2015 08 - LOINC - Panels Forms Assess

Daniel J. Vreeman, PT, DPT, MScAssociate Research Professor, Indiana University School of Medicine

Associate Director for Terminology Services, Regenstrief Institute, Inc

© 2015

Panels, Forms, Assessment Instruments

Clinical LOINC Meeting

2015 08 13

Overview1. Base model for panels

2. Advanced model of panel attributes

3. LOINC Answers

4. Panel and Answer features in RELMA

5. Sample of the content

6. Key adoptions

7. Lessons learned

photo via Vernio77

http://www.flickr.com/photos/verino77/

Base Model for Panels in LOINC

Panels in LOINCCollector terms that contain links to an enumerated set of discrete child elements

We use the word “panel” a generic concept that synonymous with battery, form, data set, etc in other domains

Panels can themselves be children, which allows nesting

Define elements as Required, Optional, or Conditionally Present

Categorizing Panel ElementsRequired (R)

Always expected to be present

Required with alternatives (R-a)

Always expected to be present, but with alternatives. (Typically a pair)

Optional (O)

May not be reported with panel depending on policy or capabilities of reporting institution

Conditional (C)

A key part of the panel, and should be assumed to be negative or not present if results do not contain it

Reflex (Rflx)

Included if it satisfies a reflex condition based on other results in the panel

Null ()

Undeclared. Typically used in “convenience” panels

Categorizing Panel ElementsRequired (R)

Always expected to be present

Required with alternatives (R-a)

Always expected to be present, but with alternatives. (Typically a pair)

Optional (O)

May not be reported with panel depending on policy or capabilities of reporting institution

Conditional (C)

A key part of the panel, and should be assumed to be negative or not present if results do not contain it

Reflex (Rflx)

Included if it satisfies a reflex condition based on other results in the panel

Null ()

Undeclared. Typically used in “convenience” panels

see User’s Guide section 8.7 “Representing conditionality”

Naming Conventions for Panels

Many (most) include panel in the Component

If defined by an authoritative body, we tend to use the official name

If elements vary on axis values (e.g. Property), the panel term name uses a dash “-“ in that field

Timing, Scale, and Method are typically specified

Naming Conventions for Panels

Many (most) include panel in the Component

If defined by an authoritative body, we tend to use the official name

If elements vary on axis values (e.g. Property), the panel term name uses a dash “-“ in that field

Timing, Scale, and Method are typically specified

see massively revised Section 8 in LOINC Users’ Guide

What Defines a Panel?

Or, when can I map my local one to a LOINC one?

With help from the S&I Framework Initiative, we developed a set of business rules for panels

The following is a brief summary

What Defines a Panel?

Or, when can I map my local one to a LOINC one?

With help from the S&I Framework Initiative, we developed a set of business rules for panels

The following is a brief summary

see Section 13 in User Guide for full rules and examples

Business Rules for Panels1. Must contain all of the required elements

2. No extra primary measurements

3. Optional elements are optional

4. Substitutions of a method-specific code for a methodless one are allowed, but not vice versa

5. Substitutions for mass versus substance Properties are allowed (newest rule)

Business Rules for Panels5. No substitutions of quantitative for

qualitative (and vice versa)

6. Pay attention to reflex components

7. Panels with only narrative definitions of the elements they should contain

Advanced model of panel attributes in LOINCAn expansion that grew out of our work to represent standardized assessment instruments

LOINC could be a

master question file and

uniform representation

Iterative RefinementStarted about 10 years ago

Informing ideas: Survey instruments have psychometric properties

Question meaning tightly coupled with answers

Many collaborators esp Tom White, Susan Bakken

CHI Functioning and Disability workgroup

ASPE, AHIMA, CMS, RTI, HL7, HITSP

Standardized Assessments and Collections

Vreeman DJ, McDonald CJ, Huff SM. Representing patient assessments in LOINC®. AMIA Annu Symp Proc. 2010;832-836. PMID: 21347095 . Vreeman DJ, McDonald CJ, Huff SM. LOINC® - A Universal Catalog of Individual Clinical Observations and Uniform Representation of Enumerated Collections. Int J Funct Inform

Personal Med. 2010;3(4):273-291.

Assessment InstrumentsWidely used…

…and not unlike other kinds of observations

Item-level AttributesQuestion Text

Question Source

External Copyright

Terms of Use

Description/Definition

Units of Measure (UCUM)

Data Types

Structured Answer ListsAnswer List Attributes

OID External Link

Answer Item Attributes ID (contains “LA” prefix) String Sequence Local code Universal code (SNOMED CT)

Score

Attributes of Items in a Panel Instance

Display name override

Coding instructions

Cardinality

Local code on that form

Skip logic

Data type in form

Answer sequence override

Consistency/validation checks

Images

Panels Available as Separate Download Look for the “Panels and Forms File”

LOINC Answers

LOINC AnswersLOINC is focused on “questions”, but…

Sometimes, questions are best understood by knowing the set of allowed answer choices

Many answer choices are highly specialized and not present in vocabulary standards

LOINC AnswersMany answer choices are highly specialized and not present in vocabulary standards

LOINC has a structured representation of answer lists

Classify them as “Example”, “Normative”, or “Preferred”

Example => Starter set, but you could use more/less

MAPPING CAUTION

Normative => This is it. Don’t mess with it!

Panel Features in RELMA

A sample of the LOINC content…

US Government Forms

CARE, MDSv2, MDSv3, OASIS B1, OASIS C, RFC, US Surgeon General’s Family Health Portrait, End Stage Renal Disease forms

Borderline Symptom List - 23 Item

Brief Interview for Mental Status (BIMS)

CARE long term care hospital (LTCH)

Confusion Assessment Method (CAM)

Core behavioral health terms (SAMHSA)

Edinburgh Postnatal Depression Scale

FACIT

Geriatric Depression Scale (GDS)

HIV Signs and Symptoms Checklist

Home Health Care Classification

howRU

Living with HIV (LIV-HIV)

Morse Fall Scale

My Mood Monitor

Neonatal Skin Risk Assessment Scale

Neuro-QOL

NIH Stroke Scale

OMAHA

OPTIMAL

PROMIS

PhenX

PHQ (9 and 2)

Quality Audit Marker (QAM)

VR 12 and 36

US Government Forms








FACIT




howRU


Morse Fall Scale

My Mood Monitor


Neuro-QOL

NIH Stroke Scale

OMAHA

OPTIMAL

PROMIS

PhenX

PHQ (9 and 2)


VR 12 and 36

15,000+ variables Oh snap!

US Government Forms








FACIT




howRU


Morse Fall Scale

My Mood Monitor


Neuro-QOL

NIH Stroke Scale

OMAHA

OPTIMAL

PROMIS

PhenX

PHQ (9 and 2)


VR 12 and 36

15,000+ variables Oh snap!

Added about 350 survey-related terms last release

Find Panels and Forms in RELMA

Find Panels and Forms in RELMA

Hit this!

Lab Panels

Clinical Assessments, Scales, Panels

Panels for Clinical Documents

Non-lab Diagnostic Studies

Government

Miscellaneous

Survey Instruments (Patient Reported)

View Panel Children

View Panel Children

Select “View Panel Children” from context menu

Panel Children

Find Panels that Contain this Term


Select “Find Panels with All These LOINCs” from context menu


Also on Comprehensive Details Pages

Also on Comprehensive Details Pages

These panels all contain this Creatinine term

Export the Full Panel Structure

LOINC adoption here is gaining some traction…

2006

Questionnaires in FHIR

DataElements in FHIR (work in progress)

CMS Data Element Library4,600+ data elements from CARE, MDS, CARE-LTCH, OASIS

Responsive to IMPACT Act

Overall goals: • Uniformity across CMS assessments and quality measures • Authoritative resource for patient assessment data

elements • Promote the sharing of electronic patient assessment data

sets and information standards • Promote EHR interoperability and care coordination

Mapped to LOINC and other national vocabularies

CMS Data Element LibraryWe are engaged as advisors

RFP out now for maintenance and oversight of the Library, which specifies the contractor must work with us to resolve gaps

Pilot Apps demonstrating LOINC form Power

NLM LForms tool Merck ePRO tool powered by OpenMRS

Lesson 1Variation abounds

Despite similarity in items, much

variation exists…many differences might have been avoided

Original PHQ-9

CARE

MDSv3

Frequency with which resident complains or shows evidence of pain (in last 7 days)? No pain, Pain less than daily, Pain daily

MDSv2

How much of the time have you experienced pain or hurting over the last 5 days? Almost constantly, Frequently, Occasionally, Rarely, Unable to answer

MDSv3

Have you had pain or hurting at any time during the last 2 days? Yes, no, unable to respond

CARE

Frequency of Pain Interfering with patient's activity or movement Patient has no pain or pain does not interfere with activity or movement, Less often than daily, Daily but not constantly, All of the time

OASIS-B1

Frequency of Pain Interfering with patient's activity or movement Patient has no pain, Patient has pain that does not interfere with activity or movement, Less often than daily, Daily but not constantly, All of the time

OASIS-B2

photo via

Weigh the cost of losing comparability before inventing something new

http://www.flickr.com/photos/toddography/

http://www.flickr.com/photos/toddography/

Lesson 2IP issues present large challenges

Weigh the cost of losing comparability before inventing something new

Lesson 3Not all use-cases need everything

Evolve gracefully.photo via Dawn Huczek

http://www.flickr.com/photos/31064702@N05/


Less than the best is sometimes OK

Quality measures, registries, etc might not need whole scored instrument

Stingy IP holders resist full modelling

Purposes fulfilled with just:

Name of some specific instrument used

Total score from a particular instrument

Graceful Evolution1. Create "panel" codes that represent the

named instrument

2. Create a total score term (as a child) for the instruments where score is needed

3. When they are needed, fully model the instrument as a complete set of questions (with answers where appropriate)

photo via milos milosevic

