AMIA 2017 Annual Symposium | Washington DC, USA

Introduction to LOINC
The global vocabulary for identifying health measurements, observations, and 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

Swapna Abhyankar, MD
Associate Director for Content Development,
LOINC and Health Data Standards
Regenstrief Center for Biomedical Informatics
@sa_abhyankar

2017
 High Level Schedule

1. An overview of LOINC
2. The LOINC Concept Model and
other Data Structures
3. Implementing LOINC

Slides available at:

https://danielvreeman.com/amia2017
photo via Vernio77
 Objectives
When its all said and done, youll be able to

1. Explain the LOINC development process

2. Apply key features of the LOINC concept model in
selecting appropriate codes
3. Design a query using metadata and relationships about
LOINC concepts beyond the concept name
4. Identify and select the key implementation tools
appropriate for their use case
5. Apply best practices for using LOINC

photo via Vernio77

 First, lets get a
sense of whos here

photo via Arran Moffat

What is your familiarity with LOINC?
https://danielvreeman.com/poll

Not much, Im new

Im relatively new
Im an advanced LONICer
What is your clinical background?
https://danielvreeman.com/poll

Laboratory professional
Physician
Nurse
Other health professional
Just love working with Health IT / data
 What do you want to learn about
LOINC?
https://danielvreeman.com/poll

Data exchange
Analytics or quality metrics
App design or decision support
Research
Other
Interoperability
The ability of health IT to communicate, exchange data,
and use the information that has been exchanged.

Foundational Structural Semantic

HIMSS Definition. Available at: http://www.himss.org/library/interoperability-standards/what-is-interoperability

 Why
interoperability
matters
photo via proimos
 Someday care will be
Comprehensive
Patient-centered
Coordinated
Accessible
Safe
High quality
Innovative
photo via proimos
Connecting Many Data Sources
Social and community determinants

Lifestyle and behavioral

Health history

Patient-generated
EHR
Genetics
Basic science
photo via Heather | cc-by-sa
 The rain forest canopy is a
seamless web through which
arboreal creatures efficiently
move to reach the edible
fruits without any attention
to the individual trees.
McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329. photo via nosha | cc-by-sa
Reality:
patients move faster and further
than their health information
https://ec.europa.eu/digital-single-market/en/news/ehealth-action-plan-2012-2020-innovative-healthcare-21st-century
Certification to require information be
accessed, exchanged and used
without special effort through
technologies such as open application
programming interfaces (API).
https://www.gsma.com/iot/wp-content/uploads/2016/10/Interoperability-report-v1.2.pdf
Why is
interoperability
in so hard?
MO MONEY 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
 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
Syntax Standards
Messages, Documents, APIs
HL7v2, C-CDA, FHIR
Also called technical standards

Semantic Standards
Vocabulary/code systems
LOINC, SNOMED CT, RxNorm, ATC, ICD, etc
LOINCs superhero
origin story

McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.
 Logical Observation Identifiers Names and Codes

The universal standard for

identifying health measurements,
observations, and documents.
Est. 1994
 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
We do measurements
LOINC is focused on one piece of
the interoperability puzzle

photo via puuikibeach| cc-by

Laboratory LOINC
Clinical LOINC
Major releases
twice per year
(June and December)

photo via striatic | cc-by

 LOINC Codes Over Time by Release
90,000
LOINC Codes

80,000 Only Lab LOINC Codes

70,000

60,000

50,000

40,000

30,000

20,000
laboratory terms only
10,000

0
 There will come a time when you believe
everything is finished.

That will be the beginning.

Louis LAmour
novelist
from Lonely on the Mountain

photo via Wikipedia | cc-by-sa

Lots cooking
Always new lab tests
Public health: emergent issues, surveillance, case reports
Document titles
Patient reported outcomes
Cardiovascular and other clinical measurements
New data models for genetics [HL7]
Structured path reporting for cancer [CAP, ICCR]
Patient reported outcomes [PCORI]
Social determinants of health [many]
MANY active collaborations with other orgs
photo via liber | cc-by
LOINC grows
because USERS ask
 Last Year:
New term requests from 50+ organizations in 14 countries
LOINC fits well with
other data standards

photo via Temari 09 | cc-by-nc

 Numeric Results
Using Hl7 version 2.x + LOINC

NM (numeric) means the

answer will be a numeric value Result Value
OBX||NM|26453-1^RBC # Bld^LN||4.82|10*6/uL|

Units
Same thing, different format
Using Hl7 FHIR + LOINC
 Coded Result Values
Using Hl7 version 2.x + LOINC + SNOMED CT

CE (coded element) Observation Identifier: LN means this code

means the answer is from LOINC
will be coded this is a blood culture

OBX||CE|600-7^Bacteria identified in Blood by Culture^LN||

17872004^Neisseria meningitidis^SCT

Answer Identifier: SCT means this

code is from
meningococcus (trouble) SNOMED CT
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
photo via Jonathan McIntosh | cc-by-sa

But I love maintaining my local dictionary,

what will happen to my precious codes?
 Relax

OBX||NM|123^RBC^MyHosp^26453-1^RBC # Bld^LN||4.82|10*6/uL

Local Code LOINC Code

photo via Julien Haler | cc-by
LOINC makes health
data more portable
and understandable
to different
computer systems.
LOINC is free,
but invaluable
Read more about
Regenstriefs approach
to licensing LOINC
danielvreeman.com/licensing-loinc
Our vision is for
LOINC to be
integrated into every
clinical information
system that shares or
aggregates data.
 Collect once. Use many.
Clinical care, public health reporting, quality
management, clinical and epidemiological research, etc

photo via pagedooley | cc-by

 Generous financial support
Many sources over the 20+ years of LOINC
AHCPR, ASPE, CDC, CHCF, CMS*, FDA*, Hartford
Foundation, IN CTSA, Regenstrief Foundation*, Regenstrief
Institute, bioMrieux*, NCATS*, NCRR, NIBIB, NIDDK*,
NLM*, LOINC User Community*
*active now

Today, the U.S. National Library of Medicine

(NLM) accounts for about 2/3 of our funding.
 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?
Growing Recognition
Trends in global adoption of
LOINC
54,000+ 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
Translations
into 18 variants
of 12 languages
A small taste of LOINC
adoption around the world
Public Health Code for
Practice of Laboratory
Medicine in France
Adopts the French specification of IHE XD-
LAB profile, including HL7 CDA for format and
structure and LOINC for lab test identification

https://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000031922237&categorieLien=id
http://esante.gouv.fr/sites/default/files/CI-SIS_CONTENU_VOLET-CR-BIOLOGIE_v1.2.0.0.pdf
Open-source LIMS in
Vietnam
Implemented at 38 hospital, public health,
and HIV testing laboratories in Vietnam.

Mapped to LOINC to facilitate data

exchange and interoperability projects

a feasible approach towards establishing a sustainable

laboratory informatics program that met the needs of health
laboratories in Vietnam.
Landgraf KM, Kakkar R, Meigs M, et al. Open-source LIMS in Vietnam: The path toward sustainability and host country ownership. Int J Med Inform. 2016 Sep;
93:92-102. Epub 2016 Jun 23. PubMed PMID: 27435952.
Austrian National Patient
Health Record (ELGA)
LOINC for laboratory tests as well as for
document and section encoding.
A value set of LOINC codes and preliminary
ELGA-wide codes was developed for
laboratory analyses and is constantly
maintained and updated in coordination with
the laboratory community.

Seerainer C, Sabutsch SW. eHealth Terminology Management in Austria. Stud Health Technol Inform. 2016;228:426-30. PubMed PMID: 27577418.
Nictiz: Netherlands
Many national projects in the
Netherlands are using LOINC

Nationwide surveillance network for bacterial

typing and antibiotic resistance surveillance
National laboratory code list (selected by NVKC
and NVMM societies)
National special test registry (WieDoetWat-
database)

Nictiz is a LOINC Premium Member

http://www.cchi.gov.sa/en/Projects/SHIP/Pages/Dictionary.aspx
International Patient
Summary (IPS)
A non-exhaustive patient summary, specialty-
agnostic, condition-independent, but readily
usable by clinicians for the cross-border
unscheduled care of a patient.

Coordinated with the IPS project mandated to

CEN TC 251 by the European Commission.

Uses LOINC for:

Document type, sections, lab results, other clinical
observations, and radiology reports

http://international-patient-summary.net
St. Petersburg Medical
Information Analytical Center
Large regional health data exchange
~300 organizations, 85 labs

Developed a standardized lab test catalog

based on LOINC and a laboratory result
interface bus using HL7 FHIR
Now, ~450k tests per month flowing
Delivering results to patients personal office

Kopanitsa G. Application of a Regenstrief RELMA V.6.6 to Map Russian Laboratory Terms to LOINC. Methods Inf Med. 2016;55(2):177-81. Epub 2015 Dec 15. PubMed PMID: 26666563.

http://www.iksmedia.ru/articles/5434116-Prakticheskaya-polza-informatizacii.html
India Ministry of Health
and Family Welfare

Adopted LOINC as standard for identifying

tests, measurements, and observations in
national guidelines for EHR standards

https://www.nhp.gov.in/NHPfiles/EHR-Standards-2016-MoHFW.pdf
Ministrio da Sade Brasil

Official adoption of LOINC for laboratory test

reporting

Used in large-scale regional data exchange

project in So Paulo for many years

Instituto HL7 Brasil has organized the

Portuguese (Brazil) LOINC translation

http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2073_31_08_2011.html
Saudi Arabia s Council of
Cooperative Health Insurance

Project aims to provide all 12 million

beneficiaries with first class medical
insurance services and improve
information exchange between various
stakeholders (beneficiaries, companies,
and health providers).

Adopted LOINC for lab orders/results

http://www.cchi.gov.sa/en/Projects/SHIP/Pages/Dictionary.aspx
Turkish Ministry of
Health

General Directorate of Health

Services recently mandated LOINC
for laboratory results in public,
university, and private health facilities

Maintain a Turkish translation of LOINC and

mapping to national billing codes (plus online
search/mapping tool).

http://www.cchi.gov.sa/en/Projects/SHIP/Pages/Dictionary.aspx
And so many more

Australia, Belgium, Canada, Estonia, Kazakhstan,

Malaysia, Mexico, New Zealand, South Africa, etc
United States
ONC
Meaningful Use regulations, 21st Century Cures Act,
Interoperability Standards Advisory

FDA
Requiring LOINC for lab test data in studies starting after March 2020
Broad vision towards using real-world evidence in post market surveillance

CDC
Longtime users of LOINC: electronic lab reporting, case reporting, immunization messaging, National
EMS Info System, National Trauma Data Standards, etc

CMS
Under Impact Act 2014, all CMS-required patient assessment instruments are standardized in LOINC

https://www.fda.gov/forindustry/datastandards/studydatastandards/default.htm

https://www.healthit.gov/isa

https://www.fda.gov/ScienceResearch/SpecialTopics/RealWorldEvidence/default.htm
 Lots o LOINC
Representing Patient Allergic Reactions
Representing Patient Family Health History
Representing Patient Functional Status and/
or Disability
Representing Imaging Diagnostics,
Interventions and Procedures
Representing Laboratory Tests
Nursing
Representing Nursing Assessments
Representing Nursing Interventions
Representing Outcomes for Nursing
Representing Patient Clinical
Problems (i.e., Conditions)
Sex at Birth, Sexual Orientation and
Gender Identity
Representing Patient Gender Identity
Representing Patient Sex (At Birth)
Representing Patient-Identified Sexual
Orientation
Social Determinants
Representing Financial Resource
Strain
Representing Level of Education
Representing Stress
Representing Depression
Representing Physical Activity
Representing Alcohol Use
Representing Social Connection and
Isolation
Representing Exposure to Violence
(Intimate Partner Violence)
Representing Patient Tobacco Use (Smoking
Status)
Representing Patient Vital Signs
Large-scale observational research
networks have adopted LOINC:

FDAs Mini-Sentinel project

PCORnet

Observational Health Data Sciences and

Informatics (OHDSI)
Advocate for the adoption of
SNOMED CT and LOINC as
national standards for clinical
data, and link them with
nursing terminologies
through mappings.
Know LOINC?
Get Hired!
We are banding together
for global good
photo via scarlatti2004_images | cc-by-sa
Collaborative
development of
complementary health
data standards

LOINC is the preferred

coding for observations
and documents across
all HL7 standards
DICOM
Uses LOINC codes for
document-level and
section level codes
within CDA-based
imaging report
standards
CDISC
Collaborating to provide
recommendations to
FDA about the use of
LOINC inside SDTM
MOU to represent IEEE
11073 standards that
support interoperable
communications among
both traditional medical
devices and personal
health devices.
We now publish the LOINC/IEEE Medical Device Code Mapping Table

Check out S115 Oral Presentations:

Enabling Interoperability between Healthcare Devices and EHR Systems
https://ivdconnectivity.org/livd
Landmark 10 year
agreement for
cooperative
development
We now publish a set of LOINC/SNOMED CT Collaboration Files
 Mutual Endorsement

IHTSDO endorses the use of LOINC Codes for

representation of orders and observations in
countries where LOINC has been adopted.

LOINC provides codes that represent the

names of information items (e.g. questions) and
SNOMED CT provides codes that may
represent nominal and ordinal values (e.g.
answers) for these named information items.
July 2013 Cooperation Agreement between Regenstrief Institute and IHTSDO.
Main LOINC/SNOMED CT
linkage activities
1. Mapping LOINC Parts to their equivalent SNOMED CT
concepts
2. LOINC Terms associated with post-coordinated
expressions using the SNOMED CT Observables model
(NOT creating duplicate SNOMED observable codes)
3. Mapping existing SNOMED CT Observables terms to
LOINC
4. Linking the set of SNOMED CT concepts that can serve
as result values for ordinal and nominal terms via the
LOINC answer structure
Long-term
agreement on a
unified model for
naming radiology
procedures
We now publish the LOINC/RSNA Radiology Playbook File
Check out S115 Oral Presentations:
The LOINC/RSNA Radiology Playbook: A unified terminology for
radiology procedures
 Everyone loves LOINC

photo via mccaughan

Part 2: The LOINC
Concept Model
and other LOINC data structures

Swapna Abhyankar, MD
The LOINC concept model and other data
structures
&
LOINC Content Domains
S u n d a y, N o v e m b e r 5 , 2 0 1 7

Swapna Abhyankar, MD
Associate Director for Content Development
Part 2 overview
LOINC concept model
Other LOINC data structures and ancillary data
LOINC content domains
Domain specializations
Query design
Q&A
Anatomy of a LOINC term
The LOINC code
Unique, permanent numeric code
Sequential
LOINC code value can help determine when code was created
No intrinsic structure except last character is a mod 10-check digit
Once released, a code is never removed from the LOINC database
Six main Parts
Part name Description
Component The analyte being measured
Property The dimension of the analyte that is being measured
Time aspect Whether the analyte is measured at a moment in time or over a specific
period of time
System The type of sample
Scale A general classification of the result type, whether
quantitative, qualitative, narrative, etc.
Method How the analyte was measured
*The Method is the only major axis that does not have to be populated for
every LOINC term
Component
Definition: the analyte that is being measured
Examples:
Sodium
HIV 1 p24 antigen
Body weight
Diameter.end diastole
Bispectral index
Note
Cytology report
Component subparts
Challenge: a chemical or physiologic stimulus given to a patient before
the analyte is measured (also called a loading or tolerance test)
Examples:
2H post 100 g glucose PO
post exercise
st nd
1 specimen/2 specimen
Adjustment: correction of a measured value
Examples:
adjusted to pH 7.4
corrected for nucleated erythrocytes
Sequence when reporting multiple results (rarely used)
Property
Definition: the dimension of the analyte that is being measured
Examples:
Mass concentration
Titer
Presence or Threshold
Length
Angle
Location
Date
Time aspect
Definition: whether the analyte is measured at a moment in time or over
a specific period of time
Examples:
Point in time
24 hours
7 days
1 year
Study maximum
Reporting period
Lifetime
System
Definition: the type of sample
Examples:
Blood
Serum or Plasma
Urine
Synovial fluid
Mitral valve
Elbow
Device
Super System
Definition: the source of the sample if the source is not the patient
Examples:
^Fetus
^Mother
^Father
^Family member
^Guardian or legally authorized representative
^BPU (blood product unit)
^Donor
Scale
Definition: a general classification of the result type
Examples:
Quantitative
Ordinal (qualitative, can be ordered)
Nominal (qualitative, cannot be ordered)
Narrative
Document
Method
Definition: how the analyte was measured or the information was obtained
Examples:
null (no method specified)
Immunoassay
Sequencing
Invasive
X-ray
MRI
Reported
Observed
 Putting the parts together
Component Property Time aspect System Scale Method

Sodium SCnc Pt Urine Qn

2955-3 Sodium [Moles/volume] in Urine

Sodium SCnc Pt CSF Qn

2948-8 Sodium [Moles/volume] in Cerebral spinal fluid

Body weight Mass Pt ^Patient Qn

29463-7 Body weight

Body weight Mass Pt ^Fetus Qn US+Estimated from AC

11728-3 Fetal Body weight estimated from Abdominal circumference on US
LOINC names
Fully Specified Name (FSN)
Six axes (Parts) separated by a colon
<Component>:<Property>:<Time aspect>:<System>:<Scale>:<Method>
Sodium: SCnc: Pt: CSF: Qn:
Long Common Name (LCN)
Programmatically generated, unique, human-readable
Sodium [Moles/volume] in Cerebral spinal fluid
Shortname
Programmatically generated, 40 characters
Sodium CSF-sCnc
LOINC term = LOINC code + LOINC name

80618-2 Zika virus IgM Ab [Units/volume] in Cerebral spinal fluid by

Immunoassay
=
80618-2
+
Zika virus IgM Ab [Units/volume] in Cerebral spinal fluid by Immunoassay
 Other attributes of a LOINC code
Attribute Description Examples
2
Units Example units of measure associated with the mg/dL, kg, cm/s, mm
result, including submitted units and UCUM units
Formula The calculation used to determine the result Ejection fraction=[(LV end-diastolic volume-LV end-systolic
volume)/LV end-diastolic volume]*100
Type General classification of the type of observation 1 (Laboratory), 2 (Clinical), 3 (HIPAA Attachments), 4 (Survey)
TypeName Name of the classification Laboratory, Clinical, Attachment, Survey
Class More specific classification within a type Microbiology, Chemistry, Cardiology, Radiology, PROMIS
surveys
Status The state of the term Active, Discouraged, Deprecated, Trial
Order/Obs Whether a term is an order, observation, or both Order, Observation, Both
 Other attributes of a LOINC code (cont.)
Attribute Description
Related Names Synonyms or other names that are related to
a given concept (e.g., disease name, allergen
code) that will help with searching
Answer list For qualitative results, an enumerated list or
pointer to such a list of possible results
Answer list type The binding of an answer list to a term
Survey question The original question text for a specific
text question from a validated survey instrument
External Copyright information for terms that have a
rd
copyright link 3 party copyright
Examples
X-ALD (for Lysophosphatidylcholine)
f434 (for Malus domestica recombinant)
LL1927-4 (for RAST class)
Example, Preferred, Normative
In the past 7 days - Stress disturbed my sleep (from PROMIS
sleep item bank)
COPYRIGHT
Organization: Kansas City Cardiomyopathy Questionnaire
Copyright: Copyright 1996-2005 John Spertus, MD, MPH.
Terms of Use: Used with permission.
URL: www.http://cvoutcomes.org/
 Other attributes of a LOINC code (cont.)
Attribute Description Examples
VersionLastChanged The release in which a term was last 2.61, 2.58
changed (or created)

Chngtype How the term changed in the version ADD, DEL, UND, NAM
last changed
Description Information at both the Part and Stroke volume is the volume of blood pumped from one
term level ventricle of the heart during a single beat. It is the difference
between the volume at the end of diastole, at which point
the ventricle is done filling and is at its maximum volume
(also known as maximum end-diastolic volume), and the end
of systole, at which point the ventricle has finished pumping
but has not yet started filling (also known as minimum end-
systolic volume).
Examples of LOINC terms + attributes
LOINC Panels
What is a panel in LOINC?
A collector term that contains an enumerated set of
discrete child elements
Panel attributes
Panel terms usually have panel in the Component, and will have a
dash as the value for Parts whose values may vary across the child
elements
Property
Method
Panel structure includes the following fields for its child elements:
Conditionality - denotes whether or not it should be present in the panel when
resulted.
Example values: Required (R), Optional (O), or Conditional (C)
Cardinality the minimum and maximum number of times a question or
answer may be repeated
Override name
Observation ID in form
Skip logic
Where to get LOINC panels
LOINC detail pages in RELMA and http://search.loinc.org
Show the panel structure, including conditionality, cardinality, etc.
Panels and forms file (https://loinc.org/downloads/accessory-
files/)
Contains the full panel structure for all panels in LOINC
RELMA Export full panel structure
Export a single panel with all of its attributes from RELMA
Examples of panels
LOINC Content Domains
 LOINC Content Types
Type Name Description
1 Laboratory Concepts from a variety of laboratory domains

2 Clinical All non-laboratory measurements, clinical information,

documents, and radiology and other procedures
3 HIPAA Concepts that identify the kinds of information communicated
Attachments between payers and providers for electronic claims
4 Survey Standardized assessment measures, including government forms
and validated survey instruments
Laboratory term classes
Allergy Fertility
Blood bank Genetics
Cell markers Hematology
Challenges HLA
Chemistry Microbiology
Coagulation Pathology
Cytology Serology
Drug/tox Urinalysis
Laboratory new areas
Emerging diseases
Zika virus
New species of Borrelia
Genetics
Veterinary medicine
Drug tests for synthetic (designer) drugs
New methodologies
PCR with Melt curve analysis
MALDI-TOF
 Laboratory Newborn screening (NBS) panel
Includes terms that represent all of the newborn
screening (NBS) tests recommended by the HHS
Secretarys Advisory Committee on Heritable
Disorders in Newborns and Children
Contains a panel to represent the NBS card data
The NBS card is a unique specimen collection device
because it not only includes the dried blood spot (DBS)
specimens, it also includes clinical information about the baby
and mother
Includes terms that represent both lab and point-of-
care testing (hearing and critical congenital heart
disease screening)
Clinical terms
LOINC type 2 terms include all types of measurements,
procedures, documents, and other clinical information that are not
in the laboratory domain
Anthropomorphic measurements
Vital signs
History and physical exam
Procedures
EKG
Echocardiography
Radiology
Ophthalmology
OB ultrasound
Documents
Clinical terms - Ophthalmology
Collaboration with National Eye Institute (NEI) to represent data
elements collected by the National Ophthalmic Disease
Genotyping and Phenotyping Network (eyeGENE)
Multiple panels for
Subjective and objective refraction
Ophthalmologic eye exam
Electroretinography
Visual fields
Slit lamp biomicroscopy
Angiography
Optical coherence tomography
All can be found searching for Class:*nei
Clinical terms I&O, Nutrition
Just for fun
HIPAA Attachments
Working closely with the HL7 Attachments Work Group (AWG) to
support the use of LOINC codes for electronic claims transactions
between payers and providers
Attachment specifications use LOINC codes to:
Identify the specific kind of information being communicated in both a
request and response (e.g., a discharge summary or diagnostic imaging
report)
Specify certain optional modifier variables for fulfilling the request for
information (e.g. variables that indicate a modification to the default time
period).
Identify the attachment (document) type, sections, and sometimes the
individual entries (tests or observations) in structured attachment responses
using HL7 CDA
Survey Terms
LOINC type 4 terms include patient reported outcomes and provider
completed forms
Include
Functional assessments/symptom indexes
Government required forms
Behavioral health/Psychiatry/Substance abuse assessments
Many of the LOINC panel attributes were created for survey panels,
including observation ID in form, override display name, skip logic
Other LOINC attributes commonly used in survey terms include
Answer lists, survey question text, and copyright information
A closer look at LOINC
Document Ontology
Document Ontology Attributes
Attribute Description
Kind of The general structure of the document at a macro level.
Document Document types are differentiated based on the need to define
distinct document headers
Type of Service Characterizes the kind of service or activity provided to/for the
patient
Setting Where the service was provided
Subject Matter A field of study or a branch of knowledge
Domain
Role Profession or occupation
Kind of Document (KOD)
Definition: the general structure of the document at a macro level
Examples:
Note
Consent
Form
Flowsheet
Prescription
Report
Type of Service (TOS)
Definition: the kind of service or activity provided
Examples:
Counseling
Evaluation and Management
Discharge summary
Referral
Plan of Care
Surgical Operation
Setting
Definition: where the service was provided
Examples:
{Setting}
Emergency Department
Hospital
Pharmacy
Recovery Room
Patients home
Telephone encounter
Subject Matter Domain (SMD)
Definition: field of study or a branch of knowledge
Examples:
Psychiatry
Pediatric cardiology
Acupuncture
Family medicine
Pharmacology
Physical therapy
Surgery
Role
Definition: profession or occupation
Examples:
{Role}
Clerk
Case Manager
Nurse
Physician attending
Medical student
Therapist
Cross-mapping between LOINC Document
Ontology and non-document parts

LOINC non-document part LOINC Document Ontology part

Component Type of Service + Kind of Document
System Setting
Method Subject Matter Domain + Role
 Putting the Doc Ontology parts together
Component Property Time aspect System Scale Method

Note Find Pt {Setting} Doc Psychiatry.Case manager

83881-3 Psychiatry Case manager Note
Plan of Care note Find Pt {Setting} Doc Child and adolescent
psychiatry
77446-3 Child and adolescent psychiatry Plan of care note
Letter Find Pt Hospital Doc Pediatric surgery
68803-6 Pediatric surgery Hospital Letter
Asthma action Find Pt {Setting} Doc {Role}
plan
69981-9 Asthma action plan
The LOINC/RadLex Unified
Model
Unified model overview
Both the LOINC Radiology and RSNA Radlex Playbook were
designed to represent radiology orderables, results, and their
attributes
Multi-year collaboration to combine and unify the useful aspects
of both models
The unified model consists of a set of attributes and sub-
attributes that comprise every term
Attributes and sub-attributes
View Maneuver
View.Aggregation Maneuver.Maneuver type
View.View type Pharmaceutical
Guidance Pharmaceutical.Substance given
Guidance for.Presence Pharmaceutical.Route
Guidance for.Approach Anatomy
Guidance for.Action Anatomic Location.Region imaged
Guidance for.Object Anatomic Location.Imaging focus
Reason for Exam AnatomicLocation.Laterality.Presence
Timing Anatomic Location.Laterality
Subject
Modality
Modality.Modality type
Modality.Modality subtype
 View
<View descriptor> <View Aggregation> <View type>

Examples
View descriptor view, multisection
Aggregation 2, greater than 3
View type AP, lateral, oblique
 Guidance
Guidance for <Approach> <Action> of <Object>

Examples
Approach percutaneous, deep
Action aspiration, placement, drainage
Object cyst, catheter, abscess
 Reason for exam
Indication or purpose of study

Examples
for shunt patency, for vertebral fracture
 Timing
<Timing>
Used with both maneuver and
pharmaceutical

Examples
Timing W, WO, WO & W
 Maneuver
<Timing> <Maneuver>

Examples
Maneuver type flexion, extension, standing
 Pharmaceutical
<Timing> <Pharmaceutical> <Route>

Examples
Pharmaceutical contrast, 18-F FDG
Route IV, PO, via nephrostomy tube,
intra fistula
 Anatomy
<Region imaged> > <Imaging focus>
laterality attached as appropriate

Examples
Region imaged head, chest, abdomen, lower extremity
Imaging focus brain, clavicle, liver, thigh, ankle
Laterality.Presence true, false
Laterality right, left, bilateral, unspecified
 Subject

When study is focused on something other than the patient

Equivalent to Super system in other parts of LOINC

Examples
fetus, surgical specimen
Modality
<Modality>.<Modality subtype>

Examples
Modality XR, CT, MR, NM,
US, PT, MG, RF
Modality subtype angio, densitometry,
spectroscopy, tomography
Relationship of unified model to LOINC and
Playbook concepts

Unified
LOINC model
RadLex
LOINC non- attributes RadLex
Playbook
term radiology (LOINC attributes
concept
parts radiology
parts)
 Cross-mapping between LOINC radiology
and non-radiology parts
LOINC non-radiology part Unified model attribute (LOINC radiology part)
Component 1st part View
Guidance
Reason for exam
Component 2nd part (challenge) Timing + Maneuver
Timing + Pharmaceutical
System Anatomy (Region imaged, Imaging focus, Laterality)
Subject
Method Modality
Examples
 Phew! You made it!
Now youre ready to do
some LOINCing!
LOINC Query Design
Tools
RELMA
http://search.loinc.org
Search based on
LOINC 6-part concept model
Other attributes
Search syntax
AND (implied)
OR
*
{Attribute}:
Query #1
How do I find all radiology codes added in the latest version of
LOINC?
class:rad
versionlastchanged:2.61
chngtype:add
Query #2
How do I find all radiology codes that are mapped to RadLex
Core Playbook codes?
Relatedcodes:rpid*

Query #3
How do I find all radiology codes that are mapped to RadLex
Core Playbook MR or CT codes?
Relatedcodes:rpid* Method:(CT or MR)
Query #4
How do I find all microbiology codes that were added in the last
version?
Class:micro
versionlastchanged:2.61
chngtype:add

Note if you dont include class: your search will return terms
with the Method of Microscopy as well as any terms with micro
in the Component
Query #5
How do I find all codes that were deprecated in the latest
version?
versionlastchanged:2.61
chngtype:del
Query #6
How do I find all terms asking about anxiety that have an
answer list?
Component:anxiety
Answerlist:true

Note if you dont include Component: your search will return

any terms with anxiety in the Related Names for one of the
Parts or any of the Parts themselves
Query #7
How do I find all panels that contain glucose in the name?
Component:glucose
Orderobs:order

Alternatively:
Component:glucose panel
LOINC Groups (https://loinc.org/groups/)
A flexible, extensible, and computable tool for rolling up groups of LOINC codes
Use cases:
Aggregating data for displaying on a flowsheet
Retrieving data for quality measure reporting
Collecting data for research
Use with caution
The distributed LOINC Group file is a work in progress. Expect the contents of this file,
including the types of Groups that are included, to change from release to release as we
receive feedback from users and refine our processes.
The contents of the file and the groupings MUST be validated by the user prior to
implementation in any aspect of clinical care.
Groups example #1
Groups example #2
Content creation and
maintenance
 Ways to submit to LOINC
RELMA
Directly through the web or by email
to submissions@loinc.org

Spreadsheet templates (loinc.org/submissions/new-terms/)

Basic template
Lab template
Form (survey) template
Radiology template
 Maintenance of LOINC
Just as community requests drive new content creation, the community
also plays a large role in content maintenance
We rely on LOINC users to tell us about changes that are needed
We update content for many reasons, such as new scientific knowledge,
nomenclature changes, and errors or ambiguity in existing concepts
Updates to existing LOINC terms are only made if the edit does not change
the meaning of the term
If a term was created incorrectly or its use is no longer recommended, we
will change the status to Deprecated or Discouraged and define a
replacement term
Available in the MAP_TO table
How to access the LOINC
database
How to access LOINC
Twice-yearly releases in June and December
June 2017 (v2.61) release had >85,000 terms
Find codes using
Regenstrief LOINC mapping assistant (RELMA) desktop application
https://search.loinc.org
Multiple download formats
New files in v2.61, including LOINC Parts, Answers, and Groups
 Part 3:
Implementing LOINC
A big toolbox for implementers

photo via Robert S Donovan | cc-by-nc

Many free
resources:
LOINC Table
RELMA
search.loinc.org
Community resources
Reference material
FHIR Vocabulary server
and more!
Most require a free loinc.org account
For importing into other IT systems
Need a loinc.org account
Need Windows
Need admin privileges
Install RELMA!
 RELMA Highlights
Browse LOINC database
Map local codes to LOINC
import/export
translate local words to LOINC-speak
powerful searching capabilities
review all the details about a LOINC term
Maintain your mappings
Submit new LOINC term requests
RELMA Search Screen
 View (LOINC Term) Details
Open the Encyclopedia of LOINC

Two ways
Context menu
Hit the View Details button

For most purposes I recommend

the Comprehensive view.
Example Details Page
 Search Syntax
RELMA uses Lucene, so syntax is Google-like

Default is to use logical AND between words

Can search within a field, use wildcards,

exclude words, and other fun tricks
 Search Within a Field
Component component:heart

Property glucose property:CCnc

Timing glucose timing:24H

System glucose system:CSF

Scale glucose scale:Ord

Method mycobacterium method:EIA

Class glucose class:UA

Tip: On grid, can use column labels for field names
Loading local codes
into RELMA

photo via john_fielding | cc-by

Creating your lab
source file for
mapping to LOINC
danielvreeman.com/source-file
 Observation Source File
Basic Format

Panel Code Panel Description Test Code Test Description Units

GLUCWB GLUCOSE WHOLE BLOOD GLUCWB GLUCOSE WHOLE BLOOD MG/DL

BGART BLD GAS ART PCO2 PCO2 MMHG

BGART BLD GAS ART PH PH

BGART BLD GAS ART PO2 PO2 MMHG

CBCDF CBC+DIFF HCT HEMATOCRIT %

CBCDF CBC+DIFF HGB HEMOGLOBIN G/DL

Ready to rock?
 The Mapping Screen
Working Set term
3 Sections Local Term and Mapping

Search Results Grid

The LOINC term
name is key

photo via quinnanya | cc-by-sa

LOINC Fully Specified Name
Includes the info necessary to
distinguish among clinically
important differences

Defines the essential uniqueness of

each term in LOINC
Local tests names are:
Notoriously short
Lacking info needed for mapping

Dont make assumptions, but

Use all available

contextual clues
photo via paurian | cc-by
Scan LOINC axes to notice
the differences needing
closer inspection

photo via jdhancock | cc-by

Confirm answer lists
for qualitative terms

photo via davefayram | cc-by

 Extracting your
mappings from RELMA

photo via dvids| cc-by

Export Options
Choose Term File

Choose Format

Choose Stuff
Oh no, roadblock
Cant install RELMA

photo via brizo_the_scot | cc-by

search.loinc.org
Pros
Always up to date
Nothing to install
Fast loading
Easy access to detail pages
Same search syntax as RELMA
Saves settings
Cons
Doesnt import local terms
Doesnt store mappings
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

Each has a detailed ReadMe and Release Notes

Mapping Exercise
Your turn!
Which LOINC Property is consistent
with the units of measure mg/dL?
https://danielvreeman.com/poll

ACnc
MoM
MFr
MCnc
Which LOINC term is best match for
Systolic Blood Pressure?
https://danielvreeman.com/poll

8480-6 Systolic blood pressure

8481-4 Systolic blood pressure 1 hour maximum
8512-6 Radial artery Systolic blood pressure
60984-2 Aorta Systolic blood pressure
Which LOINC term is best match for
Inpatient Discharge Summary?
https://danielvreeman.com/poll

68823-4 Pediatrics Hospital Discharge summary

34105-7 Hospital Discharge summary
84321-9 Physical therapy Outpatient Discharge summary
18842-5 Discharge summary
Which LOINC term is best match for
LDL Cholesterol (Direct) in mg/dL?
https://danielvreeman.com/poll

57698-3 Lipid panel with direct LDL - Serum or Plasma

69419-0 Cholesterol in LDL [Moles/volume] in Serum or
Plasma by Direct assay
18262-6 Cholesterol in LDL [Mass/volume] in Serum or
Plasma by Direct assay
2089-1 Cholesterol in LDL [Mass/ volume] in Serum or
Plasma
Which LOINC term is best match for
Cytochrome P450 3A5 (CYP3A5) Genotype (star allele notation)?

https://danielvreeman.com/poll
79717-5 CYP3A5 gene product metabolic activity interpretation in
Blood or Tissue Qualitative by CPIC
72697-6 CYP3A5 gene c.6986A>G(*3) [Presence] in Blood or
Tissue by Molecular genetics method
81139-8 CYP3A4 gene mutations found [Identifier] in Blood or
Tissue by Molecular genetics method Nominal
81140-6 CYP3A5 gene mutations found [Identifier] in Blood or
Tissue by Molecular genetics method Nominal
 Which LOINC term is best match for the test
JAK2 V617F Mutation Analysis, Quantitative (%)?
https://danielvreeman.com/poll

JAK2 gene targeted mutation analysis in Blood or Tissue

48726-4
by Molecular genetics method Narrative
JAK2 gene.p.Val617Phe mutant/Normal in Blood or
53761-3
Tissue by Molecular genetics method
JAK2 gene p.Val617Phe [Presence] in Blood or Tissue by
43399-5
Molecular genetics method
JAK2 gene p.Val617Phe [Presence] in Bone marrow by
72333-8
Molecular genetics method
Two more resources to
help implement LOINC
What LOINC Essentials covers
LOINC basics

A framework and techniques for picking out the subtle but

important distinctions between LOINC terms

A roadmap and step by step guidance for mapping with

RELMA

Best practices in LOINC mapping and how to set yourself up

for success in the long run
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
Get some help from
trusted friends
loinc.org/donate
An exceptional value

Takes as input
Local test codes, names, units, and mappings

Returns
Spreadsheet with issues detected by the evaluation process
Sample of Evaluation Rules
Unknown local units
Deprecated LOINC
Discouraged LOINC
Property/units mismatch
Scale/units mismatch
Concentration missing denominator
A small sample of
LOINC-powered
informatics
innovations
Hall PL, Marquardt G, McHugh DM, et al. Postanalytical tools improve performance of newborn screening by tandem mass spectrometry. Genet Med. 2014 Dec;
16(12):889-95. Epub 2014 May 29. PubMed PMID: 24875301.
Do you have an iPhone?

photo via Prime Number | by-nc-sa

 LOINC codes! Oh snap!

Apple Health Export in C-CDA Format

 Top 3 Tips for
Mapping to LOINC
Tip 1: Not all juice is
worth the squeeze
In standards, Pareto principle > Long Tail
photo via elwillo | cc-by
Pareto Principle 100%

Cumulative Laboratory Observation Volume (%)

90%

80%

70%

A few tests account for most volume

60%

50%

40%

30%

70% of tests take 30% of mapping time 20%

10%

0%
0 500 1000 1500 2000 2500 3000 3500 4000

Not all variables will have a LOINC Number of Laboratory Observation Codes (N)

Vreeman DJ, Finnell JT, Overhage JM. A rationale for parsimonious laboratory term mapping by frequency. AMIA Annu Symp Proc. 2007 Oct 11:771-5. PMID:
18693941.
 Tip 2: Go upstream
Let all the downstream data recipients benefit
photo via Fishking_1 | cc-by
Reference
laboratories have
all mapped their
tests to LOINC
https://ivdconnectivity.org/livd
Tip 3: Dont make
assumptions
photo via tgerus | cc-by-sa
Ambiguous test names are the norm

Units of measure are critical

You must know the specifics of what

this test actually measures

Use local experts, package inserts, etc

Sample results can help:
identify the correct LOINC Scale
get the observation/result boundary correct

Does this test measure something quantitatively?

Does it only identify positive/negative?
Does it identify or classify what was found?
Get the right people

photo via jdhancock | cc-by

Not just an I.T. problem
Bonus tip

photo via Frdric BISSON

 Bonus Tip:
Stay up to date

photo via Arul Irudayam | by-nd

LOINC recommends
that users update to
the current version of
LOINC within 90 days
of its publication.
Why?
The most recent release is always our best
release ever.

The world moves fast.

Maximize the potential benefit of

standardized data.
How?
Join the mailing list, or

Go Premium
curl -O ftps://[username]:[pwd]@loinc.regenstrief.org:990/currentversion.zip

Then, use your updated RELMA

Identify Replacement Terms
Tools -> Find Local Terms Mapped to Deprecated LOINCs

Map when ready

Review commentary

Check the alternatives

Other Updates to Your Terms
Your testing may have changed

Your codes may have changed

Watch changes to codes, names, or units
Across many INPC
institutions, in 2 years after
go live we saw half as many
new local terms appear as
what we started with.
Vreeman DJ, Stark M, Tomashefski GL, Phillips DR, Dexter PR. Embracing change in a health information exchange. AMIA Annu Symp Proc. 2008 Nov 6:768-72.
Complete Top 10 Tips available at:

danielvreeman.com/tips
Chinese translation available

Happy LOINCing!