What is a Terminology Server?
Many practices are turning to terminology servers that use specialized software for the centralized management of clinical terms and other technical jargon.
Accuracy and consistency in medical coding, billing, and record-keeping are absolutely essential not only for preventing fragmented patient care but also for ensuring that providers get reimbursed promptly.
Terminology servers are specially designed to both store and manage things like:
Terminology content
Concept definitions
Relationships
Patient mapping
Data integration
Patient data security
Interoperability
This type of unified system makes it easy to share this data with other systems and applications.
Terminology servers play a critical role in helping to standardize electronic health records (EHR) as well as other interrelated information systems. The goal is to create a central point of reference for clinical terminology that can be used consistently across different systems and applications.
Key Features of Terminology Servers
Industry-leading terminology servers have key features that empower providers with the tools they need to reduce fragmented care for their patients, while also boosting claims accuracy.
Terminology Content Management
Terminology servers make it easy for clinicians to create, edit, and manage content, such as concepts, relationships, and mappings, in a centralized location.
Terminology Versioning
A terminology server allows clinicians from different disciplines to create and manage different versions of terminology content. They can then track these changes over time.
Terminology Mapping
Terminology servers make it easy for users to create and manage mappings between different terminologies. They ensure that clinical concepts are represented consistently across different systems and throughout different healthcare disciplines. This helps providers to speak the same language, even if their specialty has its own unique terms.
Terminology Integration
The best terminology servers can be easily integrated with other systems. This streamlines patient data for EHRs, clinical decision support systems, and health information exchanges. Then all that information is displayed in a way that ensures all important clinical concepts are represented consistently for all users.
What Is a Terminology Service?
A terminology service is a suite of software that provides systematic access to clinical terminology and translates it into industry-specific terms. This helps to enable other systems to access and use terminology content consistently.
Healthcare terminology services are often used to improve the standardization and interoperability of electronic health records (EHRs) and other clinical information systems. They provide a standardized interface for accessing terminology content and enable healthcare organizations to ensure that clinical concepts are represented consistently across different systems and applications.
Key Features of a Terminology Service
Terminology services offer up some important benefits for users across multiple disciplines, in a way that helps reduce the risk of a patient experiencing fragmented care or delays in their treatment process.
Terminology Content Retrieval
Terminology services allow users to retrieve terminology content, such as concepts, relationships, and mappings, in a standardized way.
Terminology Mapping
Terminology services make it easy for users to map and retrieve terms to ensure that clinical concepts are represented consistently across different systems and applications.
Terminology Versioning
Terminology services help clinicians to interpret differing or unique terms and then track those changes over time.
Terminology Integration
Terminology services make it easy to integrate data between systems and applications. This includes EHRs, clinical decision support systems, and health information exchanges, to ensure that clinical concepts are represented consistently across different systems and applications.
Who Needs and Uses a Terminology Server?
Terminology servers can be very beneficial for healthcare organizations that need to manage and maintain a large and complex set of clinical terms.
This includes hospitals and large clinics that have providers with many different specialties inside one expansive network. They help streamline (EHR) and other clinical information systems to ensure that all the critical patient information is represented consistently from one provider to the next.
Healthcare Organizations That Benefit From Terminology Servers
Several different organizations can benefit from using terminology servers throughout the medical billing process.
Healthcare Providers
Large healthcare organizations like hospitals, clinics, and specialty physicians who use terminology servers tend to see the most benefit. They play a key role in making sure that clinical concepts are represented consistently throughout the system. This is especially important when it comes to sharing patient information throughout the network.
EHR Vendors
Electronic Health Record vendors use terminology servers to create codified data that is consistent throughout their system. This ensures interoperability with other systems when transferring patient data.
Clinical Decision Support (CDS) Vendors
CDS vendors use terminology servers to standardize clinical terminology. This provides clinicians with evidence-based recommendations for things like diagnosis, treatment, and managing a patient’s medication management.
Health Information Exchanges (HIEs)
Terminology servers make it easy for HIEs to communicate clinical concepts consistently across different networks and specialists.
How Is a Terminology Server Used?
Terminology servers are designed to help create a unified language that all providers can “Speak” to communicate critical patient information. This helps prevent problems with fragmented care for the patient while expediting the treatment process for things like referrals and specialty services throughout a large healthcare network.
Terminology Content Management
Terminology servers make it easy for providers to create, edit, and manage terminology content. This includes the ability to explain complex concepts, explain relationships, and map patient care in a centralized location.
Terminology Versioning
Terminology servers help create and manage different versions of the same terminology to help providers with different specialties communicate in a relatable language. It can also track those changes over time. This ensures that all network providers are using the most up-to-date version of new medical terms.
Terminology Integration
A terminology server is easy to integrate with other existing systems and applications. This includes:
EHRs
Clinical decision support systems
Health information exchanges
The integration process can then be carried out via standardized interfaces, such as the HL7 Fast Healthcare Interoperability Resources (FHIR) standard.
What Are the Top Terminology Server Types?
There are several different types of terminology servers being used in healthcare. Each with its own strengths and weaknesses. The one that’s best for your organization will depend on the size of your network, the different specialty provider disciplines in your network, and how often you need to make patient referrals.
Commercial Terminology Servers
Commercial terminology servers tend to be used by larger organizations such as Apelon, Clinical Architecture, and Health Language. They offer a wide range of advanced features, such as terminology mapping, versioning, and integration with other software systems.
Open Source Terminology Servers
These are terminology servers that are developed and maintained by open-source communities, like Open Source Clinical Application Resource (OSCAR). They’re also very popular with the Health Level Seven International (HL7) Terminology Service as they can be customized to meet the specific needs of healthcare organizations.
Cloud-Based Terminology Servers
These are terminology services hosted in the cloud which makes it easy to access data via the internet. Examples include the National Library of Medicine's Unified Medical Language System (UMLS) Metathesaurus and the Apelon DTS on AWS. They offer scalability, flexibility, and accessibility. Though providers need to be wise about when and how they’re used as there can be privacy compliance concerns anytime patient data is transmitted over the internet.
EHR-Specific Terminology Servers
EHR-Specific terminology servers tend to be seamlessly integrated with proprietary electronic health record systems. The major players here tend to be organizations like Epic, Cerner, and Allscripts. These terminology servers often include special features like auto-suggest and auto-complete that make it more efficient for clinicians to quickly enter patient data.
What Content Is Typically Included in a Terminology Server?
One of the strengths of a terminology server is its ability to both standardize and customize the data content entered by providers. This empowers clinicians of every disciple to communicate easily with each other regarding a patient’s care and treatment plan.
Standard Terminologies
The best terminology servers use standardized sets of clinical terminologies that are widely used in healthcare, such as SNOMED CT, LOINC, ICD-10, and CPT. This might include the entire vocabulary of a standard terminology or a subset that is relevant to a specific healthcare organization or use case.
Custom Terminologies
The ability to create new or modify an existing term helps healthcare organizations communicate effectively to meet specific patient needs. This often includes things like generating custom terminologies for:
Local lab test codes
Order sets
Diagnosis
Clinical protocols
Mapping Tables
Mapping tables help define the relationships between different healthcare terms. This includes common mappings between SNOMED CT and ICD-10 codes. It can also help with pre-built mapping tables as well as give providers the ability to create their own mappings.
Hierarchies
Terminology servers can be used to create structures that organize concepts according to their relationships with one another. For example, SNOMED CT has a hierarchical structure that organizes concepts into broader and narrower terms. This might also include pre-built hierarchies as well as give providers the ability to create their own hierarchies.
Synonyms and Alternate Terms
Synonyms and alternate terms can be used to represent the same clinical concepts even if they are formatted differently. A terminology server can be set up to include synonyms and alternate terms for each specific concept. This ensures that all relevant information is captured at every level of clinical documentation.
Cross-References
One of the strengths of a terminology server is its ability to include cross-references to external resources. This includes things like drug databases or clinical guidelines.
What Are the Benefits to Buying Your Own Terminology Server?
There are several benefits to buying your own terminology server:
Standardization
The best terminology servers empower your organization with a standardized set of clinical terms for consistency and improved accuracy. This then flows through every level of clinical documentation effortlessly.
Interoperability
When your practice uses a terminology server it improves interoperability and integration with other clinical systems. This makes it easy to exchange patient data between different organizations for patients who need a referral to a specialist.
Customization
The intuitive interface and customization features make it easy to set up your in-house terminology server to meet the specific needs of your organization. This includes the ability to add or modify terms, as well as create custom mappings between different groups of terms. You can also use it to better define custom hierarchies and cross-references.
Efficiency
Terminology servers improve overall efficiency in medical coding by reducing the time and effort it takes to find the appropriate clinical terms for a claim. It also improves claim accuracy with complete documentation of patient information.
Cost Savings
In the long term, a terminology server will help your practice reduce costs by improving the completeness and accuracy of all clinical documents. It also helps reduce coding errors while improving the overall quality of patient care.
Compliance
Terminology servers can also be set up to better ensure compliance with clinical documentation privacy requirements. This will go a long way toward reducing the risk of non-compliance penalties and other legal liability concerns.
What Are the Top Considerations to Ask When Buying a Terminology Server?
Content
When choosing the best terminology server to meet your practice’s needs, you should start by evaluating whether the server includes the clinical terms that are most relevant to your organization. This includes making sure that it supports the level of customization and mapping needed to meet your specific requirements.
Interoperability
You also need to consider just how well the terminology server integrates with other clinical systems and applications that you are currently using. This includes making sure it can fully support data exchange between different organizations and providers in your network. This includes making sure the server supports standard data exchange formats and protocols, such as HL7 and FHIR. You also need to make sure that it provides the necessary APIs and other tools to enable seamless integration.
Functionality
Next, you need to consider the terminology server’s basic functionality. This includes features such as search, browsing, mapping, and customization. You also need to consider just how intuitive or user-friendly the interface is. Especially if you have administrative staff that aren’t particularly tech-savvy.
Scalability
Ideally, you want a terminology server that will grow with your practice as it evolves. So, make sure to evaluate the server's scalability as well as other long-term performance characteristics, and whether it can support the necessary levels of usage and data volumes.
Security
Ensuring the security of patient data is of critical importance when choosing a terminology server. You should evaluate the server's security features, including its support for encryption, access controls, audit trails, and other security measures, and whether it meets the relevant regulatory requirements.
Support and Maintenance
When finding the best technology server to meet your needs you also need to consider the level of support and maintenance provided by the vendor.
Take the time to research the vendor's track record and reputation for customer service, and whether they provide the necessary support and training to ensure that your organization can effectively use and maintain the server over time.
Questions, ideas or concerns regarding your term server? Contact us today and we are available to help your organization.
For users wanting to access a terminology server in a computer-to-computer manner. These generally involve RESTful calls with queries and results sent via JSON
For users wanting a graphical representation of a concepts and complex querying ability. This provides a more user-friendly way of looking up the data rather than via JSON. The images used throughout the website are examples of that.
Note: Browsers are available on some terminology browsers