Mapping the Finnish National EHR to the LOINC Kristiina Häyrinen a,1 b and Juha Mykkänen a University of Eastern Finland, Department of Health and Social Management b University of Eastern Finland, Department of Computer Science, HIS R&D Abstract. The unified content of EHRs promote shared understanding of patient data, information exchange between information systems and health care organizations, data retrieval from EHR and reuse of data for administrative purposes, statistical analysis or clinical research. The purpose of this study was to analyze to what extent Finnish national headings can be coded with the current version LOINC. Ten (37%) of national headings can be mapped to LOINC terms in clinical class. There were LOINC terms in other classes which correspond to headings. Furthermore, inconsistency exists in the names of headings. The need for mapping national headings to all terms in LOINC is needed. Keywords. Electronic health records, classifications Introduction The content and structure of electronic health record (EHR) have been developed during a long period of time in various initiatives [1-3]. An EHR should have a clear structure to promote shared understanding of patient data, information exchange between information systems and health care organizations, data retrieval from EHR and reuse of data for administrative purposes, statistical analysis or clinical research [2,3]. The free text form introduces barriers to search, summarization, decision support, or statistical analysis. Information extraction from narrative documents of an EHR is still rarely used outside laboratories where information extraction systems have been developed [4]. The balance between structured and coded data in relation to unstructured (narrative, free text) data is one of the challenges in EHR development work. The unified content of the Finnish national EHR has been defined based on proposals for paper-based patient records and information content of widely used EHR systems [5]. Agreement on the national minimal unified structure of the EHR was reached by means of nationwide consultation and expert groups, which represented different domain experts: physicians, nurses, computing specialists, statisticians, health care administration experts and researchers. The need to model content of the Finnish national EHR within the context of a standard vocabulary has been identified [6].The purpose of this study was to analyze to what extent Finnish national headings can be coded with the current version LOINC. 1 Kristiina Häyrinen, University of Eastern Finland, Department of Health and Social Management Email kristiina.hayrinen@gmail.com.
Background In Finland, the unified content of EHR consists of documents composed from harmonised data elements. The internal organisation of the documents follows the idea of grouping meaningful data under section headings which provide the context for narrative text. e.g. [7,8,9]. The core data elements (structured data entries) which require the use of vocabularies, nomenclatures and classifications, are located under their corresponding headings. One of the aims was to achieve semantic interoperability of health information systems. The national recommendations and guidelines for EHRs have been agreed in 2007 [10]. A list of multiprofessional national headings (specifies names, codes and descriptions) is available through the national code server. Table 1. National headings of EHR in Finland Heading Aims for care Anamnesis Assessment, end Assessment, intermediate Consultation Diagnosis Functional status Health examination Health patterns (life style) Health status Intensity of care Medical statements (certifications) Medication Nursing diagnosis Nursing interventions Outcomes of care Physiological measurements Example of content Treatment goals Medical, family and social history. A description and an analysis of the patient's received treatment at end of the episode of care. A description and an analysis of the patients' received treatment during the episode of care. A request to consultation or consultation response. Medical diagnosis. Patients' ability to cope with physical psychological social and cognitive demands related to activities of daily living. Health check-up. For example special inspections of growing children and young people in monitoring the development or examinations the capability of work or education. Manners of living, e.g. smoking, the use of alcohol. Systematic and thorough inspection of the patient for physical signs of disease or abnormality. Degree of patient needs for nursing care. A medical statement is based on medical experts assessment of the patient, e.g. for a court of law. A medical certificate is a structured written document on the patient s disease written by a physician, e.g. for the patient s employers. Information related to medication. A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing action (treatment, procedure or activity) designed to achieve an outcome to a diagnosis, nursing or medical, for which the nurse is accountable. Results of care. Results of physiological measurements e.g. vital signs, oxygen saturation.
Preventive measures Problems Reason for care Rehabilitation Risk factors Surgical procedures Technical aids Test and assessment results Tests and examination The information about followup treatment Specific practices for the prevention of disease e.g. health promotion, vaccination. Patients problems. Reason for care or visit. Restoration of human functions in a person or persons suffering from disease or injury. An aspect of personal behavior or lifestyle, environmental exposure, or inborn or inherited characteristic, which, on the basis of epidemiologic evidence, is known to be associated with a health-related condition considered important to prevent. Operations carried out for the correction of deformities and defects, repair of injuries, and diagnosis and cure of certain diseases. Technical aids for disabled persons. Results of different tests such as psychological tests or nutrition assessment. Results of laboratory tests and radiology examinations. Follow-up treatment plan designed by medical nursing or other health care professional. The HL7 CDA release 2 has been adopted as the standard for XML document data exchange, encoding and structure. In HL7 Clinical Document Architecture (CDA), CDA release 1 (CDA R1) focused on the structured header, and CDA release 2 (CDA R2) introduced the concept of structured elements within the document body. The body of a CDA document contains one or more sections. Section title represents the human readable label of a section (e.g. heading). Label of a section describes section text which is unstructured data and contains the human readable content of the section [11]. Logical Observation Identifier Names and Codes (LOINC) vocabulary is a organised set of terms or words with associated codes developed for use as clinical observation identifiers in standardised messages exchanged between information systems. LOINC version 2.32 contains 58,967 terms. The clinical portion of the LOINC database covers the major headings of history and physical, discharge summary, and operative note reports [12]. Therefore, we decided to map Finnish national headings to LOINC. Methods The national headings or synonyms were entered term by term to Regenstrief LOINC Mapping Assistant (RELMA). The mapping was made by one author ensuring that the definitions of LOINC components were conceptually consistent with national headings. Furthermore, we selected that type of scale of LOINC was narrative and class type was clinical class. Results Ten (37%) of national headings can be mapped to LOINC. (see Table 1) Table 2. National headings mapped to LOINC codes.
Heading LOINC Component Scale Type Diagnosis 11535-2 Hospital discharge Dx Nar 2 Anamnesis 11329-0 History general Nar 2 Intensity of care 56839-4 Acuity assessment Nar 2 Health status 29545-1 Physical findings Nar 2 Problems 57852-6 Problem list Nar 2 Reason for care 29299-5 Reason for visit Nar 2 Aims for care 61146-7 Goals Nar 2 The information about followup 11544-4 Hospital discharge follow-up Nar 2 treatment Physiological measurements 29545-1 Physical findings Nar 2 Surgical procedures 10223-6 Surgical operation note surgical procedure Nar 2 Part of headings such as Reason for care, Anamnesis, Health status, Diagnosis, Physiological measurements can be mapped to several terms of LOINC. Headings are less specific than the corresponding LOINC term. (see examples in Table 2) For example the heading "Reason for care" can be mapped to three different terms, "Diagnosis" can be mapped to six different terms or "Anamnesis" can be mapped to 57 different terms. Table 3. Example of headings mapped to LOINC Heading LOINC Component Scale Type Reason for care 46239-0 Chief complaint+reason for visit Nar 2 57827-8 Reason for co-payment exemption Nar 2 29299-5 Reason for visit Nar 2 Diagnosis 10219-4 Surgical operation note preoperative Dx Nar 2 10218-6 Surgical operation note postoperative Dx Nar 2 59769-0 Postprocedure diagnosis Nar 2 11535-2 Hospital discharge Dx Nar 2 46241-6 Hospital admission Dx Nar 2 29548-5 Diagnosis Nar 2 Discussion The purpose of this study was to analyze to what extent Finnish national headings can be coded with the current version LOINC terms in "clinical" class. One limitation of this study is the translation of Finnish national headings to English and selection of synonyms for headings by one author. This poses risk of subjective translation and mapping. Based on this study less than half of national headings can be mapped to one or more LOINC terms in "clinical" class. These headings include reason for care, anamnesis, status, follow-up treatment plan and diagnosis which have been noted to be meaningful headings in physician documentation in Finland [5]. Several issues were found when other headings were mapped to LOINC. First, the level of specification between the headings and LOINC concepts is not equivalent and
correspondence terms were not found. Headings "Tests and examinations" and "Nursing interventions" are broader concepts than the closest matching LOINC terms. For example, the LOINC classification includes term "relevant diagnostic tests/ laboratory data". Although, the "relevant diagnostic tests/ laboratory data" does not cover radiology examinations. Correspondence to "Life style" was not found but terms concerning e.g. alcohol use or smoking are included in LOINC although the type of scale is not narrative. Furthermore, history of smoking or history of alcohol use which type of scale are narrative can be found in LOINC. Second, LOINC include also other classes than clinical class namely laboratory "claims attachments" and "surveys". Some of the national headings can mapped to terms in "Claims attachments" and "Surveys" class instead of "clinical" class. In "Claims attachments" class there are terms which correspond to headings "Technical aids", "Nursing diagnosis", "Medical statements", "Consultation" (consultation request) and "Functional status". Each nursing intervention has a corresponding term in "Survey class. Third, LOINC also includes a classification of whether LOINC code can be used for a full document, a section of a document, or both. Some headings namely Medication, "Risk factors", "Assessment end", "Functional status" and "Radiology examinations" match the names of documents in LOINC instead of sections. Finally, some headings are missing in LOINC, namely the Test and assessment results, Rehabilitation, Health examination, "Assessment, intermediate", Preventive measures and Outcomes of care. The purpose of the national headings in Finland is to structure narrative text in a coarse level. Based on this study, the LOINC terms do not cover all national headings of health professionals such as nurses or physiotherapists [8]. In Finland these healthcare professionals document their discharge summaries independently or in some cases related to physicians documentation. The further validation of national headings to LOINC is necessary. The national headings should map to terms of LOINC without presumptions of type of scale or class of LOINC. In future, it is also necessary to find out which information is necessary to structure with headings at all. Some parts of EHR such as medication and risk factors are entirely structured and in these cases the use of headings in narrative text might be unnecessary. References [1] Tange HJ, Hasman A, de Vries Robbe PF, Schouten HC. Medical narratives in electronic medical records. Int.J.Med.Inform. 1997 Aug;46(1):7-29. [2] van Ginneken AM. The computerized patient record: balancing effort and benefit. Int.J.Med.Inf. 2002 Jun;65(2):97-119. [3] Grimson J. Delivering the electronic healthcare record for the 21st century. Int.J.Med.Inf. 2001 Dec;64(2-3):111-127. [4] Meystre SM, Savova GK, Kipper-Schuler KC, Hurdle JF. Extracting information from textual documents in the electronic health record: a review of recent research. Yearb.Med.Inform. 2008:128-144. [5] The standardized data content of national EHR. Guide to implementation of the core data elements, headings, and documents as well as structured data elements of specialties and activities in EHR. Version 3. Finnish. Available from: https://www.kanta.fi/c/document_library/get_file?uuid=46b8b38a- 3488-4c6e-81d2-ae8dcfeaf848&groupId=10206 [6] Häyrinen K, Harno K, Nykänen P. Use of Headings and Classifications by Physicians in Medical Narratives of EHRs -An Evaluation in a Finnish hospital. ( accepted 2011). [7] Åhlfeldt H, Ehnfors M, Ridderstolpe L. Towards a multi-professional patient record--a study of the use of headings. Stud.Health Technol.Inform. 1999;68:813-817.
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