A proposal for interoperable health information exchange with two Esperantos: ICF and

LOINC®originally presented at:

Daniel J. Vreeman, PT, DPT, MScAssistant Research Professor, Indiana University School of MedicineAssociate Director of Terminology Services, Regenstrief Institute, Inc

Clinical LOINC Meeting 07/2010 Copyright © 2010

Quick Refresher on ICFA Brief Introduction

LOINC/ICF ModelingTimeline

• Jan 2005 – ICF/LOINC first discussed• Dec 2006 – 2-day workgroup meeting• Dec 2006 – Preparation of exemplar LOINC

modeling for each ICF component• Jan 2007 – Presentation, discussion,

refinement of draft at Clinical LOINC Committee Meeting

• July 2007 – ICF Conference• June 2009 – Renewed interest from NCHS• June 2010 – Presentation at ICF

Conference

What is ICF?• Classification of health and health-related

domains• Newest member of WHO Family of International

Classifications (ICF, ICHI, etc)• Classified from body, individual, and societal

perspectives– List of body functions and structures– List of domains of activity and participation

• Puts disability in a new light – common experience

• Can express both enabling and limiting factors

• World Health Organziation. ICF Introduction. Available at: http://www.who.int/classifications/icf/

ICF 101Components

Body FunctionsBody Functions&&

StructuresStructures

Activities Activities & &

ParticipatioParticipationn

EnvironmentEnvironmental Factorsal Factors

BarriersBarriers

FacilitatorsFacilitators

Functions Functions

Structures Structures

CapacityCapacity

PerformancePerformance

ICF 101Interaction of Components

Health Condition Health Condition (disorder/disease)(disorder/disease)

Environmental Environmental FactorsFactors

Personal Personal FactorsFactors

Body Body function&structurefunction&structure

(Impairment)(Impairment)

ActivitiesActivities(Limitation)(Limitation)

ParticipationParticipation(Restriction)(Restriction)

Qualifiers• Measures assigned after the

component category code• Placed after the decimal• Denote the magnitude of the level of

health (e.g. severity of the problem)• Without qualifiers, an ICF code has

no inherent meaning• Can have up to 4 kinds of qualifiers

per item (optional)

Generic Qualifier Scale

Even More Possible Qualifiers

Even More Possible Qualifiers

Activities/Participation Domain

A Proposal for Effective use of ICF and LOINCMaking complementary strengths productive

General Observations• No computer-interpretable version of ICF• Links with other vocabularies (UMLS,

SNOMED) don’t address qualified codes• Several ICF item collections

– Full version, short version, ICF-CY, ICF core sets, more…

• Challenge: ICF classification blends several observation question/answer pairs into 1 code– d410.1302 (changing basic body position) is

really 4 “observations”

Goals• Send a person (or population)’s ICF

classification using same machinery as other health data– To reach ICF’s goals, you need to share data

• Maximize strengths of each terminology (minimize duplication of effort)

• Be informed by real world use – Need some interested parties!

• Facilitate addressing challenges in ICF use– Relationship to standardized assessments and

clinical measures

Original Option 1• Simplest Approach: One LOINC code

– NNNN-N:Functioning Classification:Imp:^Patient:Pt:Ord:ICF

– Expected “answer” in OBX-5 would be a ICF classification

• Problems with Simplest Approach– Still have blending of question/answer in OBX-5– No indications of sets

Original Option 2• Full LOINC Modeling including panels

for ICF Sets• Example: d420 – Transferring oneself

– N-N:Transferring oneself.Performance:Imp:^Patient:Pt:Ord:ICF

– N-N:Transferring oneself.Capacity:Imp:^Patient:Pt:Ord:ICF

– Expected “answers” in OBX-5 would be the ICF qualifiers0 – No setup or physical help from staff

1 – Setup help only

2 – One person physical assist

3 – Two+ person physical assist

8 – ADL activity itself did not occur during entire 7 days

Original Option 2• Problems with this approach

– Labor intensive• Each ICF component + qualifier combination

would be a different LOINC code (assessing different attributes)

• Keeping up with sets would be very difficult

– Some modeling challenges (e.g. anatomy)

– Negotiating IP issues

New Inspiration

Clinical Genomics Model

Further Inspiration

HL7 CDA Framework for Questionnaire Assessments

• Specifies a document package representing the full assessment “form”

• For each observation/answer, enables concurrent transmission of:– Model of Use (LOINC)

• Exact measurement, as on the assessment

– Model of Meaning (SNOMED, ICF) [optional]• Representation of the conceptual assertion in another

(standard) terminology/classification

– Supporting Clinical Observations (LOINC, SNOMED) [optional]

• Data from the EHR that supports the assessment decision

Proposed ICF Result Package in LOINC

ICF classification panelICF collection, population descriptor, observation time period, other descriptors of the observation period

ICF classification panelICF collection, population descriptor, observation time period, other descriptors of the observation period

ICF classification results panelICF component, any applicable qualifiers, fully-qualified ICF item

ICF classification results panelICF component, any applicable qualifiers, fully-qualified ICF item

ICF supporting clinical observations panelAny supporting clinical measurements for that ICF

classification (direct measures, assessment scores, etc)

ICF supporting clinical observations panelAny supporting clinical measurements for that ICF

classification (direct measures, assessment scores, etc)

1 to many

0 to many

Example ICF Result Package in LOINC

R/O/C Example Answers

NN-N ICF classification panel

NN-N ICF classification collection R Full

NN-N Population description O Clinic population >65 years

NN-N Duration of observation period O Point in time

NN-N ICF classification results panel R

NN-N ICF code stem R d450

NN-N ICF functioning classification O d450.12

NN-N Activities and participation performance qualifier C 1 – MILD difficulty

NN-N Activities and participation capacity without assistance qualifier

C 2 – MODERATE difficulty

NN-N ICF supporting clinical observations panel O

59460-6 Morse Fall Risk Total 55

4195703 Mean walking speed 24H 0.9 m/sec

1 to N

0 to N

Benefits of Nested Model• Uses HL7-LOINC messaging framework while

minimizing redundant modeling• Accommodates ‘meta-data’ about the result

package• Flexes to accommodate large or small sets of ICF

codes• Enables explicit connection between ICF

classification and supporting clinical data• Accommodates sending alternate identifiers (e.g.

UMLS or SNOMED) for ICF components• Could also use the ICF classification result panel in

another context– nested under a regular clinical observation to convey the

higher level interpretation of that result

Next Steps• Looking for collaborators with live

systems that have a need to exchange ICF classifications electronically– And want to used established messaging

standards

• Comments/Suggestions from LOINC Committee