As clinical terminology solutions are being more widely investigated by HIEs and other organizations, the number of questions we’ve gotten has increased. Here are answers to often-asked questions.
Clinical terminology is the framework different organizations use to manage code sets from various sources to describe the same concept (e.g., 823.80 and S82.201A can both describe a broken leg). When you have a clinical terminology solution, you can find peace of mind knowing your entire network is speaking the same language around diagnoses, lab codes, and other key clinical terms.
Clinical terminology is important because it provides consistent meaning across patient health records, which ultimately benefits patients through improved quality of care at less cost. Terminology can also be used to trigger clinical alerts, such as drug allergies.
Clinical terminology is used by health information exchanges (HIEs) and by providers/caregivers. An HIE can create individual mappings for each of its participants in order to enrich participants’ patient records with clinical data.
The difference between clinical terminology and clinical classifications is as follows.
Classification systems code specific data items like diseases and diagnosis (ICD-10, DRG), lab reports (LOINC), procedures/services for billing (CPT), and pharma products (RXNorm, ATC). It is used for statistical analysis, billing & accounting, and reporting.
Clinical terminology systems operate across the entire healthcare domain, functioning as a common reference guide, mapping data from different sources to a single language that can be coded and queried. In addition, they are used to describe care delivery in different ways for different purposes (e.g., billing systems, decision support, medication delivery, and patient access), including taking coded values and translating them into plain language so patients and their caretakers can understand their medical records.
The difference between clinical terminology and medical terminology is as follows.
Clinical Terminology is the system used to code the entire healthcare domain and function as a common reference system that can be coded and queried.
Medical Terminology is the language used by health professionals to communicate and understand the components, processes, conditions, and procedures performed on the human body. Most of the words that describe the tissue, organ, or condition have Latin or Greek roots and prefixes/suffixes used to modify the root word. Respective examples are “intravenous” (into a vein) and “neuropathy” (disease of the nervous system).
SNOMED CT (Systematized Nomenclature of Medicine – Clinical Terms) is a comprehensive, multilingual clinical healthcare terminology. It is used in over 80 countries.
SNOMED CT represents coded items that may be used to capture, record, and share clinical data for use in healthcare. Rather than a flat list of numbers and terms, it is designed for input into electronic health records (EHRs), outputs, and reports. SNOMED CT is a very detailed model consisting of several hierarchies and relationships, which contains concepts, descriptions, relationships, and reference sets.
A concept is a unique, numeric identifier. One type of description is a fully specified name (FSN), which represents a unique (per dialect) description of a concept’s meaning. Respective examples are 22298006 and “myocardial infarction (disorder).”
LOINC (Logical Observation Identifiers Names and Codes) is a standardized universal coding system that facilitates the exchange and pooling of results, such as laboratory tests or vital signs, for clinical care, outcomes management, and research.
According to the World Health Organization, ICD (International Statistical Classification of Diseases and Related Health Problems) is the diagnostic classification standard for all clinical and research purposes.
ICD periodically has new revisions to reflect advances in medical science. An example would be ICD-9 (9th revision) to ICD-10 (10 revision) with the 11th revision (ICD-11) already underway.
Local codes or custom codes in terminology are codes and descriptions generated from either an EMR or other healthcare organizations whose data structure is not standard.
Clinical terminology is difficult to manage because of a combination of the sheer volume of standard, custom, or local codes and the many different types of EMR systems across health systems and clinics, which may all use different codes and descriptions for the same term.
SNOMED CT has over 350,000 concepts, while ICD-11 will have over 80,000 concepts. Mapping and coding these concepts is highly complex due to the large numbers and disparate healthcare systems.
Mappings among terminology and classification standards are managed, in many cases, with large spreadsheets and proprietary in-house software. Because of the limitation of spreadsheets and legacy systems, there needs to be solutions that provide the power and intelligence to coding that will provide a meaningful, scalable, repeatable solution such as cloud-based J2 Managed Terminology.
J2 Interactive offers managed terminology services, powered by HealthTerm.