A Guide to Knowing Which Healthcare Terminology Standard to Use
Let’s be clear, there are a lot of terminology standards in healthcare. Sometimes the sheer number of acronyms alone can have you scratching your head. I previously wrote about the definition of healthcare terminology here: What is Healthcare Terminology. So, which ones do you need to worry about? Well, it really depends on what you’re trying to accomplish. Different healthcare terminology standards were developed to fulfill distinct purposes. Each one generally does a good job meeting its purpose. Match your purpose to your standard, and you probably have a winner.
The first step is to identify the standard’s purpose. Basically, there are billing terminology standards and there are clinical or interoperability standards. Let me break it down for you:
Healthcare Billing Terminology: ICD, DRGs, and CPT Codes
The billing terminology standards are used by all healthcare organizations to support aspects of medical billing. International Classifications of Diseases (ICD) is a diagnosis code set. ICD-9 is the version currently being used for billing in the U.S. while ICD-10 will become required in October 2014 (just in time for ICD-11 to be released in 2015). ICD-10 is also currently used for morbidity and mortality reporting. Diagnosis-related groups (DRGs) are commonly used in the inpatient setting to bill for a patient’s hospital stay, and Current Procedural Terminology (CPT) is used to code procedures for billing.
The clinical terminology standards are increasingly being referenced by interoperability initiatives. There are a lot of different standards out there, and they tend to have a specific clinical or workflow emphasis. I will outline a few of the most common standards to give you an idea of the landscape.
Clinical Terminology: SNOMED CT
Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) was developed mainly to encode the clinical data in a patient record. It is available for use in the U.S. via licensing by the National Library of Medicine (NLM) for country-wide use. It is also used by many other countries and is managed by the International Health Terminology Standards Development Organisation (IHTSDO). Because of its clinical focus, it is considered a very useful standard for encoding clinical data sent between systems or organizations. It is also referenced in stage 2 of Meaningful Use.
Clinical Terminology: HL7
Health Level 7 (HL7) is a healthcare standards organization that produces a variety of healthcare interoperability standards. They are quite well known for their messaging standards but also produce and maintain terminology standards. Their terminology contains a mix of code sets that aren’t found in other standard terminologies and are needed for their messaging and V3 data model standards. For example, they have code sets for admission type and administrative gender among many other domains of interest.
Clinical and Laboratory Terminology: LOINC®
Logical Observation Identifiers Names and Codes (LOINC®) is a standard developed and maintained by the Regenstrief Institute. It was originally developed to encode lab observations but has since expanded to also represent clinical observations. It is an open source standard that is widely considered to be the definitive lab standard.
The pharmacy terminology space is well-represented with many commercially available solutions like First Databank, Multum, Micromedex, and Medi-Span. The interoperability standard recommended for pharmacy terminology is the open-source RxNorm. It is available from the NLM and has links into the proprietary standards to facilitate interoperability.
Healthcare Terminology Experts can help
There are other terminology standards out there for niche use cases, but that covers most of the big ones. It’s always important to clarify your objectives and do your homework before embarking on any terminology project. Consulting some terminology experts can also be helpful and save you some headache later!
What healthcare terminology standards to you find yourself using most often? For what purpose?