Terminology Standards
These standards address a fundamental requirement for
effective communication – the ability to represent concepts in an unambiguous
manner between a sender and receiver of information. Most communication between
health information systems relies on structured vocabularies, terminologies,
code sets and classification systems to represent health concepts.
Why Do We Need Standard Terminology in Health Informatics menfashdesign
Standard terminology provides a foundation for
interoperability by improving the effectiveness of information exchange. Using
standard terminology should be a simple and logical step in health IT. However,
with the complexities of many diagnoses systems, clinical narrative transferred
via PDF format, various coding systems, and the cost of digitizing volumes of
reference material/dictionaries, it isn’t as easy as you would think.
Structured terms provide a means for organizing information
and serve to define the semantics of information using consistent and
computable mechanisms. Therefore, health information specialists need the tools
to focus on delivering terminology through a common delivery system to the
software vendors and institutions in a consistent, high quality and verifiable
fashion. Vendors and institutions need to be able to write applications that
access terminology content, be it SNOMED, immunization data, demographics,
LOINC, or a coding system local to the institution in exactly the same way.
See below for some of the common terminology standards used
in health information and technology.
LOINC ethicmenvoguee
Logical Observation Identifiers Names and Codes (LOINC®) is
a universal code system for identifying health measurements, observations, and
documents. These codes represent the “question” for a test or measurement.
LOINC codes can be grouped into Laboratory and Clinical tests, measurements and
observations. Visit LOINC’s database to explore these data standards.
UCUM
The Unified Code for Units of Measure (UCUM) is a code
system intended to include all units of measures used in international science,
engineering and business to facilitate unambiguous electronic communication of
quantities together with their units.
SNOMED CT
Systematized Nomenclature of Medicine--Clinical Terms
(SNOMED CT) is a comprehensive clinical health terminology product, owned and
distributed by SNOMED International. It enables the consistent, processable
representation of clinical content in electronic health records. These codes
often represent the “answer” for a test or measurement to the LOINC “question”
code. Explore these standards.
RxNorm businessdirectorypc
RxNorm provides normalized names for clinical drugs and
links its names to many of the drug vocabularies commonly used in pharmacy
management and drug interaction software. By providing links between these
vocabularies, RxNorm can mediate messages between systems not using the same
software and vocabulary. RxNorm now includes the National Drug File - Reference
Terminology (NDF-RT) from the Veterans Health Administration. NDF-RT is a
terminology used to code clinical drug properties, including mechanism of
action, physiologic effect, and therapeutic category. Explore the RxNorm
standards database.
RadLex
RadLex is a unified language of radiology terms for
standardized indexing and retrieval of radiology information resources. It
unifies and supplements other lexicons and standards, such as SNOMED-CT and
DICOM. It is managed by the Radiological Society of North America.
MEDCIN
MEDCIN is a medical terminology, maintained by Medicomp
Systems, that encompasses symptoms, history, physical examination, tests,
diagnoses and therapies.
ICD-10
ICD-10 is the 10th revision of the International Statistical
Classification of Diseases and Related Health Problems(ICD), a medical
classification list by the World Health Organization (WHO). It contains codes
for diseases, signs and symptoms, abnormal findings, complaints, social
circumstances, and external causes of injury or diseases.
CPT®
Current Procedural Terminology (CPT®) is a code set,
maintained by the American Medical Association (AMA) used to bill outpatient
and office procedures. allinternetbuziness
HCPCS
The Healthcare Common Procedure Coding System (HCPCS) is a
set of healthcare procedure codes based on CPT that is leveraged for Medicare
reimbursement.
CDC CVX and MVX
The Centers for Disease Control and Prevention (CDC) provide
a number of code sets for vaccines (Vaccines Administered (CVX)) and
manufacturers (Manufacturers of Vaccines (MVX)). These codes can be used in
immunization messages. Explore the CVX database.
NDC
The National Drug Code (NDC) is maintained by the Food and
Drug Administration (FDA) and provides a list of all drugs manufactured,
prepared, propagated, compounded or processed for commercial distribution.
Search the NDC database.
