1. aLOINC Order Code Project: Public Health Test Orders Ruby M. Phelps September 24, 2014 Laboratory Practice Standards Branch Division of Laboratory Programs, Standards, and Services

2. Background  Agreed-upon Logical Observation Identifiers Names and Codes (aLOINC) Code Project  Meaningful use certification requires that laboratories use LOINC® to transmit laboratory results  Currently, non-standardized local codes or terminology are used by laboratories to describe laboratory test orders  The structured format of laboratory tests and orders should provide the ability to incorporate LOINC® terminology for both ordering and reporting lab testing

3. Purpose  Identify and standardize LOINC® codes for public health tests  Develop/create new LOINC® order codes for public health tests/panels identified as missing from LOINC®  Review current panels applicable to public health  Provide recommendations to incorporate into Meaningful Use Stage 3 Certification Criteria  Laboratory orders interface – EHR (Electronic Health Record) must have the ability to transmit lab orders using the lab order and results interface guidelines produced by the S & I Framework Initiative  Receipt of a laboratory test order for some diseases is reportable, as this is considered suspicion of the disease

4. Who Orders a Public Health Test?  Licensed or certified health care providers  Inpatient or Outpatient settings  Laboratories seeking reference or confirmatory testing  Public health laboratories using the services of another state public health laboratory  CDC laboratory services  Perform tests requested by public health laboratories and other federal agencies Specimens from private healthcare providers and institutions must be submitted to the local state health department laboratory for processing prior to CDC submission

5. The Challenge: Test Order Codes – Current Practice  Example: Borrelia burgdorferi Ab * There are ~270 LOINC® codes for Lyme Disease LOINC® (best fit) Lab1 (best fit) Lab2 (best fit) Public Health Lab (ex.) CPT®CDC Lab Code 11006-4*00502162235869203086618CDC-10298 Short Name Borrelia burgdorferi Ab [Presence] in Serum Borrelia burgdorferi Abs, Total by ELISA Lyme Ab, Total/IgM Responses Lyme Disease Serology Lyme Disease Antibody Borrelia Burgdorferi (Lyme disease) Serology

6. Standard Test Order Codes: One Small Step Towards The “Miracle” of Interoperability Reference Lab EHR System Commercial Lab Physician’s Office Clinic/Ambulatory Care Public Health Laboratories Public Health Departments CDC Laboratory CDC Surveillance Systems LIMS Test Order Code Standards for PH Patient Lab 1Lab 2 Lab 3 Data Hub

7. Scope of Review  Focus was on tests for infectious diseases performed by state public health laboratories  Started with test requisitions rather than result codes  Limited  Start with the ~98% that fit a pattern (not the exceptions)  The number of result codes is overwhelming  Exclusions from first round (eventually should be done)  Animal testing  Bird (for WNV)  Blood lead  Drug screen  Environmental  Food  Maternal screening for congenital abnormalities, HCG, AFP, etc.  Metals  Newborn screen  “Standard” laboratory tests offered by some state health depts.

8. Process Step 1 – Test categories used from Reportable Conditions Mapping Table (RCMT) Step 2 – Eight state laboratory test directories and 10 additional state test requisitions matched to list. CPT® codes were included if provided by at least one state. Step 3 – List consolidated, tests named and LOINC® coded if possible

9. Process (continued)  Any test where an organism was defined to the species level as described in the test directory was given its own line  Newer organisms not in the RCMT were added  Taxonomic name of the organism was used rather than the disease for which the test was performed. This was for consistency and to eliminate redundancy  While not exactly in scope a test order name was proposed after creating some naming conventions  A LOINC® order code was proposed if a potential code was available  Unspecified specimen source with some exceptions (serum or stool samples)  Methodless with some exceptions

10. Test Order Name Rules  Used state test requisition forms as a guide for terms most commonly used  Names were created in lower case with capital letters as follows:  The beginning of the name  Proper nouns or locations within the name (e.g., West Nile, Saint Louis, etc)  Acronyms and abbreviations used sparingly and only for accepted usage (e.g., IgG, IgM, DNA, RNA, Ab, Ag, etc.)  Ab before IgG or IgM (e.g., Measles virus Ab IgM)  “Virus” included for all viruses  Organism listed first with a few exceptions  Minimal punctuation for ease in electronic use  No commas or special characters

11. Limitations  Non-laboratorian organized and created this list  Could not always determine if tests were single tests or only available as part of a panel  Method and how results were reported were not always described. This information was helpful in categorizing the tests  Sometimes unclear whether a test was for Ab or Ag  LOINC® codes for organism identification, subtyping and serotyping may not be broad enough to be order codes  LOINC® and SNOMED® result coding was not in scope  Every reportable condition does not necessarily have a test listed in the state public health lab test directory  Rarely performed – “Other”  Relies on clinical diagnosis only

12. Next Steps?  Much more to be done  Is this approach reasonable? Are we on the right track?  Review and vetting of list with public health partners  Need to add tests missed during first phase of review  Determine handling of tests that have reflex testing or may be reflex tests  Provide consensus on test naming conventions and possible LOINC® codes  Incorporate decisions on PH tests with the ambulatory test codes list Some PH testing is also done in non-public health laboratories  Review content of panels  Provide list of tests that can be flagged as “public health” to Regenstrief  Guidance on the best way to implement

13. Future  Publish the list  Sustainability – Identification of who would provide regular review and update of the list  Includes application for new LOINC® codes

14. The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Laboratory Practice Standards Branch Division of Laboratory Programs, Standards, and Services Thank you!