(Editor's note: this is the first part of a three-part series on LOINC, SMOMED, and ICD-10. Check back in the coming weeks for parts 2 and 3.)
When I became a laboratorian I thought the only thing I had to worry about was quality, accuracy and turnaround time. Not long after stepping into the workplace, I learned there was a whole different side to laboratory medicine. The flying monkeys of ICD-9, DRGs and CPTs ran the world of medical coding to ensure you were reimbursed for all the quality, accuracy and timely work we call testing.
A few decades have passed since I was that naive tech and not much has changed. There's still a whole different world within the lab. It is the world of medical coding, driven by the Federal Government's ARRA HITECH Act and the recently passed Affordable Care Act (ACA). Now that the tornado that is ARRA/ACA has dropped us in a new world, it's important to know the friends who will help us navigate our way home to reimbursement. Their names are LOINC, SMOMED, and ICD-10.
With the ARRA Stage 1 adoption period in full swing, many laboratorians have been struggling to find time to do patient centric work and code all their testing. The Stage 1 criteria for enhanced reimbursement requires that an organization be able to electronically send and receive lab data in a meaningful way with another organization not sharing the same health information system.
To accomplish this, most lab tests must be LOINC coded. What is LOINC and why use it? That answer could be provided in a long technical way, or in a short meaningful way. The short answer is LOINC is a decoder ring for all health information exchange (HIE) systems that allows them to receive information and share it so it is the same on both ends. The focus is to ensure that when you share a 24-hour Creatinine Clearance that the urine and serum creatinine values, the urine volume, time collected, and clearance results all appear and contain the same units of measure.
Why do we need a terminology server to accomplish this? Think about the computer world. Inside the matrix everything is based on 1s and 0s. The LOINC code defines the sequence of 1s and 0s for the method, specimen, time or type of collection and units of measure that give meaning to the actual result. After all, if a provider in New York was receiving a Creatinine Clearance result from California, would she understand the meaning of "341"? Or would this make more sense; "Creatinine Clearance 341 mg/24 hours?"
Coding 5,000 Tests
Knowing what LOINC is and why it is needed is only a small part of the task. When I undertook coding my organization's lab test dictionaries, they consisted of Microbiology, Anatomic Pathology, Blood Bank, and General Lab; approximately 5,000 tests. At the time, very few people had even read about LOINC and ARRA HITECH's Stage 1 adoption in the USA. So like Dorothy, I was on a lonely road filled with strange and scary things. Luckily, there were a couple companions who helped me on my journey; the LOINC coder for my reference lab ARUP and some highly experienced colleagues at Europe's BITAC MAP SL. With their input and guidance, I learned enough to get the project done. But the real question you are asking right now is what did it take to get it done?
To code my 5,000 tests the following steps needed to occur. First, I exported all my tests into an Excel spreadsheet to capture their name, method, units of measure, collection method or time, specimen type and performance location. Once I had a comprehensive list, I began contacting my reference labs for a copy of their LOINC list. After all, if I was not performing the test or receiving reimbursement for it, why should I need to code it? Lucky for me, I am an ARUP customer as ARUP was part of the initial group that tested the process in the USA.
Now it was time to set about coding my tests using the online LOINC "calculator." It is quite simple. Like doing a Google search, you enter your analyte and click "Search." A list of potential options appears for review to find the right fit. LOINC, the simple trustworthy scarecrow, became my initial companion. Like the scarecrow, LOINC has limits. The most difficult part of this process is what happens when it does not work or when you find the limit.
Why wouldn't the calculator work? There are a few answers. As lab testing is always changing, all of our menus are living documents in continual need of revision. So tests may be too new to be in the LOINC terminology server yet. So like a garden, there is the need to tend to your list regularly for new and revised codes.
Another reason is the common name is not listed, while the scientific name is. For example, my Vitamin D method was listed as "Calcidiol + Calciferol." Lastly, there is not a LOINC code for the result. This is the case in many microbiology exams where an organism identification result is based on a biogram and not a DNA PCR exam. What then? There is the choice of LOINC coding a "Gram Negative Organism identified" or offering more complete clinical information by listing the organism itself. To list the organism, I learned I would have to switch terminology services to SNOMED CT. SNOMED, as it is commonly referred to, is a similar decoder ring for different types on information and for discussion another time. It looks complicated, doesn't it? It is.
Back to the question about the amount of time to code each test; the average was 3 minutes. Just to code each test took two 250 hours over the course of one year. Luckily for my organization, I was the point of care coordinator and informatics analyst at the time and could split my time to address this project. However, coding the test dictionary into an Excel spreadsheet is only half the journey. The LOINC codes can only perform their role when added to the information system at the LIS or EMR level.
To accomplish this, some systems may offer a fee for service to import the information. I was not so fortunate. As there was no import option, each test had to be opened and revised in the system by manually adding the code. Like the coding, this is no small labor. For 3 weeks, I literally did nothing except revise tests. Only then was I prepared to perform a test and attest to my organization's Stage 1 Adoption Committee that the task was complete and compliant.
Human Resource Capital
So what did it take? Approximately 50 hours of education, 250 hours of coding, and 120 hours of test revision, or a grand total of 420 hours of highly skilled, technical time. In a budgetary light this is approximately $17,000 in human resource capital (based on the average Scientist wage). Broken down, that is approximately $3.36 per test.
What have I learned and what I would do differently? Since completing the initial coding almost 2 years ago, many consultants and service companies have entered the USA market place. If there had been adequate data to project the cost to complete the LOINC and SNOMED CT coding for my organization's laboratory services and service providers to contract the task to, I would have recommended outsourcing the project. While I learned that I enjoyed the challenge of figuring out the puzzle to obtain the correct LOINC or SNOMED code, it was frustrating to try to wedge time to concentrate on this task into a very full plate. Like Dorothy, at the end of the journey, I had some new friends, interesting memories, and got to peek behind the curtain into a world most scientists would rather avoid.
Since the draft of this article and completion of her LOINC/SNOMED CT coding project, Ms. Baker has joined BITAC MAP SL as the Head of USA Business Development in addition to her duties as the Laboratory Operations Manager of St Peter's Hospital in Helena, Montana, and her other professional activities. She did so out of a desire to share with others the alternatives to struggling through this process alone.