What type of data is considered ‘lab data’?

Lab data consists of any type of clinical information gleaned from testing a sample of something collected from the body, like blood or saliva. Examples of common lab tests include complete blood count (CBC), lipid panels, and metabolic panels.

Where is this data collected and stored?

Typically, the results from these tests are stored electronically within a patient’s electronic health record (EHR). Lab data may also be stored in databases used for clinical research.

Who uses lab data?

Primarily, clinicians use the results of clinical laboratory tests to learn more about a patient’s health status and to inform clinical decision making. However, lab data can have a host of secondary uses. Organizations such as Health Information Exchanges (HIEs), Life Science and Clinical Data Repositories (CDRs), and Integrated Delivery Networks (IDNs) often rely on aggregated lab data to complete work for population health initiatives, medical research, public health reporting, and clinical documentation improvement.

What is the standard language for lab coding?

While standardized code systems like SNOMED CT® and Current Procedural Terminology (CPT®) include laboratory procedure codes within their manuals, LOINC® – which stands for Logical Observation Identifiers Names and Codes – is a standardized coding system specifically focused on allowing lab data to be transferred between systems, improving interoperability in healthcare.

Who uses lab codes?

Healthcare providers, insurance companies, researchers, health IT software developers, and many other organizations use LOINC codes to share clinical lab data.

What happens when LOINC isn’t used?

Organizations who don’t use LOINC or other standardized code systems when sharing lab information with other entities often rely on local codes or shorthand instead. This means their clinical documentation isn’t adopted throughout the industry, as these local codes are non-standard abbreviations of the lab test name and do not encompass all the information that is included in a LOINC code.

What are some of the key challenges with how lab data is documented?

The key challenges all stem from the same core issue – a lack of widespread adoption of a standardized lab code system like LOINC to document clinical lab tests. Because of this, interoperability in healthcare can quickly become a challenge. Staff must spend extra time and resources to standardize data from different sources that are in different formats. Without healthcare data standardization, endeavors like reporting lab results to public health departments or performing clinical research are stymied.

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