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Industry Activities & Emerging Issues
Clinical Terminologies & Vocabularies
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.
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.
Description (i.e. description of category, relevance to HIM and AHIMA)
According to AHIMA’s Vision of the e-HIM™ Future report, the future state of health information is electronic, patient centered, comprehensive, longitudinal, accessible, and credible. Collectively, vocabularies, terminologies, and classification systems provide the common medical language necessary for this future state.
- 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 o 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 (ANSI-approved) published by Health Level Seven (HL7) 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. This comprehensive reference terminology also a required standard in interoperability specifications of the U.S. Healthcare Information Technology Standards Panel.
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Standards & Industry Activities
Common Terminology Services (CTS 2 Project) Technical Committee
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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 SNOMED CT® with the National Library of Medicine charged with distribution of standards
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ISO is the International Organization for Standardization which 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 215 Technical Advisory Group and follows the work of ISO Working Group 3 Health Concept Representation.
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NCVHS study identified the core set of Patient Medical Record Information terminology standards (National Committee on Vital and Health Statistics. 2003 (November). Recommendations for PMRI Terminology Standards.. In February, 2008 Linda Kloss and Keith Campbell provided testimony to NCVHS concerning terminology related initiative important to the association.
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CHI – Terminology Standards (Department of Health and Human Services, Office of the Secretary. 2005 (December 23). Consolidated Health Informatics (CHI) Initiative; Health Care and Vocabulary Standards for Use in Federal Health Information Technology Systems. Federal Register. 70(246): p. 76287-76288. The Federal Health Architecture (FHA) is engaged in the standards development process through the Consolidated Health Informatics (CHI) initiative.
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Other Resources & Links
- Greene, M. & Fenton, S.H. (2006). Clinical Classifications and Terminologies. K.M. LaTour & S. Eichenwald-Maki (Eds.), Health information management: Concepts, principles, and practice, (3rd ed., pp. 305-342). Chicago: American Health Information Management Association.
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AHIMA Resources
- HIM Body of Knowledge (requires membership for access)
- Clinical Classifications and Terminologies.
Greene, M. & Fenton, S.H. (2006), K.M. LaTour & S. Eichenwald-Maki (Eds.), Health information management: Concepts, principles, and practice, (3rd ed., pp. 305-342). Chicago: American Health Information Management Association.
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