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Clinical LOINC Meeting - Salt Lake City, UT USA

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

2016

Overview
1.
2.
3.
4.

Origins of a Document Ontology


HL7/LOINC Model
Evaluation and Ongoing Development
Future Directions

photo via Vernio77

http://loinc.org/slideshows

Origins of a Document
Ontology

Local systems have idiosyncratic names

Outpatient Pain
Note

Dr. Smiths Tues


Pain Clinic

Chronic Pain
Clinic

need a common, controlled vocabulary

Document Type Codes


Provide consistent semantics for names of documents
exchanged between systems for any purpose

Display

Retrieval

Organization

Templates

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.

What is a Document?
a collection of information

photo via striatic

Title
Sections
Sentences
Sentences
Other content

an information collection

photo via karen horton

Title
Sections
Sentences
Sentences
Other content

an information collection

Different than a panel


enumerated, discrete elements
photo via karen horton

Clinical Notes
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.

Formal Document Ontology model and rules


apply to clinical notes, but not (yet) to reports.

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

Photo via Jeffrey Beall

Ultra-specific local
names
Dr. Evils 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

Names are based on

expected information
content

NOT document format


photo via karen horton

Names Based on Content


Same LOINC code for

if information content is the same

Not Part of the Name


Author name
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 (e.g. metadata)

Subject Matter Domain


Domain of the content in the document
e.g. Cardiology, Pediatric Cardiology, Physical Therapy

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

Setting
Modest extension of CMSs definition (not equivalent to location)
e.g. Hospital, Outpatient, Emergency Department

Type of Service
Service or activity provided to patient
e.g. Consultation, History and Physical, Discharge Summary

Kind of Document
General structure of the document
e.g. Note, Letter, Consent

Rules for
constructing
names

photo via Robert S Donovan

1. Enumerated List
Document names are constructed from enumerated
lists of values for each axis.

2. Document + One Other


Names need to specify a Kind of Document value and
at least one of the other four axes.
Component
<Type of Service> <Kind of Document>
Property
Find
System
<Setting>
Scale
Doc
Method
<Subject Matter Domain>.<Role>

3. Combinations
Combinations from within an axis are allowed where
they are reasonable (SMD, Service).

Only a few examples currently:


Assessment+Plan note
Treatment plan+summary note
Hematology+Medical oncology

Example LOINC Names


Component

Prop Time System

Scale

Method

Group counseling note

Find

Pt

Hospital

Doc

{Author Type}

History and physical note

Find

Pt

{Setting}

Doc

{Author Type}

Initial evaluation note

Find

Pt

{Setting}

Doc

Physician

Note

Find

Pt

Outpatient Doc

Diabetology

Note

Find

Pt

{Setting}

Mental health

Doc

{Curly Braces} notation: send that content as a


separate item in the message (field or segment).

Find All the Terms


In the LOINC database (and RELMA),
all of the terms conforming to the
rules of the ontology are placed in
the DOC.ONTOLOGY class.
Before LOINC version 2.50, they were (non-intuatively) in
the class DOC.CLINRPT

LOINC Terms for Sharing Ontology Values

Pro Tip: find them with this search


http://search.loinc.org/search.zul?query=LOINC+Document+Ontology

LOINC Accessory Files


Special representations of LOINC content

Accessory Files
LOINC Panels and Forms File
An export of key panels, survey instruments, and forms in a detailed data structure.

LOINC Document Ontology File


Special file for the detailed naming conventions for clinical document titles.

LOINC Multiaxial Hierarchy File


Hierarchical organization of LOINC terms based on their axes.

LOINC/IEEE Medical Device Code Mapping File


Linkages between LOINC terms and content from IEEE EMB/11073 standard.

LOINC/RSNA Radiology Playbook File


Special file for the detailed naming conventions for radiology procedure titles.

LOINC/SNOMED CT Expression Association and Map Sets


Draft status (Technology Preview) file containing a) mappings between LOINC parts and
SNOMED CT concepts and b) SNOMED CT expressions linked to LOINC codes.

Accessory Files
LOINC Panels and Forms File
An export of key panels, survey instruments, and forms in a detailed data structure.

LOINC Document Ontology File


Special file for the detailed naming conventions for clinical document titles.

LOINC Multiaxial Hierarchy File


Hierarchical organization of LOINC terms based on their axes.

LOINC/IEEE Medical Device Code Mapping File


Linkages between LOINC terms and content from IEEE EMB/11073 standard.

LOINC/RSNA Radiology Playbook File


Special file for the detailed naming conventions for radiology procedure titles.

LOINC/SNOMED CT Expression Association and Map Sets


Draft status (Technology Preview) file containing a) mappings between LOINC parts and
SNOMED CT concepts and b) SNOMED CT expressions linked to LOINC codes.

Hierarchy in RELMA

Document Ontology File


Links all Document Ontology terms to their
constituent axis values
Axis values given unique Part identifiers
categorized by axis
Download from LOINC site

New (Free) Resource


HL7 Implementation Guide

Evolution + Evaluation
Were not done yet

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

Major Focus: Expanded original SMD values


with ABMS specialty names and iterative
discussion
More ontology additions from submissions

Development Milestones
2000 06

Document Ontology Task Force

2003 09

First axis values and LOINC codes released

2005 06

Expanded SMD domain

2007 10

Revised axis values approved

2013 06

Special Document Ontology File in releases

2013 12

Major harmonization completed

Iterative Evaluation
Case Study
NYPH-CUMC

Case Study
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%

99.9%

99.9%

98.5%
(n=935)

39.1%

100%

98.5%
1. Expanded CDO is better
2. Many local documents map to 1 LOINC
3. Inter-rater reliability was good

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.

Cross-site Mapping Study of DO Axes


Terms whose titles specified this axis
SMD

Role

Setting

Type of Service

None

West Campus
(n=1644)

67.6%

34.6%

28.9%

59.4%

8.2%

East Campus
(n=1124)

69.1%

56.0%

12.7%

69.0%

7.1%

1. Majority of titles map to at least one axis


2. Sites varied in how they specified titles; creates
granularity issues in cross-site aggregation
Li L, Morrey CP, Baorto D. Cross-mapping clinical notes between hospitals: An application of the LOINC Document Ontology. AMIA Symp Proc; 2011:;777-783.

The LOINC document ontology model


can provide a robust representation of
clinical documents. This can be
exploited to assist in common naming
conventions, finding notes by
traversing the axis categories of
Subject, Setting, Role and Type of
Service. However, the granularity of
representation can be an issue in
mapping across sites.

Other Evaluations

photo via Okko Pyykk

Other Evaluations
Dugas M, Thun S, Frankewitsch T, Heitmann KU.
LOINC codes for hospital information systems documents
J Am Med Inform Assoc. 2009 May-Jun;16(3):400-3.
PMID: 19261942.
Hyrinen K, Mykknen J.
Mapping the Finnish National EHR to the LOINC.
Stud Health Technol Inform. 2011;165:161-6.
PMID: 21685603.
Reeves RM, FitzHenry F, Brown SH, et al.
Who said it? Establishing professional attribution among authors
of Veterans' Electronic Health Records.
AMIA Annu Symp Proc. 2012;2012:753-62. Epub 2012 Nov 3.
PMID: 23304349.

Still ongoing development

photo via shutterrunner

The Future
Great Scott!

Future Directions
More v1 and v2 axis value harmonization
Identifiers for the axis values
Axis definitions
Computable hierarchy
Extension to other Kind of Documents
Empiric analysis of document contents

photo via milos milosevic