What Is a Terminology Browser?
Accurate, detailed information plays a critical role in maintaining electronic health records (EHR), medical coding, and medical billing.
Not to mention ensuring that all providers and referral specialists have the information they need to provide a patient with the specific care they need.
When accurate information isn’t available, or the wrong term is used in a patient’s electronic health records, the risk of fragmented care goes up. At the same time, it also increases the risk of medical coding errors, which can make it hard for a provider to be reimbursed promptly for their services.
One of the ways a lot of thriving practices deal with this is by using a terminology browser. It’s a special software tool that providers at every level can use to browse and search terminologies related to a patient’s care.
It incorporates sets of standardized terms, definitions, and relationships to describe concepts not only for medicine, but also for other industries such as engineering, or finance.
In the healthcare industry, terminology browsers offer up a user-friendly interface to help providers explore related terms and hierarchical relationships between them.
It searches for synonyms, related terms, and cross-referenced jargon to find specific terms that other providers can clearly understand. This becomes a handy tool for making sure all providers and clinicians are essentially “Speaking the same language” regardless of their area of specialty.
How Are Terminology Browsers Used in Healthcare Applications?
Terminology browsers are increasingly popular in the healthcare industry. They provide clinicians of different disciplines with a set of standardized clinical terminology. This helps improve the accuracy of EHRs as well as enhance clinical decision-making and helps with accurate coding.
Here are some of the ways that terminology browsers are used in healthcare applications:
Clinical Documentation
Healthcare providers often use terminology browsers to search for and select standardized terms for documenting patient information in EHRs. This ensures consistency in the way that information is recorded, which can improve the quality of care and empowers analytics.
Clinical Decision Support
Terminology browsers can be used to help with clinical decision support decisions. They do this using consistent rules and algorithms which lead to standardized terminologies that clearly explain clinical concepts. This helps in-network providers and referral specialists to more accurately identify patients who may be at risk of adverse events or who might benefit from certain interventions.
Quality Measurement and Reporting
Healthcare organizations use terminology browsers to map data from EHRs in an effort to standardize medical terminologies. This helps to facilitate quality measurement and reporting, as well as supporting accurate claim generation. This helps organizations to monitor and improve patient outcomes, identify areas for improvement, and report on their performance to regulatory bodies.
Research
A lot of researchers in the healthcare industry use terminology browsers to identify and select standardized terminology concepts for use in research studies. This facilitates the integration of data from multiple sources and enables the comparison of results across studies.
What Are the Popular Clinical Terminologies Used in Healthcare Applications?
There are several popular clinical terminologies that are widely used in healthcare industry. They are used to represent clinical concepts and support the standardization of data.
The following are some of the most popular ones:
SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms): SNOMED CT is a comprehensive clinical terminology that covers a wide range of clinical concepts, including diseases, procedures, medications, and anatomy. It is used in electronic health records, clinical decision support systems, and research.
LOINC (Logical Observation Identifiers Names and Codes): LOINC is a standardized terminology used to identify laboratory and clinical observations, such as test results, vital signs, and imaging findings. It is used to facilitate interoperability between different healthcare systems and to support quality measurement and research.
RxNorm: RxNorm is a standardized nomenclature for clinical drugs and medications. It includes information on drug ingredients, strengths, and dosages, as well as information on drug interactions and adverse effects. It is used to support medication management, drug safety, and clinical decision-making.
ICD-10 (International Classification of Diseases, 10th Revision): ICD-10 is a standardized classification system used to code and classify diseases and health problems. It is used for clinical documentation, billing, and research, and is required for use in electronic health records.
CPT (Current Procedural Terminology): CPT is a standardized nomenclature used to describe medical procedures and services. It is used for billing and coding and is required for use in electronic health records.
Though these are just a few examples of the most popular terminology browsers being used by larger practices. There are others available throughout the industry that might work better for niche specialists and small practices.
What Type of Healthcare Organizations Use a Terminology Browser?
Terminology browsers can be used by a wide range of healthcare organizations that need to standardize their clinical terminology as well as ensure accurate and consistent documenting of patient information.
The following are some prime examples of healthcare organizations that may use a terminology browser:
Hospitals and Health Systems
Hospitals and health systems often use terminology browsers for the standardization of clinical terminology across multiple departments and specialties. This helps to ensure that patient information is recorded consistently and accurately, regardless of where the care is provided.
Clinics and Small Practices
A lot of clinics and small practices use terminology browsers to ensure accurate documentation of patient information in EHRs. This helps to ensure that clinical concepts are represented consistently across different providers and that the patient's medical history and care plan are accurately documented.
Health Information Exchanges
HIEs often use terminology browsers to assist in the sharing of clinical information between different healthcare providers and systems. By using standardized terms HIEs can ensure that clinical concepts are represented consistently across different disciplines. This improves the accuracy and usefulness of all shared information.
Government Agencies
Government agencies and public health institutions like the Centers for Medicare and Medicaid Services (CMS) and the National Institutes of Health (NIH), use terminology browsers to help standardize clinical terminology. This helps in many facets included for reporting, quality measurement, and research purposes.
What Is the History of Terminology Browsers?
The healthcare industry has spent decades trying to come up with ways to improve communication between different disciplines. Terminology browsers represent one of the most effective methods to help providers and clinicians with a standard language.
One of the earliest examples of a terminology system is the International Classification of Diseases (ICD), which was first developed in the 19th century to classify causes of death. The ICD has since been expanded to include a wide range of diseases and health problems and is now used for clinical documentation, billing, and research.
In the 1960s and 70s, a concerted effort was made to develop more comprehensive clinical terminologies that could be used to represent a wide range of clinical concepts. One of the earliest examples of such a terminology system was the Medical Entities Dictionary (MED), which was developed by the National Library of Medicine in the United States.
In the 1980s thru the 90s electronic health records became increasingly popular. Though the need for standardized terminologies became more pressing. This led to the development of several new clinical terminologies, including SNOMED CT, LOINC, and RxNorm, which are still widely used today.
The first terminology browsers were developed in the 1990s, to provide users with an intuitive interface for searching and navigating through large, complex terminologies. Today, terminology browsers are widely used throughout the healthcare industry to support the standardization of clinical terminology. This helps improve the accuracy of electronic health records and enhance clinical decision-making.
What Is the Future for Terminology Browsers?
The future for terminology browsers looks bright, as the use of standardization of clinical terminology continues to play an increasingly important role in the healthcare industry. There are some current trends that are further driving the development of terminology browsers today and into the future.
Increased Adoption of EHRs
The majority of healthcare organizations use EHRs and similar information systems, which further drives up the need for standardized terms. This means that the innately intuitive interface of popular terminology browsers will continue to grow.
Advances in Artificial Intelligence
Advances in natural language processing (NLP), AI and similar technologies are increasingly being used to extract clinical information from unstructured text. This includes clinical notes as well as physician narratives. Terminology browsers that are designed to work with these technologies are becoming increasingly important to a plethora of industries.
Expansion of SNOMED CT
SNOMED CT is the most comprehensive clinical terminology system available. It covers a wide range of clinical concepts. These days an increasing number of healthcare organizations are adopting SNOMED CT. To meet demand, terminology browsers are being optimized to work with SNOMED CT, facilitating their use.
Integration with Clinical Decision Support
CDS systems can be easily integrated with terminology browsers to provide clinicians with real-time, evidence-based recommendations for diagnosis, treatment, and medication management. As CDS systems become more sophisticated, the need for intuitive terminology browsers that can work seamlessly with these systems will grow.
Collaboration and Standardization:
In the U.S. the Core Data for Interoperability (USCDI) initiative, has been working to establish a common set of data elements and standards for the healthcare industry. As these efforts gain momentum, terminology browsers that are designed to support these standards will become increasingly important.
Overall, the future for terminology browsers has a bright outlook going forward, as the need for standardized clinical terminologies and intuitive interfaces for providing and utilizing these terminologies continues to grow throughout healthcare facility needs and beyond.
Questions, ideas or concerns regarding your terminology browser usage? Contact us today and we are available to help your organization.