon  performance  qualifier   C 1 – MILD difficulty

NN-­‐N          AcBviBes  and  parBcipaBon  capacity  without                                assistance  qualifier  

C 2 – MODERATE difficulty

NN-­‐N          ICF  suppor9ng  clinical  observa9ons  panel   O

59460-­‐6          Morse  Fall  Risk  Total   55

4195703        Mean  walking  speed  24H   0.9 m/sec

1 to N

0 to N

Benefits of Nested Model •  Uses HL7-LOINC messaging framework while minimizing

redundant modeling •  Accommodates ‘meta-data’ about the result package •  Flexes to accommodate large or small sets of ICF codes •  Enables explicit connection between ICF classification

and supporting clinical data •  Accommodates sending alternate identifiers (e.g. UMLS

or SNOMED) for ICF components •  Could also use the ICF classification result panel in

another context –  nested under a regular clinical observation to convey the

higher level interpretation of that result

Next Steps •  Looking for collaborators with live

systems that have a need to exchange ICF classifications electronically – And want to used established messaging

standards

•  Present to Clinical LOINC Committee 7/16/2010

•  To infinity and beyond…