A proposal for interoperable health
information exchange with two
Esperantos: ICF and LOINC®
originally presented at:
Daniel J. Vreeman, PT, DPT, MSc
Assistant Research Professor, Indiana University School of Medicine
Associate Director of Terminology Services, Regenstrief Institute, Inc
Clinical LOINC Meeting 07/2010
Copyright © 2010
Quick Refresher on ICF
A Brief Introduction
LOINC/ICF Modeling
Timeline
• 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 101
Components
Body Functions
&
Structures
Activities
&
Participation
Environmental
Factors
Functions
Capacity
Barriers
Structures
Performance
Facilitators
ICF 101
Interaction of Components
Health Condition
(disorder/disease)
Body
function&structure
(Impairment)
Activities
(Limitation)
Environmental
Factors
Participation
(Restriction)
Personal
Factors
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 LOINC
Making 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 qualifiers
0 – 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 panel
ICF collection, population descriptor, observation time period, other descriptors
of the observation period
1 to many
ICF classification results panel
ICF component, any applicable qualifiers, fully-qualified ICF item
0 to many
ICF supporting clinical observations panel
Any supporting clinical measurements for that ICF
classification (direct measures, assessment scores, etc)
Example ICF Result Package in LOINC
NN-N
1 to N
R/O/
C
Example Answers
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
0 to N
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
NN-N
ICF supporting clinical observations panel
59460-6
Morse Fall Risk Total
4195703 Mean walking speed 24H
C
2 – MODERATE difficulty
O
55
0.9 m/sec
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