Professional Documents
Culture Documents
© 2018 © 2019
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.
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Contracts NO1-LM-4-3510, N01-LM-6-3546, N01- Agency for Health Care Policy and Research
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bioMérieux
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California Healthcare Foundation Grant 3UL1TR001108-04S1
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Diseases
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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
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
IOM Recommends SDH in the EHR
Race or ethnic group
Education Tobacco use
Financial-resource strain Alcohol use
Stress Social connection & isolation
Depression Intimate-partner violence
Physical activity Neighborhood income
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.
Challenges
Collected, but not available (narrative, paper)
Gold R, Cottrell E, Bunce A, Middendorf M, Hollombe C, Cowburn S, Mahr P, Melgar G. 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
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
Semantic Standards
Vocabulary/code systems
LOINC, SNOMED CT, RxNorm, HPO, ICD, MONDO
The Superhero Origin Story
Life without LOINC
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
The universal standard for identifying health
measurements, observations, and documents.
📷 CaptionTime
72,000+ registered users from 175 countries
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": [
{
danielvreeman.com/fhirdevdays
📷 Marco Verch | cc-by
Codes for individual observations
6690-2 Leukocytes [#/volume] in Blood by Automated
75626-2 count
Total score [AUDIT-C]
29463-7 Body weight
55423-8 Number of steps in unspecified time Pedometer
📷 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
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.