Clinical LOINC Meeting | Salt Lake City, UT USA


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

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1. Origins of a Document Ontology
2. HL7/LOINC Model
3. Evaluation and Ongoing
4. Future Directions

photo via Vernio77
Origins of a Document
Local systems have idiosyncratic names

Dr. Smith’s
Outpatient Chronic Pain
Tues Pain
Pain Note 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
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

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.
Empiric analysis of >2000 document
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
• Dr. Evil’s Friday Afternoon Pain
Clinic Note

Commonly understood
• Outpatient Pain Clinic Note
Local Codes and Names
Still probably needed
Can send both in HL7
Mapping to a standard enables:
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 a LOINC 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.
Subject Matter Domain
Domain of the content in the document
e.g. Cardiology, Pediatric Cardiology, Physical Therapy

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

Modest extension of CMS’s 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
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.

<Type of Service> <Kind of Document>
<Subject Matter Domain>.<Role>
3. Combinations
Combinations from within an axis are allowed
where they are reasonable (SMD, Service).

Only a few examples currently:

Evaluation+Plan note
Plan of care+summary note
Hematology+Medical oncology
Example LOINC Names
Component Prop Time System Scale Method

Group counseling note Find Pt Hospital Doc {Role}

History and physical note Find Pt {Setting} Doc {Role}
Initial evaluation note Find Pt {Setting} Doc Physician

Note Find Pt Outpatient Doc Diabetology

Note Find Pt {Setting} Doc Mental health

{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.

Pro Tip: find them with the search
LOINC Terms for Sharing Ontology Values

Pro Tip: find them with the search “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.
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
We’re not done yet
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
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
Case Study
SMD Role Setting Type Service Kind of Doc Overall Distinct
Original 26.7% 99.9% 99.9% 43.5% 100% 23.4% 7.9%
CDO (n=894)

Expanded 98.6% 100% 100% 99.9% 99.9% 98.5% 39.1%
CDO (n=935)

1. Expanded CDO is better 98.5 %
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 67.6% 34.6% 28.9% 59.4% 8.2%
East Campus 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 Pyykkö
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.

Häyrinen K, Mykkänen 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

photo via shutterrunner
The Future
Great Scott!

Hancock | cc-by
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