요검사 항목의 상호운용성 강화를 위한 LOINC 및 SNOMED-CT 기반 용어 표준화 연구

초록

Background: Urinalysis is a routine diagnostic procedure in clinical laboratories and is critical for identifying and monitoring renal and urinary tract conditions. However, inter-institutional variations in specimen types, collection methods, test names, and reporting formats, impairs data interoperability in healthcare systems. Methods: We surveyed nine Korean hospitals participating in urinalysis quality assurance programs to collect information on specimen types, preservatives, collection methods, test items, and reporting formats. Each item was mapped to Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) for specimen-related terms and Logical Observation Identifiers Names and Codes (LOINC) for test names. The mappings were independently reviewed and verified by two clinical pathologists, and international guidelines from EFLM, JCCLS, and CLSI were referenced. Results: Most institutions primarily used codes for spot urine and 24-hour urine specimens, whereas detailed standardization for other collection methods and specimen types was limited. Reporting formats for dipstick tests were generally similar across institutions; however, terminology and item composition for microscopic urinalysis varied considerably among laboratories. SNOMED-CT codes were applied to 16 specimen types and collection procedures, and LOINC codes were mapped to dipstick and sediment tests based on automated equipment usage. Conclusions: This study provides foundational data for standardizing urinalysis terminology in Korea. The proposed LOINC and SNOMED-CT mappings may serve as a practical reference for clinical laboratories, referral laboratories, and in vitro diagnostic device manufacturers to enhane interoperability in test ordering and result reporting.

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