What Is Healthcare Terminology?

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Healthcare terminologyHealthcare terminology can be complex, to say the least. I learned this lesson time and time again while working as a hospital unit coordinator, a women’s clinic assistant, and a medical biller. For the last 10 years, however, I’ve been in the healthcare IT side of the business, which gave me the opportunity to take part in development, implementation, and maintenance projects. And every step of the way, I’ve worked to ensure that healthcare terminology standards were used effectively.

When I tell people what I do, there is always some level of confusion. What do you mean by healthcare terminology?  Do you maintain the medical dictionary? Well, not exactly … but sort of. While terminology can refer to a number of different things in healthcare, the terminology I’m referring to is associated with electronic health records (EHRs) and the “language” used to code entries in these records including ICD-9, ICD-10, LOINC and SNOMED, among others.

In the world of electronic health records (EHRs), terminology is one of the keys to true interoperability between systems and integrating data. Say, for example, you want to send data between two systems. For the data to be usable, those systems have to “talk” to the same language. This means codes from one system have to be mapped to the codes from the other system. While you can combine data from multiple systems in one place, if you’re not mapping those codes to one another, you’re not unlocking the data.

Healthcare billing systems have been using terminology standards for many years and healthcare organizations have complied with these standards. Why? Because people will always comply with a standard when money is on the line. (With billing systems, if you don’t send the codes in a terminology that’s requested, claims don’t get paid.) The result is that, now, standard billing terminologies like Current Procedural Terminology (CPT®), International Classification of Diseases (ICD), among others, have a clear place in electronic systems.

But on the patient-care side of systems, terminology standardization is just beginning to get the attention it needs.  Why has it taken so long?  First, because clinicians often favor customization over predefined lists of questions and drop-down menus that often come with standardization. Plus, healthcare is more complex than other industries – which means standardization associated with the uniqueness of care is just simply hard to do. From my experience, it’s difficult enough to get one organization to agree on a standard for something, let alone the whole country to agree – and beyond.

Thankfully the informatics community has been working on these terminology standards for years. They recognized the potential and power of healthcare terminology standardization. It’s because of these efforts that we have more mature standards like Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and Logical Observation Identifiers Names and Codes (LOINC).  These and other standards are referenced by many initiatives including Meaningful Use. These initiatives are being developed to encourage more broad adoption of standardization so the benefits of using consistent terminology can be more rapidly realized. EHR vendors are also incorporating standards in certain areas of their applications increasing the efficiency of data exchange.

Terminology standards facilitate decision support, consistent reporting and analytics in addition to interoperability. There is a lot of potential, but it also comes at a cost. Implementation is difficult and generally requires a lot of tedious mapping work. Thankfully the tools available in the market are improving, so mapping local codes to standards and maintaining those mappings is becoming easier.

As we progress through this era of standardization and interoperability, terminology standards will become much more prevalent and understood. They have a big role to play and will continue to become more prevalent in various healthcare systems to facilitate data consumption objectives.

Do you have more questions or concerns about terminology? Jot them down below, and I’ll try to answer them in an upcoming blog post or interview video.

Starting a project? Watch our short video for tips about which healthcare terminology to use, how to make projects more manageable, and even why healthcare terminology continually changes and what’s on the horizon.

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