2012 02 16 - clinical loinc tutorial - documents
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TRANSCRIPT
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LOINC Tutorial Documents
Daniel J. Vreeman, PT, DPT, MSc Assistant Research Professor, Indiana University School of Medicine
Research Scientist, Regenstrief Institute, Inc
Clinical LOINC Meeting
02.16.2012 © 2012 [email protected]
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Overview
photo via Vernio77
1. Origins of a Document Ontology 2. HL7/LOINC Model 3. Evaluation and Ongoing
Development 4. Future Directions
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Origins of a Document Ontology
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Local systems have idiosyncratic names…
…need a common, controlled vocabulary
Outpatient Pain Note
Dr. Smith’s Tues Pain Clinic Note
Chronic Pain Clinic
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06/2000 • Document Ontology
Task Force
09/2003 • First Axis Values and LOINC
Codes 06/2005 • Expanded SMD Domain
10/2007 • Revised Axis
Value Approval
Ongoing • Harmonization Efforts • New Content Creation
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Document Type Codes Provide consistent semantics for names of documents exchanged b/w systems
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.
Retrieval
Organization
Display Preparation of Templates
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What is a Document? a collection of information
photo via striatic
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an information collection
Sections Sentences Sentences
Other content
photo via karen horton
Different than a panel enumerated, discrete elements
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Clinical Notes
Formal Document Ontology model and rules apply to clinical notes, but not (yet) to reports.
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.
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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
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Ultra-specific local names • Dr. Evil’s Friday Afternoon Pain
Clinic Note
Commonly understood elements • Outpatient Pain Clinic
Note
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Local Codes and Names
Still probably needed
Can send both in HL7 Mapping to a standard enables:
Interoperability
Aggregation
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Document Ontology Model Multi-axial / Poly-hierarchical
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Names are based on
expected information content
NOT document format photo via karen horton
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Names Based on Content
Same LOINC code for…
…if information content is the same
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Not Part of the Name Author Location of service Date of service Status (e.g. signed, unsigned) Security/privacy flags (e.g. protected) Updates or amendments to a document
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Assume that these other important attributes would be sent in different fields of the message
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Model of Document Names
Subject Matter Domain • e.g. Cardiology, Pediatric Cardiology, Physical Therapy
Role • Author training/professional classification (not @ subspecialty) • e.g. Physician, Nursing, Case Manager, Therapist, Patient
Setting • 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 • Eg. Consultation, History and Physical, Discharge Summary
Kind of Document • General structure of the document • E.g. Note, Letter, Consent
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Rules for Constructing Names
photo via Robert S Donovan
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1. Enumerated List Document names are constructed from enumerated lists of values for each axis.
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2. Document + One Other Document name needs specification of a Kind of Document value and at least one of the other four axes.
• <Type of Service> <Kind of Document> Component
• Find Property
• Pt Time
• <Setting> System
• Doc Scale
• <SMD>.<Role> Method
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3. Combinations Combinations from within an axis are allowed where they make sense (SMD, Service).
Assessment + Plan
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Example LOINC Names Component Prop Time System Scale Method
Group counseling note Find Pt Hospital Doc {Provider}
Evaluation and management note Find Pt Outpatient Doc {Provider}
Evaluation and management note Find Pt {Setting} Doc {Provider}
History and physical note Find Pt {Setting} Doc {Provider}
Initial evaluation note Find Pt {Setting} Doc Physician
{curly braces} notation: send that content as a separate item in the message (field or segment).
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Hierarchy Made a 1st pass Component hierarchy
– Based on Type of Service Axis – Ignored Kind of Document
Multi-axial hierarchy is auto-generated – Available as a separate download
Custom hierarchies (e.g. context-specific) ones are easily imagined
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Hierarchy in RELMA
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Evolution, Evaluation We’re not done yet
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Evolution Ongoing evaluation and evolution Exceptional contributions from Columbia University and the VA
More ontology additions from submissions
Expanded original SMD values with ABMS specialty names and iterative discussion
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Iterative Evaluation Case Study NYPH-CUMC
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Case Study
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.
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% 100% 99.9% 99.9% 98.5% (n=935)
39.1%
1. Expanded CDO is better 2. Many local documents map to 1 LOINC 3. Inter-rater reliability was good
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Nursing
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.
SMD Role Setting Type Service Kind of Doc Overall Distinct SMD ++ CDO
74% 100% 100% 100% 100% 74.5% (n=94)
33%
In a separate analysis…
Section headings from nursing documents that could be mapped to existing LOINCs Hyun S, Bakken S. Toward the creation of an ontology for nursing document sections: mapping section names to the LOINC semantic model. AMIA Annu Symp Proc. 2006:364-8.
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Cross-site Mapping Study of DO Axes Terms whose titles specified this axis
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.
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,
which creates granularity issues in cross-site aggregation
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Cross-site Mapping to LOINC Using LOINC v2.34
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.
Combination of LOINC DO axes (null values allowed)
West Campus mapping rate
East Campus mapping rate
Subject Matter Domain, Type of Service, Role, and Setting
22.3% (n=367) 18.7% (n=210)
Subject Matter Domain, Type of Service, and Role
30.8% (n=506) 22.6% (n=254)
Subject Matter Domain and Type of Service
46.9% (n=771) 39.2% (n=441)
1. Majority of titles map to at least one axis 2. Documents assigned LOINC codes were
less specified than those in their EHR
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e LOINC document ontology model can provide a robust representation of clinical documents. is can be exploited to assist in common naming conventions, "nding 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.
“
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Case Study German University Hospital
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German University Hospital
86 Document Types (1.2 mil documents)
44%
44%
12% Mapped to LOINC
Not specific enough mapping
No LOINC match
Dugas M, Thun S, Frankewitsch T, Heitmann KU. LOINC codes for hospital information systems documents: a case study. J Am Med Inform Assoc. 2009 May-Jun;16(3):400-3.
Used LOINC v2.24 (original DocOnt terms)
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German University Hospital
LOINC codes that existed for documents in their set (by volume)
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Ongoing Development
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A Work-in-Progress LOINC User’s Guide is definitive source for current policy
Collaboration/discussion Clinical LOINC Meetings HL7 SDTC Online
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The Future Great Scott!
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Future Directions More v1 and v2 axis value harmonization Axis definitions Extension to other Kind of Documents Empiric analysis of document contents
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photo via milos milosevic