The "WHAT, HOW and WHY" of terminology standards as essential instruments in today's digital health and interoperability markets.
What are they ?
In digital healthcare, a standardised vocabulary is a common nomenclature and classification system for medical terminology designed to be shared among users. Vocabularies address the ability to represent clinical concepts unambiguously between a sender and a receiver of information.
There is great diversity of standard vocabularies coming from various organisations and initiatives, many of which have organically emerged and grown to meet interoperability needs around specific uses.
How to use them?
Terminology users can match their purpose with the correct standard by first identifying the standard’s purpose. Examples of purposes encompass:
- Healthcare billing terminology
- Clinical terminology
- Clinical and laboratory terminology
- Pharmacy terminology
Some of the most widespread vocabularies currently used in the marketplace include:
| Purpose | Vocabulary | Description |
|---|---|---|
| Healthcare billing | ICD, DRGs, CPT | International Classifications of Diseases (ICD) is a diagnosis code set. Diagnosis-related groups (DRGs) are common in the inpatient setting to bill for a patient’s hospital stay. Current Procedural Terminology (CPT) generally covers procedure billing. |
| Clinical terminology | SNOMED-CT | It primarily encodes the clinical data in a patient record. With SNOMED’s clinical focus, it’s a useful standard for encoding clinical data sent between systems or organizations. |
| Laboratory terminology | LOINC | Used for identifying health measurements, observations and documents. LOINC codes can be grouped into laboratory and clinical tests, measurements and observations. |
| Pharmaceutical | RxNorm | Used to normalize names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software. |
Why use them?
Standardized vocabularies are essential to clearly and accurately document assessments, care, and outcomes. Their use ensures that systems can talk to each other and mean the same thing.
If you are collecting patient data electronically, recording and sharing that information while adhering to a standard terminology will pay-off in the long term for a number of reasons:
1. Interoperability
Interoperability makes it possible for organizations to study data trends, past performance and make data-driven improvements in patient care and other areas.
Data interoperability can also reduce the amount of redundant administrative work both within and outside organizations, creating a more satisfying experiences both for employees, those they serve and any potential clients.
Among those who might benefit from this include: software and automated instrument vendors, healthcare facility management, insurance and pharmaceutical companies.
2. Communication
With access to data, a patient's care team has an easier time accessing the patient’s most important health information, which can lead to fewer repeat tests, prevent inadvertent treatment interactions and reduce miscommunications.
3. Shared pathways
A shared pathway in the context of healthcare refers to all the stages a patient experiences in the management of their disease. To improve existing pathways or creating new ones it is necessary to easily track and study the data available.
Studying those pathways (also called patient's journey) help researchers found new set of patients who could benefit from a different care approach. It is critical for research to use standard vocabulary to be able to compare patients that are... comparable.
Among those who might benefit from this include: clinical researchers, healthcare providers, insurance and pharmaceutical companies.
Vocabularies are an essential asset in today's data marketplace
The lack of data interoperability is a key obstacle in the implementation and use of EHR to achieve its full benefits. Standard vocabularies provide the means for organizations to exchange, compare and aggregate data externally.
To apply them is in the best interest of all players in the healthcare domain, but more importantly, their value lies in improved patient care quality.
