AMIA 2017 Annual Symposium | Washington DC, USA

The LOINC/RSNA Radiology Playbook

A unified terminology for radiology procedures

Daniel J. Vreeman, PT, DPT, MS

Regenstrief-McDonald Scholar in Data Standards
Indiana University School of Medicine

Director, LOINC and Health Data Standards

@djvreeman Regenstrief Center for Biomedical Informatics

2017
Acknowledgements
Kenneth C. Wang, MD, PhD3,4
Chris Carr5
Beverly Collins, PhD5
Swapna Abhyankar, MD1
Jamalynne Deckard, MS1
Clement J. McDonald, MD6
Daniel Rubin, MD, MS7,8
Curtis P. Langlotz, MD, PhD7

1. Regenstrief Institute, Inc, Indianapolis, IN

2. Indiana University School of Medicine, Indianapolis, IN;
3. VA Maryland Health Care System, Baltimore, MD;
4. University of Maryland School of Medicine, Baltimore, MD;
5. Radiological Society of North America, Chicago, Illinois;
6. National Library of Medicine, National Institutes of Health, Bethesda, Maryland;
7. Department of Radiology Stanford University, Stanford, California
8. Department of Biomedical Data Science Stanford University, Stanford, California

Funding sources
National Institutes of Health (HHSN268201500247A, HHSN276201400239P), U.S. Department of
Defense, and the Regenstrief Foundation for funding support.
Disclosure
Im the author of the book LOINC Essentials published by
Blue Sky Premise, LLC where I serve as President. Also
have some consultant activities related to LOINC.

PI on a contract from bioMrieux for LOINC content

 An uncommon
standards story
Two SDOs joining paths to unify their
terminologies and produce a single standard
 Variation Abounds
CODE NAME
HEADW CT HEAD W/CONTRAST
11884 Head CT with Contrast
CT1005 CT Brain W
OCT003 CT BRAIN/HEAD W/C
CTHEAD CT HEAD WITH
25284D CT Head with IV Contrast
CTHW Head W Contrast
3332251 CT HEAD W/Contrast
CTH2203 CT HEAD W/C
99234 HEAD CT W/Contr
A114 CT Brain/Head W Cont IV
ZCT9992 Head CT WC IV
CTHC332 CT Head W C
POBPD CT Head w Cont (70460)
Problems
Idiosyncratic local terms MO DATA MO PROBLEMS

hinder all kinds of important

goals like data sharing,
aggregation, decision
support, registry reporting,
quality initiatives, etc.
Only way to overcome these problems is
with data standards
Universal standard for measurements, observations
and documents

Used in more than 170 countries

Radiology content added in 2000, now with 5,000+

procedure codes

Terms are assigned a code and structured, pre-

coordinated name based on attributes called Parts
Developed by RSNA as a component of RadLex

Launched in 2011 as standard for radiology

procedures

Contained ~1,000 codes in Core Playbook

Grammar and set of pre-coordinated codes

(RPIDs) with attributes from RadLex (RIDs)
 LOINC/RSNA
Radiology Playbook
Initiated in 2013 as a jointly developed,
unified source of names and codes for
radiology procedures
 Main Ideas
Join Regenstriefs globally recognized terminology
experience with RSNAs preeminent domain
expertise

Unify, dont just do mappings (eternal work)

LOINC codes would serve as the primary identifiers

for procedures in the unified terminology

Distribute the standard at no cost worldwide

 Main Deliverables
A Unified Model for Radiology Procedure Names

Transform existing LOINC terms into the unified model

Mapping between RadLex RPIDs and LOINC codes

Creating new LOINC codes where needed

Mapping of attribute-values between each terminology (i.e.

LOINC Parts to RadLex RIDs)

Publish the artifacts for the world to use

Develop a single integrated governance process

Results of the
Collaboration
Phase 1 (2013 to 2015)
Created the unified model

Agreed on a model for collaborative governance

Implemented the model and mappings for all CT terms

Designed the release artifacts

Published first release and Users Guide in Dec 2015

Phase 2 ( 2015 to 2017)
late

Expanded the modeling and mapping for all modalities

Iteratively improved the model and its application

Current version (June 2017) includes 5,500+ terms

Transitioning into an ongoing, sustained activity jointly

maintained and governed by the two organizations,
with oversight by the new LOINC/RadLex Committee
 Unified Model
Complete Attribute Set

Modality Maneuver

Radiology Procedure
Modality.Modality Type
Modality.Modality Subtype
Maneuver.Maneuver Type
Pharmaceutical
Anatomy
Naming Model
Anatomic Location.Region Imaged
Pharmaceutical.Substance Given
Pharmaceutical.Route
First some general
Anatomic Location.Imaging Focus principles
Reason for Exam
Anatomic Guidance
Location.Laterality.Presence Guidance for.Presence
Anatomic Location.Laterality Guidance for.Approach
View Guidance for.Action
View.Aggregation Guidance for.Object
View.View type Subject
Timing
LOINC Users Guide
https://loinc.org/downloads/loinc/
 Unified Model
Complete Attribute Set

Modality Maneuver
Modality.Modality Type Maneuver.Maneuver Type
Modality.Modality Subtype Pharmaceutical
Anatomy Pharmaceutical.Substance Given
Anatomic Location.Region Imaged Pharmaceutical.Route
Anatomic Location.Imaging Focus Reason for Exam
Anatomic Guidance
Location.Laterality.Presence Guidance for.Presence
Anatomic Location.Laterality Guidance for.Approach
View Guidance for.Action
View.Aggregation Guidance for.Object
View.View type Subject
Timing
 Anatomy of a LOINC Term
37842-2:View AP:Find:Pt:Upper extremity>Shoulder:Doc:XR

37842-2 LOINC Code

View AP Component
Find Property Measured
Pt Timing

Upper extremity>Shoulder System

Doc Scale

XR Method

Six major LOINC axes

 View
Component 1st Subpart

<view descriptor> [<view aggregation>] [<view type>]

Views descriptor Views, Multisection,

View aggregation 3, greater than 3
View type AP, lateral
 Timing/Existence
Component 2nd Subpart

Used in conjunction with both the

Pharmaceutical and Maneuver
attributes (stay tuned)

Example values
W, WO & W, WO
 Pharmaceutical
Component 2nd Subpart

<timing/existence> <substance given> <route>

Substance given contrast, adenosine,

Tc-99m Sestamibi

Route IV, PO, etc

 Maneuver
Component 2nd Subpart

<timing/existence> <maneuver>

Maneuvers relate to a challenge presented to a patient, often with

the goal of elucidating or testing some dynamic aspect of anatomy
or physiology. Maneuvers often carry an implication of patient
exertion (e.g. Valsalva maneuver), although some maneuvers do
not involve patient exertion (e.g. pharmacologic cardiac stress).

Example values
flexion, extension, standing, inspiration, etc
 Anatomic Location
System

<region imaged> > <imaging focus>

Region imaged is used in two ways. First, as a coarse-

grained descriptor of the area imaged and a grouper for
finding related imaging exams; or, it is used just as a grouper.
Values drawn from a constrained list (11 regions now).

Imaging focus is defined as a more fine grained descriptor of

the specific target structure of an imaging exam. In many
areas, the focus should be a specific organ.
A tiny sample of
LOINC/RSNA
names and
attribute values
Radiology Procedure Terms
> 5500 active terms in v2.61

Modality Terms (#)

CT 807
MG 158
MR 871
NM 529
US 505
XR 1953
RF 681
 CT Abdomen and Pelvis W contrast IV

PartName PartType
Rad.Modality.Modality type CT

Rad.Pharmaceutical.Substance Given Contrast

Rad.Timing W

Rad.Pharmaceutical.Route IV

Rad.Anatomic Location.Region Imaged Abdomen

Rad.Anatomic Location.Region Imaged Pelvis

 XR Ankle - right AP and lateral

PartName PartType
Rad.Modality.Modality type XR
Rad.Timing W
Rad.Maneuver.Maneuver type Stress
Rad.View.Aggregation Views
Rad.View.View type AP
Rad.View.View type Lateral
Rad.Anatomic Location.Region Imaged Lower extremity
Rad.Anatomic Location.Laterality.Presence TRUE
Rad.Anatomic Location.Imaging Focus Ankle
Rad.Anatomic Location.Laterality Right
LOINC/RSNA Radiology
Playbook File
The main distribution of this joint work
 Version 2.61 (June 2017)
5,500+ LOINC terms (all in main LOINC file, special
representation in the LOINC/RSNA Radiology Playbook File)

Over 37,000 attribute value relationships linking more than 830

LOINC Parts to RadLex clinical terms.

766 LOINC terms are mapped to unique RPID concepts

Version 2.61 had completed modeling for all modalities

For December 2017, last remaining content will be included:

modality-agnostic interventional procedures
 CT Abdomen and Pelvis W contrast IV
LOINCLongC PartSeq
LOINC PartNumber PartName PartType RID PreferredName RPID LongName
ommonName Order

CT Abdomen and
CT Abdomen/Pelvis
36813-4 Pelvis W contrast LP200067-9 Rad.Modality.Modality type CT A RID10321 computed tomography RPID145
w IV Contrast
IV

CT Abdomen and
Rad.Pharmaceutical.Substanc CT Abdomen/Pelvis
36813-4 Pelvis W contrast LP200085-1 Contrast A RID11582 Contrast agent RPID145
e Given w IV Contrast
IV

CT Abdomen and
CT Abdomen/Pelvis
36813-4 Pelvis W contrast LP200088-5 Rad.Timing W A RID49853 W RPID145
w IV Contrast
IV

CT Abdomen and
CT Abdomen/Pelvis
36813-4 Pelvis W contrast LP200078-6 Rad.Pharmaceutical.Route IV A RID11160 intravenous RPID145
w IV Contrast
IV

CT Abdomen and
Rad.Anatomic CT Abdomen/Pelvis
36813-4 Pelvis W contrast LP199956-6 Abdomen A.A RID56 Abdomen RPID145
Location.Region Imaged w IV Contrast
IV

CT Abdomen and
Rad.Anatomic CT Abdomen/Pelvis
36813-4 Pelvis W contrast LP199998-8 Pelvis A.B RID2507 Pelvis RPID145
Location.Region Imaged w IV Contrast
IV
search.loinc.org
 Wrap up

photo via National Museum of Health and Medicine | cc-by

The Regenstrief Institute and the RSNA have
created a unified terminology standard for
radiology procedures that builds on the
strengths of LOINC and the RadLex Playbook.

Use it!
(as required in HL7s C-CDA, recommended in ONCs ISA)

Attributes can be exploited for many purposes

If you find gaps, request new content at:

https://loinc.org/submissions/new-terms/
Smile!

photo via Karen Roe