LOINC® Codes for Hospital Information Systems Documents: A Case Study
- aDepartment of Medical Informatics and Biomathematics, University of Münster, Münster, Germany
- bGerman Institute of Medical Documentation and Information, Cologne, Germany
- cIT Center, University Hospital of Münster, Münster, Germany
- dDirector International Affiliates, HL7
- Correspondence: Martin Dugas, MD, MSc, Department of Medical Informatics and Biomathematics, University of Münster, Germany, Domagkstr 9; D-48149 Münster; Germany; e-mail: <dugas{at}uni-muenster.de>
- Received 4 June 2008
- Accepted 6 January 2009
Abstract
Hospital Information Systems (HIS) handle a large number of different types of documents. Exchange and analysis of data from different HIS is facilitated by the use of standardized codes to identify document types. HL7's Clinical Document Architecture (CDA) uses LOINC (logical observation identifiers names and Codes) codes for clinical documents. The authors assessed the coverage of LOINC codes for document types in a German HIS. The authors analyzed document types that occurred more than 10 times in approximately 1.3 million documents in a commercial HIS at a major German University Hospital. Document types were mapped manually to LOINC using the Regenstrief LOINC Mapping Assistant (RELMA). Each document type was coded by two physicians. In case of discrepancies a third expert was consulted to reach consensus. For 76 of 86 document categories a LOINC code was identified, but for 38 of these categories, the LOINC code was not specific as deemed necessary. More than 93% of our local HIS documents had local document types that could be assigned a LOINC code.
Footnotes
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Prof. Dr. Martin Dugas is supported by the European Leukemia Network (funded by the 6th Framework Program of the European Community). Dr. Matthias Lange and Markus Eckholt provided HIS reports. MD designed research, analyzed data and wrote the manuscript. ST, TF, and KH designed research, analyzed data, and reviewed the manuscript. The authors declare that they have no competing interests.
