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1 Regenstrief Institute, Indianapolis, IN 46202.
2 Indiana University School of Medicine, Indianapolis, IN 46202.
3 University of Utah, Salt Lake City, UT 84120.
4 The Hospital For Sick Children, Toronto, ON, MG5 1X8 Canada.
5 Mayo Medical Laboratories, Rochester, MN 55901.
6 Los Angeles County Department of Health, Los Angeles, CA 90012.
7 University of Washington, Seattle, WA 98195.
8 Ghent University, Ghent, Belgium.
9 Centers for Disease Control and Prevention, Atlanta, GA 30341.
10 California Animal Health and Food Safety Laboratory System, Davis, CA 95617.
11 Quest Diagnostics Incorporated, Teterboro, NJ 07608.
aAddress correspondence to this author at: Regenstrief Institute, Inc., 1050 Wishard Blvd., 5th Floor, Indianapolis, IN 46202. Fax 317-630-6962; e-mail cmcdonald{at}regenstrief.org.
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Abstract |
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 Top Abstract IntroductionStructure and Purpose of...Scope of the Current...RELMADistribution and Copyright,...ConclusionsReferences |
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Introduction |
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TopAbstractIntroductionStructure and Purpose of...Scope of the Current...RELMADistribution and Copyright,...ConclusionsReferences |
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Before 1994, no universal pre-coordinated code system for laboratory test names existed, although considerable background work had been done within organizations such as the IFCC/IUPAC Committee/Commission on Properties and Units in Clinical Chemistry (3)(4), and EUCLIDES(5). In 1994, a group of researchers met in Indianapolis at the Regenstrief Institute to begin the development of such a system, which they called the Logical Observation Identifiers Names and Codes (LOINC®) code system. The initial release, in the spring of 1995, included a 70-page Users’ Guide and identifiers and names for more than 6000 laboratory test results (6)(7).
Since this first release, the Regenstrief Institute and the LOINC Committee have delivered 17 releases, increased the size of the database fivefold, added codes for many clinical subjects beyond the laboratory, added short names for laboratory tests, developed and enhanced a free browsing program, the Regenstrief LOINC Mapping Assistant (RELMATM) (8), and watched adoption of the LOINC coding system grow. Here we report this progress.
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Structure and Purpose of LOINC Codes |
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TopAbstractIntroductionStructure and Purpose of...Scope of the Current...RELMADistribution and Copyright,...ConclusionsReferences |
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Our initial emphasis was on developing codes for single test observations, not the batteries, panels, or packages that might contain multiple test readers. However, the LOINC code used to report a single observation, e.g., serum potassium (LOINC code 2823-3) can also be used to order that observation. Similarly, in clinical domains, the LOINC code for reporting a "chest x-ray PA & lateral" result could also be used to order a chest x-ray study. The LOINC database now also includes codes for some test packages (panels) such as arterial blood gases, differential count, and hemogram, but only the most common and standardized ones. We will expand the LOINC coverage for order packages over time.
As of July 2002, the LOINC database carried records for more than 30 000 different observations. Each record carries the formal six-part LOINC name; the LOINC code, a number with a check digit (see Table 1
); the observation class (e.g., chemistry, hematology, and radiology); related names (to assist searches of the database); and other attributes. For most classes of laboratory observations, the database also includes a "short" report name that is <30 characters, is less formal, and is more readable. Short names have not yet been finalized for the nonlaboratory LOINC concepts.
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LOINC follows good coding system practices (16). LOINC codes carry no embedded meaning, and they are never reused or deleted. If a LOINC term happens to be identified as a duplicate of a coding record previously entered into the LOINC database, it will be flagged as "deprecated" but not removed from the database.
We used many sources for constructing the original LOINC database as described in the original Clinical Chemistry article (6). The development of LOINC codes has been an empirical process, based on the examination of existing laboratory master test files and the contents of millions of HL7 messages, as well as requirements discovered during the adoption of LOINC codes by individual laboratories and the development of new testing technology.
LOINC clinical observation names (including laboratory test results, clinical measurements, and results of other diagnostic studies) are defined in terms of six major, and up to four minor, axes. The formal LOINC name must include entries for the first six major axes (shown in Table 2
). The method axis is included only when the method distinction makes an important difference to the clinical interpretation of the result. Examples of LOINC terms are shown in Table 1
.
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The minor axes include challenge information; adjustments; supersystem, e.g., fetus, blood product; and time operators (maximum, minimum, last, first). The challenge axis is the most complex and includes the amount, route, and timing (e.g., oral glucose tolerance test). The details about these other axes can be found in the LOINC Users’ Guide (17).
Examples of clinical LOINC terms and names are shown in Table 3
, in which each of the axes is separated into a separate column for easier reading.
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Scope of the Current LOINC Database |
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TopAbstractIntroductionStructure and Purpose of...Scope of the Current...RELMADistribution and Copyright,...ConclusionsReferences |
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The categories of laboratory test procedures that are included in the LOINC database are identified in Table 4
along with the number of LOINC terms defined for each category.
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The clinical LOINC division is concerned with nonlaboratory diagnostic studies, critical care, and nursing measures, as well as the history, physical, and survey instruments. The clinical LOINC division, chaired by Stan Huff, MD, includes several new projects for defining clinical notes, report titles, and dental observations.
The categories and numbers of clinical LOINC terms per categories that are available in the LOINC database are described in Table 5
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The third division focuses on proposals for the Health Insurance Portability and Accountability Act (HIPAA) (18) attachments. HIPAA mandates the promulgation of 10 administrative standards. The first nine deal with payment, enrollment, and other purely administrative functions. These have already been delivered (19). More time was provided under the law for developing the tenth administrative standard, the one for claims attachments. The draft rule for claims attachments proposes a HL7, unsolicited observational report message as the attachment "structure" and uses LOINC codes to identify the individual observations within the attachment. A payer who wanted a specified set of results, e.g., chemistry tests, obtained at a given encounter would request the set of codes by sending a request for LOINC code 18719-5, the LOINC code for all chemistry tests. The care provider’s system would use LOINC codes to identify the chemistry test results that it included in its query response.
The content of HIPAA attachments is developed by the HL7 Attachment Special Interest Group (ASIG), not by the LOINC Committee. Members of the LOINC Committee provide technical advice to the HL7 ASIG, and the Regenstrief Institute constructs the attachment set and adds new LOINC codes as required. Six HIPAA attachments have been drafted, including (a) laboratory reports, (b) nonlaboratory clinical reports, (c) ambulance transport, (d) emergency room visits, (e) medications, and (f) rehabilitation. These can be found at http://www.hl7.org/Special/committees/claims/claims_attachments.htm#Publications. New LOINC terms had to be developed for some of these attachments, but existing LOINC codes were adequate for most of the laboratory and clinical reports attachments. Work is underway in the HL7 ASIG to add attachments and associated LOINC codes for durable medical equipment, home healthcare, and other subject matter.
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RELMA |
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TopAbstractIntroductionStructure and Purpose of...Scope of the Current...RELMADistribution and Copyright,...ConclusionsReferences |
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Most users will explore the capabilities of RELMA and the content of the LOINC databases by entering the individual words that make up a test name into the RELMA mapping screen. RELMA will then search the LOINC database and display a grid showing all of the LOINC terms that include the entered words. When mapping large numbers of local laboratory tests, users can create an import file that carries information about their local tests. This import file includes fields for the local test name and code (both required) as well as the units of measure, the producing laboratory section, and the code and name of the local battery under which the test is ordered (all optional). RELMA takes advantage of these optional fields to make the mapping process more precise and efficient. The LOINC manual (17) gives details about the structure and formats required for creating an import file.
When an import file is used, the first step in the mapping process is to run a special program to find words and units within the import file that RELMA does not understand. The user then corrects typographical errors and maps these unrecognized words into words that RELMA does understand before starting the mapping process.
Once the local test field has been edited, the user can map each local test to its corresponding LOINC code. RELMA parses the local test names into separate "words", using blanks and special characters as word boundaries, and places these words in the fields of the RELMA mapping screen (see far left column of five input fields in Fig. 1
). The user can add further search specifications and add or remove words to facilitate the search.
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Fig. 1
shows the search screen for a local test that has "SNA" for its code and "Sodium" for its name. This example test is ordered under the electrolytes panel. RELMA automatically restricts the search to tests that are consistent with the local name and the local units (the local units field contains "mmol/dl" in the field at the top left of Fig. 1
). In Fig. 1
the RELMA program has retrieved the 14 LOINC terms that contain the word sodium and are consistent with the units of mmol/dl. The search is very fast, less than 0.1 s on a 600 MHz personal computer for most searches. In this example, the local laboratory uses "Sodium" as shorthand for "Serum Sodium", so the user would have to click on row 11 to link the LOINC code for serum sodium to their local serum sodium test.
The user can adjust the search by adding or removing words within the fields labeled "local words" in Fig. 1
and by relating the words by logical NOTs or ORs. The user can reorganize the grid column order by dragging the field labels and can resort the grid according to the content of any column by clicking on the column header. In the example (Fig. 1
), the test name does not include any hint that it is a serum sodium, so RELMA returns sodium tests for the many different specimens. If the name had included some string, e.g., "ser", that indicated this was a serum sodium or if the user had typed "serum" in the second search word field, RELMA would have returned just one test, serum sodium, in its grid.
The second tab on this screen (see Fig. 2
) permits the user to set global search options. For example, the user could request that RELMA find only molar measurements, as preferred in most European countries, or the mass measurements that are more commonly preferred in the US by clicking on "favor substance property" or "favor mass property". The radio buttons are at the bottom of this form. This screen also has an option to control the search based on the number of words in the analyte name, which is useful for excluding the more unusual forms of analytes, such as hemoglobin Chesapeake or hemoglobin Seattle, when looking for the blood hemoglobin.
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The other tabs permit users to restrict the search to broad categories of classes, systems (specimens), and components, respectively. When these tabs are opened, they display a tree of concepts. Fig. 3
shows the component tree with the virus branch of microbiology opened, and below that the hepatitis viruses subtree is opened and hepatitis viruses are selected. This choice would restrict the search to tests for hepatitis viruses. The same kind of selection capability is available for test classes (e.g., chemistry test or hematology tests) and systems (specimens).
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When all terms are mapped, the user can recover the "import file", which will now carry links to the corresponding LOINC codes, and import this mapping table into their laboratory system or interface engine.
RELMA has options for importing and exporting the local mapping file, for reporting the contents of the local mapping file and LOINC database, for finding words and units in the local system that LOINC does not recognize (often typographical errors or irrelevant words), and for converting these into words and units, respectively, that RELMA understands.
RELMA is provided at no cost from the Regenstrief Institute (8). Users can also run RELMA via the Web and a Citrix client (available at http://www.regenstrief.org/loinc).
LOINC has been adopted widely. In the US, most federal agencies with healthcare interests have adopted LOINC. The CDC recommends HL7 messages with LOINC codes for delivering laboratory results that identify cases of reportable conditions to public health departments (20)(21)(22)(23). The New York State Public Health Department, Indiana State Department of Health, and Washington State Public Health Laboratories are among the public health departments now using this approach (24). The CDC is also proposing a LOINC- and HL7-based (25) standard for tumor registry reporting and emergency encounter reporting [Data Elements for Emergency Department Systems (DEEDS)] (26). The National Library of Medicine (NLM) has included LOINC as one of the source vocabularies in the Unified Medical Language System (UMLS) Metathesaurus.
The Veterans Administration is mapping the test codes in all of its hospital laboratories to LOINC codes to facilitate clinical care and research (27) across Veterans Administration hospitals. We have already mentioned the Department of Health and Human Service’s (28) involvement in LOINC for use in electronic claims attachments. The Clinical Data Interchange Standards Consortium, which includes all of the major pharmaceutical manufacturers and the Food and Drug Administration as a liaison participant, uses LOINC codes for identifying laboratory tests and EKG results in new drug submissions (10). The American Clinical Laboratories Association, which includes many of the large referral laboratories, endorsed LOINC from its beginning.
Large reference laboratories, including the largest, Quest (29) and LabCorp(30), have mapped their internal codes to LOINC and will include the LOINC codes along with their local codes in HL7 result messages. For Quest, this endeavor required the mapping of more than 200 000 local codes from the many laboratories that are now part of Quest. Other large laboratories and the 26 veterinary medicine laboratories in the US are also currently mapping their local test codes to LOINC.
Large healthcare institutions have taken advantage of LOINC to standardize the information coming from many different sources. Notable users include Partners HealthCare of Boston, Intermountain Health Care, Kaiser Foundation Health Plan, the Hospital for Sick Children in Toronto, all of the major hospitals in Indianapolis, New York-Presbyterian, and the University Hospitals of Columbia and Cornell. Many health insurance companies require their laboratory vendors to supply them with LOINC-coded laboratory HL7 messages so that they can pool these results for clinical management purposes. LOINC is being adopted internationally as well. In Germany, the Deutsches Institut für Normung has specified LOINC as a national standard for laboratory reporting (31). In Switzerland, the Swiss Center for Quality Control introduced a LOINC-based service (32)(33) for clinical laboratorians worldwide, CUMUL, which has contributed their French, German, and Italian names for close to 3000 of the most common laboratory tests to the LOINC database. The CUMUL project is now endorsed by European Laboratory Medicine as "a platform to develop co-ordination between European societies of all laboratory disciplines", thereby spreading interest for LOINC across Europe. LOINC is part of a province-wide laboratory information standardization in Ontario and British Columbia and is used in Australia, Korea, Estonia, Brazil, and New Zealand.
Some instrument vendors, including Dade MicroScan’s antibiotic susceptibility and Beckman Coulter’s cell counting instruments, have been mapping each of their distinct instrument measurements to LOINC codes for years, and interest in having laboratory instruments deliver LOINC codes with the results they produce has recently increased. Roche Diagnostics now has mapped all of the distinct test measurements produced by their large-scale chemistry analyzers to their corresponding LOINC codes. Table 6
lists the vendors who indicate ability to transmit LOINC codes as identifiers of results they deliver in outbound messages to laboratory information systems (LIS) (34)(35)(36)(37)(38)(39). We are particularly pleased to see the number of vendors of immunoassay instruments who can provide LOINC codes because immunoassays are one of the more challenging areas for assignment of LOINC codes because of methodology-specific coding differences and unusual analytes. The Department of Veterans Affairs has been considering making instrument delivery of LOINC codes a requirement in future system-wide bids for laboratory instruments.
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The adoption by instrument vendors is welcome for two reasons. Instrument manufacturers have the most knowledge about the tests they produce and are best positioned to identify the appropriate LOINC code and/or to argue for new LOINC codes when required by new testing technology. In addition, when instrument vendors provide LOINC codes as part of the result output message, they decrease the need for mapping work at the hundreds of laboratories that use their instruments.
Some LIS vendors, including Compromed, M/Mgmt, McKesson, Northern, Soft Computer, and Sysware, provide the full LOINC database with each new installation. Many LIS vendors (25 vendors in the November 2001 CAP Today survey) now include an indexed field for the LOINC code in their test database (40). (As an aside, we do not recommend that laboratories use LOINC as the primary internal identifier in their LIS; rather that every test defined in the LIS include a field for carrying the appropriate LOINC code so that it can be included as the alternative observation identifier, along with the local test code, within outbound HL7 messages.)
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Distribution and Copyright, Communications and Meetings |
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TopAbstractIntroductionStructure and Purpose of...Scope of the Current...RELMADistribution and Copyright,...ConclusionsReferences |
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The LOINC database and associated documents and programs are copyrighted, but the copyright permits all commercial and noncommercial uses in perpetuity at no cost. If the LOINC database or its contents are distributed as a database, such distributions must include all parts of the formal LOINC term, the LOINC short name, the LOINC code, the deprecated flag, and the copyright. The copyright notice is needed to prevent variants, which would defeat the purpose of this standard. No such notice is required when LOINC codes are used in messages to report test results.
LOINC has four to six committee meetings per year, one-half clinical and one-half laboratory. At least one laboratory and one clinical meeting are open to the public. New releases of the LOINC database and/or RELMA program occur three to four times per year. We announce new releases and public meetings to all who subscribe to our e-mail list. Interested parties can subscribe to the LOINC e-mail news and mailing announcements by going to http://www.regenstrief.org/loinc/mlist/. Public meetings are also announced through the NLM UMLS listserv, the American Medical Informatics Association (AMIA) monthly electronic newsletter list (ACCESS AMIA), and the HL7 Calendar of Events website.
We welcome suggestions about observation terms that have not yet been included in the LOINC database. The LOINC Users’ Guide defines the structure and format required for new submissions.
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Conclusions |
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TopAbstractIntroductionStructure and Purpose of...Scope of the Current...RELMADistribution and Copyright,...ConclusionsReferences |
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To facilitate the mapping of local test codes to LOINC codes, we encourage laboratories to be more specific in their naming conventions for tests. In particular, laboratories should always include an indication of the specimen type (e.g., Ser for serum, Ur for urine) and the scale (e.g., QL for ordinal tests and QN for quantitative tests) in their test names. With that additional specification, laboratories with semiautomatic methods could map most of their routine tests to universal LOINC codes in a few days.
Laboratories should adopt LOINC codes internally, include them in their outbound HL7 messages, and demand LOINC codes from their reference laboratories and instrument vendors. Practices and HMOs should demand LOINC codes in the HL7 results messages they receive from laboratories so that they can collate and analyze results from many independent sources automatically.
laboratory loinc developers
Raymond Aller (Los Angeles County Department of Health, Los Angeles, CA); Pam Banning (3M, West Linn, OR); Rita Barsoum (Kaiser Permanente, Northridge, CA); Jack Bierens de Haan (Quality Control Center-Switzerland, Geneva, Switzerland); James Case (California Animal Health and Food Safety Laboratory System, Davis, CA); Ronda Crist (ARUP Laboratories, Salt Lake City, UT); Georges DeMoor (Ghent University, Ghent, Belgium); Brian Dixon (Regenstrief Institute, Indianapolis, IN); Diane Esteva (Kaiser Permanente, Northridge, CA); Arden Forrey (University of Washington, Seattle, WA); Andy Gajda (Clinical Laboratory Consultation, Ontario, Canada); Kaleem Gill (Regenstrief Institute, Indianapolis, IN); Barry Gordon (C/NET Solutions, Berkeley, CA); Gilbert Hill (The Hospital For Sick Children, Toronto, Ontario, Canada); John Hook (Regenstrief Institute, Indianapolis, IN); Stanley M. Huff (University of Utah, Salt Lake City, UT); Major Jeff Lamothe (United States Air Force, Biloxi, MS); Dennis Leavelle (Mayo Medical Laboratories, Rochester, MN); Diane Leland (Indiana University School of Medicine, Indianapolis, IN); Pat Maloney (Quest Diagnostics Incorporated, Teterboro, NJ); Ken McCaslin (Quest Diagnostics Incorporated, Teterboro, NJ); Clement J. McDonald (Regenstrief Institute, Indianapolis, IN and Indiana University School of Medicine, Indianapolis, IN); Kathy Mercer (Regenstrief Institute, Indianapolis, IN); Deirdre O’Neill (National Medical Services Association, Willow Grove, PA); Rick Press (Oregon Health Sciences University, Portland, OR); Christine Raine (Partners Healthcare Inc., Brookline, MA); Frank Stalling (Department of Veterans’ Affairs, Dallas, TX); John Stelling (World Health Organization, Geneva, Switzerland); Jeffrey G. Suico (Regenstrief Institute, Indianapolis, IN and Indiana University School of Medicine, Indianapolis, IN); Wayne Tracy (Health Patterns LLC, Overland Park, KS); Alex Tuszynski [Strategic Healthcare Group (VA), Washington, DC]; Margaret Vaughn (Partners HealthCare System, Inc., Boston, MA); and Warren Williams (Centers for Disease Control and Prevention, Atlanta, GA).
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Acknowledgments |
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Footnotes |
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2 Members of the Laboratory LOINC Development Group are listed in an Appendix at the end of this article.
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References |
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TopAbstractIntroductionStructure and Purpose of...Scope of the Current...RELMADistribution and Copyright,...ConclusionsReferences |
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The following articles in journals at HighWire Press have cited this article:
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  M. Dugas, S. Thun, T. Frankewitsch, and K. U. Heitmann LOINC(R) Codes for Hospital Information Systems Documents: A Case Study J. Am. Med. Inform. Assoc., May 1, 2009; 16(3): 400 - 403. [Abstract] [Full Text] [PDF]
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 R. F. Stewart, H. Edgar, C. Tatlock, and P. J. Kroth Developing a Standardized Cephalometric Vocabulary: Choices and Possible Strategies J Dent Educ., September 1, 2008; 72(9): 989 - 997. [Abstract] [Full Text] [PDF]
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F. Bakhshi-Raiez, R. Cornet, and N. F. de Keizer Development and Application of a Framework for Maintenance of Medical Terminological Systems J. Am. Med. Inform. Assoc., September 1, 2008; 15(5): 687 - 700. [Abstract] [Full Text] [PDF]
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S. B. Johnson, S. Bakken, D. Dine, S. Hyun, E. Mendonca, F. Morrison, T. Bright, T. Van Vleck, J. Wrenn, and P. Stetson An Electronic Health Record Based on Structured Narrative J. Am. Med. Inform. Assoc., January 1, 2008; 15(1): 54 - 64. [Abstract] [Full Text] [PDF]
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 X. Bossuyt, K. Verweire, and N. Blanckaert Laboratory Medicine: Challenges and Opportunities Clin. Chem., October 1, 2007; 53(10): 1730 - 1733. [Abstract] [Full Text] [PDF]
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S. W. Tu, J. R. Campbell, J. Glasgow, M. A. Nyman, R. McClure, J. McClay, C. Parker, K. M. Hrabak, D. Berg, T. Weida, et al. The SAGE Guideline Model: Achievements and Overview J. Am. Med. Inform. Assoc., September 1, 2007; 14(5): 589 - 598. [Abstract] [Full Text] [PDF]
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H. Min, Y. Perl, Y. Chen, M. Halper, J. Geller, and Y. Wang Auditing as Part of the Terminology Design Life Cycle J. Am. Med. Inform. Assoc., November 1, 2006; 13(6): 676 - 690. [Abstract] [Full Text] [PDF]
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J. Y. Sun and Y. Sun A System for Automated Lexical Mapping J. Am. Med. Inform. Assoc., May 1, 2006; 13(3): 334 - 343. [Abstract] [Full Text] [PDF]
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J. M. Ferranti, R. C. Musser, K. Kawamoto, and W. E. Hammond The Clinical Document Architecture and the Continuity of Care Record: A Critical Analysis J. Am. Med. Inform. Assoc., May 1, 2006; 13(3): 245 - 252. [Abstract] [Full Text] [PDF]
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 T. D. Sequist, T. Cullen, and J. Z. Ayanian Information Technology as a Tool to Improve the Quality of American Indian Health Care Am J Public Health, December 1, 2005; 95(12): 2173 - 2179. [Abstract] [Full Text] [PDF]
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 C. J. McDonald, J. M. Overhage, M. Barnes, G. Schadow, L. Blevins, P. R. Dexter, B. Mamlin, and the INPC Management Committee The Indiana Network For Patient Care: A Working Local Health Information Infrastructure Health Aff., September 1, 2005; 24(5): 1214 - 1220. [Abstract] [Full Text] [PDF]
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C. J. Staes, S. M. Huff, R. S. Evans, S. P. Narus, C. Tilley, and J. B. Sorensen Development of an Information Model for Storing Organ Donor Data Within an Electronic Medical Record J. Am. Med. Inform. Assoc., May 1, 2005; 12(3): 357 - 363. [Abstract] [Full Text] [PDF]
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J. J. Frassica Frequency of Laboratory Test Utilization in the Intensive Care Unit and Its Implications for Large-Scale Data Collection Efforts J. Am. Med. Inform. Assoc., March 1, 2005; 12(2): 229 - 233. [Abstract] [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
