Académique Documents
Professionnel Documents
Culture Documents
© 2018
Disclosure
I’m President of Blue Sky Premise, LLC which published the book LOINC
Essentials.
This material contains content from LOINC® (http://loinc.org). The LOINC Table, LOINC Table Core, LOINC Panels and Forms File, LOINC
Answer File, LOINC Part File, LOINC Group File, LOINC Document Ontology File, LOINC Hierarchies, LOINC Linguistic Variants File, LOINC/
RSNA Radiology Playbook, and LOINC/IEEE Medical Device Code Mapping Table are copyright © 1995-2018, Regenstrief Institute, Inc. and
the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://loinc.org/license.
Financial Support for LOINC
Regenstrief Institute RTI International
Regenstrief Foundation Contract 0-312-0209853
U.S. National Library of Medicine John A. Hartford Foundation
Contracts NO1-LM-4-3510, N01-LM-6-3546, N01- Agency for Health Care Policy and Research
LM-9-3517, and HHSN276200800006C, Grants HS 08750 and HS 07719-03
HHSN276201400138P, HHSN276201400239P
Centers for Disease Control and Prevention
U.S. Food and Drug Administration
Grant and Contracts R13/CCR517099 and H75/
Contract HHSF223201710178P CCH520501
American Physical Therapy Association Centers for Medicare and Medicaid Services
bioMérieux
Contract HHSM-500-2016-00040C
Indiana Clinical and Translational Sciences Institute National Center for Advancing Translational Sciences
California Healthcare Foundation Grant 3UL1TR001108-04S1
Radiological Society of North America through the National
National Institute of Diabetes and Digestive and Kidney
Institute of Biomedical Imaging and Bioengineering
Diseases
Contract HHSN268201500247A Contract HHSN275201600752P
AHIMA Foundation Members of the LOINC Community who have made donations
Contract FORE-ASPE-2007-5 or became Premium Members
Overview
1. Part 1
1. Emerging perspectives on SDH and informatics: Interoperability as a
key challenge
2. Role of vocabulary standards in SDH: focus on LOINC
2. Part 2
1. Informatics vision: collect once, use many
2. Planning to incorporate standardized SDH data elements in your EHR
📷 Verino77 | cc-by-sa
loinc.org/sdh
Note: these slides (with references) will be available
Mr. V
24 y.o. Hispanic male
Complete C4-5 tetraplegia
ASIA A. Zone of partial preservation to C5.
📷 undpeuropeandcis | cc-by-nc-sa
Injury due to self-inflicted GSW
Self-description:
didn’t have much, drug addict, gang member
📷 ismetbenismail | cc-by-nc-nd
Needs total assistance with positioning, transfers,
bowel/bladder
Challenging family/caregiver dynamics
Institute of Medicine of the National Academies Committee on the Recommended Social and Behavioral Domains and Measures for Electronic Health Records. Capturing social and behavioral domains in Electronic Health
Records: Phase 2. Washington, DC: The National Academies Press; 2014.
Why SDH + Health IT?
Inform shared clinical decision making
Adler NE, Stead WW. Patients in context--EHR capture of social and behavioral determinants of health. N Engl J Med. 2015 Feb 19;372(8):698-701. doi: 10.1056/NEJMp1413945. PubMed PMID: 25693009.
Hossein Estiri, Chirag J Patel, Shawn N Murphy; Informatics can help providers incorporate context into care, JAMIA Open, Volume 1, Issue 1, 1 July 2018, Pages 3–6, https://doi.org/10.1093/jamiaopen/ooy025
What might it enable?
More effective and personalized care
More effective population management
Discover new insights
📷 proimos | cc-by-nc
Challenges
Collected, but not available (narrative, paper)
Hossein Estiri, Chirag J Patel, Shawn N Murphy; Informatics can help providers incorporate context into care, JAMIA Open, Volume 1, Issue 1, 1 July 2018, Pages 3–6, https://doi.org/10.1093/jamiaopen/ooy025
Interoperability
Why it matters
Connecting Many Data Sources
McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.
Reality:
patients move faster and further
than their health information
Variation abounds…
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
It's like, the
data
more money we
come across,
the more
problems we see
Problems
Health IT systems often lack common
mechanisms for exchanging data.
📷 puuikibeach | cc-by
66,500+ registered users from 172 countries
📷 tgerus | cc-by-sa
Syntax Standards
Messages, Documents, APIs
HL7v2, C-CDA, FHIR
Semantic Standards
Vocabulary/code systems
LOINC, SNOMED CT, RxNorm, CPT, ICD
meerkat meerkat mere cat meerkat
📷 CaptionTime
No single vocabulary
standard covers it all
Observables (and collections of them): LOINC
Problems, Organisms, Conditions, etc: SNOMED CT, ICD, HPO
Medications: RxNorm, ACT
Reimbursement: National codesets (e.g. CPT)
LOINC is a rich trove of 87,000+ standardized variables
Genetics Lifestyle
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?
📷 glasgowamateur | cc-by-sa
📷 unamid-photo | cc-by-nd
{
"resourceType": "Observation",
"id": "body-height",
"meta": {…},
"text": {…},
"status": "final",
"category": [
{
"coding": […],
"text": "Vital Signs"
},
"reference": "Patient/example"
"effectiveDateTime": "1999-07-02",
"valueQuantity": {
"value": 66.899999999999991,
"unit": "in",
"system": "http://unitsofmeasure.org",
"code": "[in_i]"
}
}
FHIR and LOINC go together
like chips and salsa
danielvreeman.com/fhirdevdays
📷 Marco Verch | cc-by
Codes for individual observations
6690-2 Leukocytes [#/volume] in Blood by Automated count
2339-0 Glucose [Mass/volume] in Blood
29463-7 Body weight
75626-2 Total score [AUDIT-C]
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.
LOINC Distribution
Major releases twice per year
Many release artifacts
Online and desktop browser, API
Documentation
LOINC Release Distribution
LOINC Table
LOINC Table Core
LOINC Part File
LOINC Answer File
LOINC Panels and Forms File
LOINC Group 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
search.loinc.org
Our newest release addition:
API via FHIR (beta)
We’re now deploying a rich set of FHIR terminology services
[base] = https://fhir.loinc.org
[base]/ValueSet/LL4730-9/$expand
{
"resourceType": "ValueSet",
"status": "active",
"compose": {
"include": [
{
"system": "http://loinc.org",
"concept": [
{
"code": "LA28397-0",
"display": "Often true"
},
{
"code": "LA6729-3",
"display": "Sometimes true"
},
{
"code": "LA28398-8",
"display": "Never true"
},
{
"code": "LA15775-2",
"display": "Don't know/refused"
}
]
Detailed Tutorial and Exercises
https://danielvreeman.com/fhir/
10,000+ assessment terms
and growing…
Social, psychological and behavioral observations - 2015 Edition Geriatric Depression Scale (GDS)
Health IT Certification Criteria set
Humiliation, Afraid, Rape, and Kick questionnaire
Adverse Childhood Events
HIV Signs and Symptoms Checklist
ADAPTABLE patient report item set
howRU
Borderline Symptom List - 23 Item
International Physical Activity Questionnaire
Brief Interview for Mental Status (BIMS)
Living with HIV (LIV-HIV)
Comprehensive Behavior Health Screen
Morse Fall Scale
Confusion Assessment Method (CAM)
My Mood Monitor
Core behavioral health terms (SAMHSA)
Neuro-QOL
Edinburgh Postnatal Depression Scale
PROMIS (e.g. Social Isolation item bank)
Everyday Cognition
PhenX (eg. Social Environments domain)
Exercise Vital Sign
PHQ
FACIT
VR 12 and 36
LOINC License
No cost use
Worldwide
In perpetuity
Commercial or noncommercial
Encourages translation
One major prohibition…
CANNOT use any Licensed
Material to develop or
promulgate a different standard
for orders or observations.
What if I can’t find a code for
the variable I’m looking for?
Vocabulary standards grow
because USERS ask
(you don’t need to invent your own)
📷 pagedooley | cc-by
Start capturing
key SDH data
Gold R, Cottrell E, Bunce A, et al. Developing Electronic Health Record (EHR) Strategies Related to Health Center Patients' Social Determinants of Health. J Am Board Fam Med. 2017 Jul-Aug;30(4):428-447. doi: 10.3122/
jabfm.2017.04.170046. PubMed PMID: 28720625.
Leverage
informatics
Could also try NLP
vs. discrete data
Standardize
"text": "Stress means a situation in which a
person feels tense, restless, nervous, or
anxious, or is unable to sleep at night because
his/her mind is troubled all the time. Do you
feel this kind of stress these days?"
at the source.
},
"valueCodeableConcept": {
"coding": [
{
"system": "http://loinc.org",
"code": "LA13914-9",
"display": "Very much"
Let all downstream }
]
recipients benefit
}
}
},
Hughes LS, Phillips RL Jr, DeVoe JE, Bazemore AW. Community Vital Signs: Taking the Pulse of the Community While Caring for Patients. J Am Board Fam Med. 2016 May-Jun;29(3):419-22. doi: 10.3122/jabfm.2016.03.150172. PubMed PMID: 27170802.
Cantor MN, Chandras R, Pulgarin C. FACETS: using open data to measure community social determinants of health. J Am Med Inform Assoc. 2018 Apr 1;25(4):419-422. doi: 10.1093/jamia/ocx117. PubMed PMID: 29092049.
Bazemore AW, Cottrell EK, Gold R,et al. "Community vital signs": incorporating geocoded social determinants into electronic records to promote patient and population health. J Am Med Inform Assoc. 2016 Mar;23(2):407-12. doi: 10.1093/jamia/ocv088. Epub 2015 Jul 13. PubMed PMID: 26174867.
If this, then that…
If {Stress Score} ≤ 2
&& {Patient preference} != No)
Then
initiate {stress management care plan}
Reporting / Analytics
% Patients for whom social isolation screening performed
62933-7 PhenX - social isolation protocol
77800-1 PROMIS short form - social isolation 4a - version 2.0 raw score
77799-5 PROMIS short form - social isolation 6a - version 2.0 raw score
77798-7 PROMIS short form - social isolation 8a - version 2.0 raw score
📷 elwillo | cc-by
Starter questions…
How can I build consensus on selecting a social needs screening/
assessment tool?
Who owns these assessment tools?
Are there intellectual property issues with their use?
Which clinical vocabulary should I use (am I focused on coding
screening, diagnosis, or interventions)?
Should I request new codes?
How do I integrate them into my EHR?
What is the optimal data collection workflow (who, how, when)?
How should I capture patient preferences about SDH
Follow the trailblazers
LaForge K, Gold R, Cottrell E, et al. How 6 Organizations Developed Tools and Processes for Social Determinants of Health Screening in Primary Care: An Overview. J Ambul Care Manage. 2018 Jan/Mar;41(1):2-14. doi: 10.1097/JAC.0000000000000221. PubMed PMID: 28990990.
Byhoff E, Cohen AJ, Hamati MC, et al. Screening for Social Determinants of Health in Michigan Health Centers. J Am Board Fam Med. 2017 Jul-Aug;30(4):418-427. doi: 10.3122/jabfm.2017.04.170079. PubMed PMID: 28720624.
https://sirenetwork.ucsf.edu/node/17826
Application questions…
How will we put these data to use (CDS, CQI)?
Which other care team members would benefit (and how might we
share this information with them)?
What resources (e.g. from ONC, SDOs, SIREN, other experts) are
available to help?
How might I participate in the stakeholder community as we
continue learning best practices?
What are future innovation opportunities?
http://www.nachc.org/research-and-data/prapare/toolkit/
https://www.chcs.org/resource/screening-social-determinants-health-populations-complex-needs-implementation-considerations/
https://sirenetwork.ucsf.edu/tools-resources/mmi/compendium-medical-terminology-codes-social-risk-factors
ONC’s Interoperability Standards Advisory
Open for comment now
https://www.healthit.gov/isa/
We still have a lot to learn …
How to best incorporate and use community-level data
Tailoring the approach by setting (FQHC, acute, post-acute, etc)
Closing feedback loops (referrals, orders, etc)
Anticipate needing an SDH informatics research agenda
LOINC grows because
USERS ask
SDH requests welcome
Take home lesson:
Once represented in data standards, SDH data
elements can be shared and understood by diverse IT
applications for the benefit of many.