Assistance creating a value set for all LOINC procedure concepts

General
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I’m reaching out to this community for suggestions on creating a value set of any LOINC concept representing a procedure.

I suspect this can be done either via inclusion (class = ?), or exclusion (document ontology, panels, parts, answer lists), but would like to hear input from anyone who has tried something like this.

For context - this is under discussion at HL7 for the US Realm IGs - see https://jira.hl7.org/browse/FHIR-54415
Thanks.

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Welcome to the LOINC forum, @ccouderc

To address your question, it depends on your operational definition of “procedure.” (Thanks also for the jira.) Typically “procedures” such as noted in USCDI Procedure class would be mapped to SCT Procedure hierarchy codes.

However, many refer to lab orders, radiology orders, pulmonary function tests (PFTs) as “procedures.” It might be good to delineate by the types.

For example, while some refer to lab orders as procedures (perhaps due to US billing CPT codes or because SNOMED includes them in the procedure hierarchy), in the US and many countries they would be mapped to LOINCs. It’d be expected that these would be LOINC Type = 1, and for orders, OrdObs would be Order or Both (but not Observation only LOINCs). For lab test results, these are also mainly LOINC Type=1, where OrdObs= Both or Observation only LOINCs (Should not include Order only LOINCs).

There are also similar considerations for radiology.

It would be helpful to understand which domain areas are of interest and what you consider to be procedures.

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fyi. I added more comments in the FHIR jira linked above on LOINC Types, the document ontology, etc. and for other content areas. “Procedure” occurs in 392 LOINCs in v 2.82 across Type=1, 2, and 4. Also listed LOINC Committee chairs for some of these “domain” areas.

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Hi Andrea. The content logical definition for the value set named US Core Procedure Codes includes an expression to include all of LOINC. This value set is bound in the general US Core Procedure profile so the context is very broad and covers any procedure. USCDI defines procedure as Activity performed for or on a patient as part of the provision of care. USCDI doesn’t list LOINC as an applicable vocabulary standard, and if its not appropriate, perhaps it should be removed from the content logical definition.

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I thnk this is stil a good topic to figure out, but for the specific use case you are asking I think LOINC should hjust be removed from the value set, because it is not listed for that USCDI element this FHIR resource is intended to represent.

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Hi All,

From a USCDI perspective, the confusion appears to come in during the transition from V4 to V5. In USCDI V4, there was no “Order” category so the most logical way to think of laboratory orders from a functional perspective was to place them under the USCDI procedure category.

In USCDI version 5, the “Order” category was added with the definition of “Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care.” with specific entries in the category to address Laboratory Order, Diagnostic Imaging order, clinical testing and “Procedure Order”.

The inclusion of “procedure Order” is propagated through USCDI V6 and Draft V7, even though it appears to be duplicate content given the presence of the “Procedure” topic in the “Procedure” category.

Given this history, I would agree with Riki and Andrea and suggest the following:

  • ASTP/ONC may want to consider removing “Procedure Order” from the Order category for USCDI V6 and Draft V7 OR enhance the definition to differentiate it from the “Procedure” item in the Procedures category.
  • Remove LOINC as an applicable terminology from the value sets or terminology definition for a “Procedure” because laboratory, radiology, and other clinical tests have already been defined by USCDI as services and addressed under the “Orders” category.

In lieu of better terminology, I am using the term category to represent each boxed topic on the USCDI pages.

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Thanks Carmela for sharing your operational definition. Given this is US Core, would exclude LOINC from Procedures. The issue as John points out is it depends on the USCDI version. The Order Class isn’t yet requried so folks are currently using Procedure Class, and coding for many of the orders delineated in the USCDI Order Class. There’s also a distinction between orders and procedures (I’m ordering XYZ versus a XYZ procedure was performed). Sometimes the procedure is dual purpose too. A colonocopy may spawn a procedure for a Polypectomy to collect a polyp seen. Expect the Polypectomy to be mapped to the SCT Procedure hierarchy code. Not only does it indicate it was done, it is also used as the specimen collection procedure for the Polyp Specimen sent to pathology with a Surgical Pathology order (which would have a LOINC code). In FHIR, the Specimen Collection procedure/method would be indicated on the FHIR Specimen Resource too.

Agree that LOINC may need to be removed from the content logical definition, especially if all needed Procedure Codes are in the Procedure hierarchy. If any gaps/missing items, they could be requested.

From responses, we are also seeing different understandings of what a procedure is and is not. Some may think it includes orders and others do not (hence the Order Class). There was a similar discussion on the cross call from vendors as to what constitutes a “test” with similar delineations of lab test orders and lab test results versus clinical test (non lab, non radiology). These details are very helpful for vendors, developers, and users to ensure they are using the same element the same way, encoding with the correct terminology, populating the correct fields/Resources in HL7 for exchanges and those receiving. Having crisp definitions, examples, details are helpful to ensure quality implementations and usage.

John brings up the issue with waht folks are doing currently (to meet requirements) and what is needed in the future. When Order Class content is required, it would be good to add information recognizing some may have been using Procedure Class content and encoding for orders and there may need to switch to the requirements in the Orders Class. (Some vendors may not wish to invest in the development to do so. Will there be any consequences if they do not and continue to “interpret’ the content as Procedure class?) Asking as seeing 3 different FHIR Resources used for a lab test order, and 3 for lab test result based on different “interpretations” by different entities.

Thanks for asking as it helps to ensure we are unambiguous in terms/meaning and avoid cross talk or other issues!

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