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.
Definition and Description of Topic
According to AHIMA's Vision of the e-HIM® Future report, a preferred future is patient centered, comprehensive, longitudinal, accessible, and credible. Collectively, vocabularies, terminologies, and classification systems provide the common medical language necessary for this future state.
The following definitions are useful to better understand subtle difference between vocabulary and terminology terms used in healthcare:
- A vocabulary is a collection of words or phrases with their meanings
- A terminology refers to a set of terms representing the system of concepts of a particular subject field
- A clinical terminology is a set of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions to support clinical care, decision support, outcomes research, and quality improvement
- A reference terminology is a set of concepts and relationships that provides a common consultation point for comparison and aggregation of data about the entire healthcare process
The EHR-S Functional Model Normative Standard (ISO/HL7 Standard 10781) contains references to the use of various types of standard terminologies and vocabularies in relation to the mentioned functions of the EHR-S. For example, the type of terminology needed for care management functions is one which can encode clinical terms and support the collection of structured data such as the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) or Logical Observation Identifiers Names and Codes (LOINC).
SNOMED CT is one of a suite of designated standards for use in U.S. Federal Government systems for the electronic exchange of clinical health information. Additional coded data standards are identified within
the United
States Health Information Knowledge Base (USHIK),
SNOMED CT is owned by the International Health
Terminology Standards Development Organization (IHTSDO).
This comprehensive reference terminology also a required standard in
interoperability specifications of the former U.S.
Healthcare Information Technology Standards Panel and
is included in the requirements for meaningful use in electronic health records
by the U.S. Office of the National Coordinator.
Industry and Standards Activities
AHIMA actively
participates in the standards development activities listed to advocate for HIM
principles and advocacy for the profession. Organizations and initiatives are
listed below.
- IHTSDO International Health
Terminology Standards Development Organisation .
IHTSDO is located in
Copenhagen, Denmark and owns and maintains SNOMED CT®. The United
States is included in the list of member nations http://www.ihtsdo.org/members/ SNOMED CT® with the
National Library of Medicine charged with distribution of standards. AHIMA
staff participates on the Mapping Special Interest Group, SNOMED CT to
ICD-10 Mapping project, Education Special Interest Group, and supports
activities to advance Implementation of SNOMED CT.
- ISO TC/215 and US TAG
The International Organization
for Standardization includes health informatics standards through
designated Technical Committees .ISO is a network of the national
standards institutes of 147 countries, on the basis of one member per
country (ANSI for the USA). AHIMA participates in the US TC 215 Technical
Advisory Group and follows the work of ISO Working Group 3 Health Concept
Representation and other Working Groups involved with EHR related
standards. AHIMA currently holds the American National
Standards Institute (ANSI) designation of the ISO/TC 215 Health Informatics
Secretary and Administrator of the U.S. TAG for ISO TC 215 Health
Informatics
- NCVHS Recommendations Terminology
Standards are actively monitored and testimony provided to
the committee as appropriate.
- The World Health
Organization Family of International Classifications (WHO)
provides classifications and terminology publications including
ICD-10, ICD-O and the International Classification of Functioning,
Disability and Health (ICF). AHIMA is actively supporting the
development of the next version of the International
Classification of Diseases.