Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations. First developed in 1994, it was created and is maintained by the Regenstrief Institute, a US nonprofit medical research organization. LOINC was created in response to the demand for an electronic clinical care and management database and is publicly available at no cost.
It is endorsed by the American Clinical Laboratory Association. Since its inception, the database has expanded to include not just medical laboratory code names but also nursing diagnosis, nursing interventions, outcomes classification, and patient care data sets.
LOINC applies universal code names and identifiers to medical terminology related to electronic health records. The purpose is to assist in the electronic exchange and gathering of clinical results (such as laboratory tests, clinical observations, outcomes management and research). LOINC has two main parts: laboratory LOINC and clinical LOINC. Clinical LOINC contains a subdomain of Document Ontology which captures types of clinical reports and documents. [1] [2]
Several standards, such as IHE or HL7 , use LOINC to electronically transfer results from different reporting systems to the appropriate healthcare networks[ citation needed ]. However, the health information enclosed is identified by a multiplicity of code values that may vary according to the entity producing those results. This has obvious disadvantages to the healthcare network that may need to adopt different codes to access and manage information coming from multiple sources. Managed care providers, for example, often have negotiated contracts that reimburse episodes of care and unique coding to trigger automated claim payment. Mapping each entity-specific code to its corresponding universal code can represent a significant investment of both human and financial capital.
A universal code system will enable facilities and departments across the world to receive and send results from their areas for comparison and consultation and may contribute toward a larger public health initiative of improving clinical outcomes and quality of care.
LOINC is one of the standards used in U.S. Federal Government systems for the electronic exchange of clinical health information. In 1999, it was identified by the HL7 Standards Development Organization as a preferred code set for laboratory test names in transactions between health care facilities, laboratories, laboratory testing devices, and public health authorities. [3]
LOINC terminology has two main parts: [4]
A formal, distinct, and unique 6-part name is given to each term for test or observation identity. [5] The database currently has over 71,000 observation terms that can be accessed and understood universally. Each database record includes six fields for the unique specification of each identified single test, observation, or measurement:
A unique code (format: nnnnn-n) is assigned to each entry upon registration. Other database fields include status and mapping information for database change management, synonyms, related terms, substance information (e.g. molar mass, CAS registry number), choices of answers for nominal scales, translations.
Some of the advantages resulting from adopting LOINC may include improved communication in integrated healthcare delivery networks, improved community wide electronic health records, the automatic transfer to public health authorities of case reports for reportable diseases (e.g. for disease control or detection of epidemics), improved transfer of payment information for services rendered and a significant improvement in the overall quality of health care by reducing errors in the system.
The fact that universal standards are being promoted (if not adopted by national organizations and agencies) is an indication that the dialogue will continue regarding the development, structure, financing, monitoring, enforcement, and integration of standards within the broader health care system.
International interest in LOINC continues to grow. A number of efforts have been undertaken to translate the LOINC documents and terms into various languages, such as Simplified Chinese, German, Spanish. As of January, 2009, the software RELMA (Regenstrief LOINC Mapping Assistant) is available in separate downloads that contain an additional word index in Spanish, Simplified Chinese, or Korean, which allows searching in these languages in addition to English. [6] Harmonization efforts between LOINC and SNOMED CT were initiated in 2012.
LOINC ID (P4338) (see uses )
Health informatics is the study and implementation of computer structures and algorithms to improve communication, understanding, and management of medical information. It can be viewed as branch of engineering and applied science.
Health Level Seven, abbreviated to HL7, is a range of global standards for the transfer of clinical and administrative health data between applications with the aim to improve patient outcomes and health system performance. The HL7 standards focus on the application layer, which is "layer 7" in the Open Systems Interconnection model. The standards are produced by Health Level Seven International, an international standards organization, and are adopted by other standards issuing bodies such as American National Standards Institute and International Organization for Standardization. There are a range of primary standards that are commonly used across the industry, as well as secondary standards which are less frequently adopted.
A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart disease, and infectious diseases such as norovirus, the flu, and athlete's foot. Procedure classifications list procedure code, which are used to capture interventional data. These diagnosis and procedure codes are used by health care providers, government health programs, private health insurance companies, workers' compensation carriers, software developers, and others for a variety of applications in medicine, public health and medical informatics, including:
openEHR is an open standard specification in health informatics that describes the management and storage, retrieval and exchange of health data in electronic health records (EHRs). In openEHR, all health data for a person is stored in a "one lifetime", vendor-independent, person-centred EHR. The openEHR specifications include an EHR Extract specification but are otherwise not primarily concerned with the exchange of data between EHR-systems as this is the focus of other standards such as EN 13606 and HL7.
SNOMED CT or SNOMED Clinical Terms is a systematically organized computer-processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting. SNOMED CT is considered to be the most comprehensive, multilingual clinical healthcare terminology in the world. The primary purpose of SNOMED CT is to encode the meanings that are used in health information and to support the effective clinical recording of data with the aim of improving patient care. SNOMED CT provides the core general terminology for electronic health records. SNOMED CT comprehensive coverage includes: clinical findings, symptoms, diagnoses, procedures, body structures, organisms and other etiologies, substances, pharmaceuticals, devices and specimens.
The Clinical Data Interchange Standards Consortium (CDISC) is a standards developing organization (SDO) dealing with medical research data linked with healthcare, to "enable information system interoperability to improve medical research and related areas of healthcare". The standards support medical research from protocol through analysis and reporting of results and have been shown to decrease resources needed by 60% overall and 70–90% in the start-up stages when they are implemented at the beginning of the research process.
The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. In November 2000, HL7 published Release 1.0. The organization published Release 2.0 with its "2005 Normative Edition".
Public health informatics has been defined as the systematic application of information and computer science and technology to public health practice, research, and learning. It is one of the subdomains of health informatics.
Medcin, is a system of standardized medical terminology, a proprietary medical vocabulary and was developed by Medicomp Systems, Inc. MEDCIN is a point-of-care terminology, intended for use in Electronic Health Record (EHR) systems, and it includes over 280,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. This clinical vocabulary contains over 38 years of research and development as well as the capability to cross map to leading codification systems such as SNOMED CT, CPT, ICD-9-CM/ICD-10-CM, DSM, LOINC, CDT, CVX, and the Clinical Care Classification (CCC) System for nursing and allied health.
OpenMRS is a collaborative open-source project to develop software to support the delivery of health care in developing countries.
The International Health Terminology Standards Development Organisation (IHTSDO), trading as SNOMED International, is an international non-profit organization that owns SNOMED CT, a leading clinical terminology used in electronic health records. IHTSDO was founded in 2007 by 9 charter member countries in order to acquire the rights of SNOMED CT from the College of American Pathologists (CAP) and make the development of a global clinical language for healthcare an international, collaborative effort.
DOCLE, is a non-numeric health coding and medical classification system. The DOCLE system is used in Health Communication Network's electronic medical record and patient management software package, Medical Director. Medical Director is the most widely used electronic medical record system by Australian primary health care providers.
The Continuity of Care Document (CCD) specification is an XML-based markup standard intended to specify the encoding, structure, and semantics of a patient summary clinical document for exchange.
The Veterans Health Information Systems and Technology Architecture (VISTA) is the system of record for the clinical, administrative and financial operations of the Veterans Health Administration VISTA consists of over 180 clinical, financial, and administrative applications integrated within a single shared lifelong database (figure 1).
The Omaha System is a standardized health care terminology consisting of an assessment component, a care plan/services component, and an evaluation component. Approximately 22,000 health care practitioners, educators, and researchers use Omaha System to improve clinical practice, structure documentation, and analyze secondary data. Omaha System users from Canada, China, The Czech Republic, Estonia, Hong Kong, Japan, Mexico, New Zealand, The Netherlands, Turkey, the United States, and Wales, have presented at Omaha System International Conferences.
Read codes are a clinical terminology system that was in widespread use in General Practice in the United Kingdom until around 2018, when NHS England switched to using SNOMED CT. Read codes are still in use in Scotland and in England were permitted for use in NHS secondary care settings, such as dentistry and mental health care until 31 March 2020. Read codes support detailed clinical encoding of multiple patient phenomena including: occupation; social circumstances; ethnicity and religion; clinical signs, symptoms and observations; laboratory tests and results; diagnoses; diagnostic, therapeutic or surgical procedures performed; and a variety of administrative items. It therefore includes but goes significantly beyond the expressivity of a diagnosis coding system.
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings.
Integrating the Healthcare Enterprise (IHE) is a non-profit organization based in the US state of Illinois. It sponsors an initiative by the healthcare industry to improve the way computer systems share information. IHE was established in 1998 by a consortium of radiologists and information technology (IT) experts.
NPU terminology is a patient centered clinical laboratory terminology for use in the clinical laboratory sciences. Its function is to enable results of clinical laboratory examinations to be used safely across technology, time and geography. To achieve this, the NPU terminology supplies:
Clinical data standards are used to store and communicate information related to healthcare so that its meaning is unambiguous. They are used in clinical practice, in activity analysis and finding, and in research and development.