Healthcare Terminology
What are Healthcare Terminologies?
Healthcare terminologies are specialized words and phrases used in the medical field to describe various medical conditions, procedures, treatments, and equipment. Examples of healthcare terminologies include anatomical terms, medical abbreviations, diagnostic codes, drug names, and medical procedures. These terms are crucial in ensuring accurate and precise communication between healthcare providers, patients, and medical records.
Beyond words and phrases, healthcare terminologies attach codes to represent meanings in an unambiguous way. These codes are stable over time, but can change as knowledge about medicine evolves over time.
Which ones Healthcare Terminologies are Standards?
There are several healthcare terminologies that are considered standards, including:
SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms): a comprehensive clinical terminology used in electronic health records.
ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification): a classification system used to categorize diseases and health conditions.
LOINC (Logical Observation Identifiers Names and Codes): a universal standard for identifying laboratory and clinical observations.
RXNORM: a standardized terminology for clinical drugs in the US. It provides unique identifiers for medications, including prescription and over-the-counter drugs, as well as dietary supplements..
CPT (Current Procedural Terminology): a standardized code set used to describe medical procedures and services.
These standards are widely used and recognized in the healthcare industry and help ensure the interoperability and exchange of health information between systems and organizations.
Who defines healthcare terminology standards in the United States?
In the United States, several organizations are responsible for defining and maintaining healthcare terminology standards. These organizations include:
Centers for Medicare & Medicaid Services (CMS): CMS is responsible for setting standards for electronic transactions, including those related to healthcare terminology, such as the implementation of ICD-10 codes.
Office of the National Coordinator (ONC): ONC is an office within the U.S. Department of Health and Human Services (HHS) and is responsible for coordinating the nationwide implementation of health information technology, including electronic health records (EHRs). It publishes important resources for healthcare interoperability, including:
National Library of Medicine (NLM): NLM is responsible for the development and publication of several healthcare terminology resources, including the Unified Medical Language System (UMLS) and SNOMED CT.
Health Level Seven International (HL7): HL7 is a non-profit organization responsible for developing and maintaining international standards for the exchange, management, and integration of healthcare information.
These organizations work together to establish and maintain standards for healthcare terminologies in the United States, with the goal of improving the accuracy and reliability of health information exchange.