Ranallo Piper A, Adam Terrence J, Nelson Katherine J, Krueger Robert F, LaVenture Martin, Chute Christopher G
Institute for Health Informatics, University of Minnesota, Minneapolis, MN;
Institute for Health Informatics, University of Minnesota, Minneapolis, MN; ; College of Pharmacy, University of Minnesota, Minneapolis, MN;
AMIA Annu Symp Proc. 2013 Nov 16;2013:1333-40. eCollection 2013.
Psychometric instruments, inventories, surveys, and questionnaires are widely accepted tools in the field of behavioral health. They are used extensively in primary and clinical research, patient care, quality measurement, and payor oversight. To accurately capture and communicate instrument-related activities and results in electronic systems, existing healthcare standards must be capable of representing the full range of psychometric instruments used in research and clinical care. Several terminologies and controlled vocabularies contain representations of psychological instruments. While a handful of studies have assessed the representational adequacy of terminologies in this domain, no study to date has assessed content coverage. The current study was designed to fill this gap. Using a sample of 63 commonly used instruments, we found no concept in any of the three terminologies evaluated for more than half of all instruments. Of the three terminologies studied, SNOMED CT (Standard Nomenclature of Medicine - Clinical Terms) had the greatest breadth, but least granular coverage of all systems. While SNOMED CT contained concepts for over one third (36%) of the instrument classes in this sample, only 11% of the actual instruments were represented in SNOMED CT. LOINC (Logical Observation Identifiers, Names, and Codes), on the other hand, was able to represent instruments with the greatest level of granularity of the three terminologies. However, LOINC had the poorest coverage, covering fewer than 8% of the instruments in our sample. Given that instruments selected for this study were selected on the basis of their status as gold standard measures for conditions most likely to present in clinical settings, we believe these results overestimate the actual coverage provided by these terminologies. The results of this study demonstrate significant gaps in existing healthcare terminologies vis-à-vis psychological instruments and instrument-related procedures. Based on these findings, we recommend that systematic efforts be made to enhance standard healthcare terminologies to provide better coverage of this domain.
心理测量工具、量表、调查和问卷是行为健康领域广泛接受的工具。它们在初级和临床研究、患者护理、质量测量和付款方监督中被广泛使用。为了在电子系统中准确捕获和传达与工具相关的活动及结果，现有的医疗保健标准必须能够表示研究和临床护理中使用的所有心理测量工具。有几种术语表和受控词汇表包含心理工具的表示。虽然少数研究评估了该领域术语表的表示充分性，但迄今为止尚无研究评估内容覆盖范围。本研究旨在填补这一空白。通过对63种常用工具的抽样，我们发现，在所评估的三种术语表中，没有一个术语表涵盖超过一半工具的任何概念。在所研究的三种术语表中，SNOMED CT（医学临床术语标准命名法）涵盖范围最广，但在所有系统中粒度覆盖最少。虽然SNOMED CT包含了该样本中超过三分之一（36%）的工具类别的概念，但在SNOMED CT中仅表示了11%的实际工具。另一方面，LOINC（逻辑观察标识符、名称和代码）能够以三种术语表中最高的粒度级别表示工具。然而，LOINC的覆盖范围最差，覆盖我们样本中不到8%的工具。鉴于本研究选择的工具是根据其作为临床环境中最可能出现的病症的金标准测量方法的地位而选择的，我们认为这些结果高估了这些术语表提供的实际覆盖范围。本研究结果表明，现有医疗保健术语表在心理工具和与工具相关的程序方面存在重大差距。基于这些发现，我们建议做出系统性努力来增强标准医疗保健术语表，以更好地覆盖该领域。
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