Background

The Centers for Medicare & Medicaid Services (CMS) is providing incentive payments to health care providers who adopt certified electronic health record technology and use it to demonstrate meaningful use of that technology. The CMS incentive program is being implemented in several stages or phases. Stage 2 criteria for meaningful use focuses on the electronic capturing of health information, including laboratory test results, in a structured format. The structured format for laboratory tests and orders allows the ability to incorporate LOINC (Logical Observation Identifiers Names and Codes) terminology for ordering and reporting laboratory testing. Because of meaningful use certification requirements, laboratories are required to use LOINC terminology in the electronic transmission of laboratory results. However, at this time, laboratories are not required to adopt any standardized vocabulary for the electronic ordering of laboratory tests.

The use of non-standardized local codes or terminology to describe laboratory test orders varies widely among laboratories. Universal use of LOINC coding for laboratory order and result information in a structured and systematic fashion is an essential component of interoperability between providers, clinical laboratories and public health laboratories.

This project focused on the enhancement and expansion of the standardized list of Logical Observation Identifiers Names and Codes (LOINC) Codes for the Most Commonly Ordered Laboratory Tests in ambulatory care settings (Common Order Codes Value Set) that is published by Regenstrief Institute (www.loinc.org).