Computerized Physician Order Sets for Meaningful Use – Getting Attention from LOINC and Regenstrief Institute

Oct. 5, 2015 / By Pam Banning

There’s been a lot of attention on standardizing laboratory order sets in the past year in preparation for the Meaningful Use requirements for computerized physician order sets (CPOE). The Standards & Interoperability (S&I) Framework group known as a LOINC Order Code met for fifteen months. Representatives from the Centers for Disease Control (CDC), Regenstrief Institute and various national reference laboratories and consultants were involved, with 3M as a principal participant. The group took on the scope of examining ambulatory patient laboratory orders.

Bear in mind, when setting the context for laboratory orders against LOINC terms, there’s a difference between single lab test orders (what is my glucose level?) vs panel orders (what are my electrolytes?). A potassium level, a single lab test with a single result will have the same LOINC term for its order and result answer. However, if a panel of electrolytes is desired, there is an Order LOINC term for electrolytes and four accompanying result LOINC terms for the sodium, potassium, chloride and carbon dioxide.

3M was able to provide perspective to the S&I group on the variety of ways a laboratory information system (LIS) can be built and how that will affect the uptake of standardized coding. Other participants in the group may have mapped their enterprise catalogs; but the 3M team has offered mapping as a service for almost ten years, so over time, we have the unique position of being the submitter of over nine percent of the laboratory LOINC observation database, and we continue our stance by submitting both orders and observations seen in our maintenance customers’ catalogs.

In June 2015, the recommendations from a LOINC Order Code group were forwarded as a final report to the Office of the National Coordinator (ONC). Included in the recommendations on enhancing LOINC adoption in the US, were guidelines for a site to follow when comparing their panels or batteries to LOINC Order terms. 3M starting applying the S&I recommendations and guidelines to clients wanting an early start on identifying their LOINC order code mappings. 3M clients who currently mapped with LOINC Order codes identified having 50% to 94% LOINC Order code coverage across a flat file of lab test orders for both ambulatory and inpatient statuses. Key discriminators include the complexity of the laboratory catalog, the result level LOINC terms and the amount of variability from the published LOINC Order terms. 3M is extrapolating the differences between client panels and standardized LOINC Order panels to provide Regenstrief Institute the materials needed to refine existing panels or build new panels to increase available coding.

As a result of our lessons learned, we want to give you some successful key factors in compliance of the S&I initiatives.

Step 1 – Know what to look for while you’re evaluating your panels.

• Pull all active, orderable assays that chart on a patient, along with group/single test indicator, specimen type, result name and mnemonic for each, along with result format and units of measure. LOINC uses HL7 based relationships of R-required, O-optional and C-conditional to allow the standard panel to expand and contract with local variations of an order set. There is nothing similar to a test descriptor in a commercial off-the-shelf laboratory system. Instead, there may be additional tables, listing red cell morphological conditions that can be added onto a differential of a patient that needs the abnormal annotation. This is an example of the HL7 Optional relationship. Be sure to pull in accessory tables for red cell morphology, urinalysis cellular elements, blood bank antigens and microorganism susceptibilities. These are all add on tests as the laboratory finds a workup necessary.
• Have a senior lab expert examine the file for completeness. Can all possible lab values produced by the lab be found in this file?

Step 2 – Get started…

• Perform LOINC mapping on all chartable result fields. Perform a quality audit or peer review to affirm level of confidence.
• For the group tests, panel definitions are available in Regenstrief’s Electronic Laboratory Mapping Assistant (RELMA) with the “Find Panels using these LOINCs” on Review Panels, Forms and Surveys tab [lower left corner of version 6.10]
  • There are instances where clients are several result fields off from a published panel; 3M is providing feedback to Regenstrief in those areas for their consideration. We suggest the public does the same.
  • There are LOINC Order sets that don’t have any components specified, and are simply a name match. We’re not certain if those will be added or if it will stay as is. At this point, if it’s agreed to convey the intent of the local order, use it and let Regenstrief know what components (observation LOINC terms) are in this panel.

Step 3 – Keep it rolling! (aka Keeping your database synchronized to LOINC into the future):

• Does your database administration team know which types of changes on a lab test trigger the need to audit that LOINC?
• Have they incorporated a daily workload indicator of the terminology coding to review?
• Does the team have reminders if a single result LOINC change occurs, to update your order level LOINC too?
• Is there a process in place for bi-annual review against new LOINC versions for discouraged statuses, improved panel definitions, more appropriate LOINCs to use? Perhaps one is available now that your team submitted?

Do you want an indicator of how prepared your team is for sustainability in terminology coding? If already implemented, do you have a change management plan in place? The benefits in harmonization, data mining and big data analysis are indisputable when a standardized terminology is in place.

Happy LOINCing!

Pamela Banning, BS, is a senior healthcare data analyst for 3M Health Information Systems.