Coding of Electronic Laboratory Reports for Biosurveillance, Selected United States Hospitals, 2011

Abstract

Objective Electronic laboratory reporting has been promoted as a public health priority. The Office of the U.S. National Coordinator for Health Information Technology has endorsed two coding systems: Logical Observation Identifiers Names and Codes (LOINC) for laboratory test orders and Systemized Nomenclature of Medicine-Clinical Terms (SNOMED CT) for test results. Materials and Methods We examined LOINC and SNOMED CT code use in electronic laboratory data reported in 2011 by 63 non-federal hospitals to BioSense electronic syndromic surveillance system. We analyzed the frequencies, characteristics, and code concepts of test orders and results. Results A total of 14,028,774 laboratory test orders or results were reported. No test orders used SNOMED CT codes. To describe test orders, 77% used a LOINC code, 17% had no value, and 6% had a non-informative value, "OTH". Thirty-three percent (33%) of test results had missing or non-informative codes. For test results with at least one informative value, 91.8% had only LOINC codes, 0.7% had only SNOMED codes, and 7.4% had both. Of 108 SNOMED CT codes reported without LOINC codes, 45% could be matched to at least one LOINC code. Conclusion Missing or non-informative codes comprised almost a quarter of laboratory test orders and a third of test results reported to BioSense by non-federal hospitals. Use of LOINC codes for laboratory test results was more common than use of SNOMED CT. Complete and standardized coding could improve the usefulness of laboratory data for public health surveillance and response.

Keywords: Logical Observation Identifiers Names and Codes (LOINC); Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT); biosurveillance; computerized medical record systems; electronic laboratory report.