Evaluation of the clinical LOINC (Logical Observation Identifiers, Names, and Codes) semantic structure as a terminology model for standardized assessment measures

Objective: The purpose of this study was to test the adequacy of the Clinic al LOINC (Logical Observation Identifiers, Names, and Codes) semantic struc ture as a terminology model for standardized assessment measures. Methods: After extension of the definitions, 1,096 items from 35 standardiz ed assessment instruments were dissected into the elements of the Clinical LOINC semantic structure. An additional coder dissected at least one random ly selected item from each instrument. When multiple scale types occurred i n a single instrument, a second coder dissected one randomly selected item representative of each scale type. Results: The results support the adequacy of the Clinical LOINC semantic st ructure as a terminology model for standardized assessments. Using the revi sed definitions, the coders were able to dissect into the elements of Clini cal LOINC all the standardized assessment items in the sample instruments. Percentage agreement for each element was as follows: component, 100 percen t; property, 87.8 percent; timing, 82.9 percent; system/sample, 100 percent ; scale, 92.6 percent; and method, 97.6 percent. Discussion: This evaluation was an initial step toward the representation o f standardized assessment items in a manner that facilitates data sharing a nd re-use. Further clarification of the definitions, especially those relat ed to time and property, is required to improve inter-rater reliability and to harmonize the representations with similar items already in LOINC.