The Importance of Clinical Terminologies
The language of medicine and health is as complex and vast as the concepts it represents-and it is continually changing to reflect new knowledge, skills, and capabilities. Healthcare terminologies and classifications are the systems that describe, organize, and standardize this rapidly evolving language. They serve as dictionaries that organize and define words and related concepts. Health Information Management professionals work with multiple clinical terminologies, some formally defined and recognized as International standards, along with others used at the national, region or local health care delivery systems.
Clinical information systems (CISs) that capture data to directly support patient care and the EHR infrastructure use a number of applications often focused on clinical function to enable the collection, storage, and processing of discrete or structured data for various purposes. Terminologies and vocabularies supply the discrete or structured data and thereby form the information content in the electronic health record (EHR), including the personal health record (PHR). They are integral to interoperability, and thus, to deployment of a nationwide health information network capable of delivering on the promise of safer and more cost-effective results. International terminologies enable comparison of clinical data globally, supporting interoperability and exchange of information between countries to improve population health and follow disease outbreaks.
Clinical terminologies, vocabularies and coding systems are a foundational element of electronic data capture and health information exchange. Messaging standards use coded data within value sets and bindings to enable semantic interoperability. In plain language this means that conditions and health interventions can use different words to express the same clinical concepts and use the standard terminology as the basis for information exchange.