WHITE PAPER BY DR. WHITTENBURG, RN, PM, FHIMSS
Accessible and shareable health information is an accepted prerequisite of good healthcare. Shareable health information employs a concept based approach achieved by internationally standardized reference terminologies. The white paper below discusses the value of standardized terminologies in the exchange and documentation of health information. This paper presents the value of terminologies from the viewpoints of clinicians, patients and healthcare organizations.
Standard terminologies are essential in the accurate communication of data in health information exchange and to healthcare interoperability specifications. ONC recognizes standardized terminologies as vital to establishing quality conformance measures to achieve comparable health data across diverse systems. Standardized terminologies normalize health communication with usable, consistent, congruent and unambiguous understanding of a patient’s medical history.
Standardized terminology is essential to the knowledge-based healthcare environment. The value of standardized healthcare terminologies is the ability to collect and document comparable healthcare data concepts. This allows insight into the health care and services required to achieve optimal patient health outcomes. We employ standardized terminologies to strengthen clinical decision systems as data congruency increases technical, business and management capabilities.
Standardized Terminologies for Data Interoperability in Health Information Exchange (pdf)
CLINICAL TERMINOLOGIES
Our clinical terminology consulting services at JPSYS cover many facets of healthcare EHR systems.
JPSys provides professional services for: terminology matching, terminology data models, terminology data standards and the curation of data sets.
We provide terminology mapping services for LOINC and SNOMED CT. We can assist all types of clients including academic medical centers, community hospitals, biotechnology companies, research organizations or IVD vendors. Research labs, commercial labs and IVD vendors are now being held responsible for mapping their testing to LOINC by the FDA. For research labs it was a mandate in 2020, for other it is strongly suggested by the FDA. Our subject matter experts are here to help you with LOINC mapping or submissions.
The Healthcare Information Technology (HIT) standards development process is the result of a world-wide effort of Standards Development Organizations (SDOs).
We meet with representatives from governments, private corporations and non-profit organizations in SDO work groups to determine the data formats for information exchange. Here we reach a consensus on which data values will be associated with specific fields as a standard value set. These values become the standard ones used for transmission in messages sent between healthcare providers. In this way, all recipients can utilize the data and derive precise meanings. The underlying problem in data exchange is that the actual coded values in the database files of a given healthcare providers are NOT interoperable with other hospital systems EHR data files. This is true even if the two hospitals have the same EHR system.
The data values stored in a specific data field are coded in different ways by different hospital EHR systems.
For example, for a field such as blood type, one EHR might store a coded number (9253) while another EHR might store text ('O+'). One way to solve this is an expensive study of every single data element in every data file and the creation and validation of maps between the two EHR systems. If they want to share data, years of work has to be done. Every time one adds a new data exchange partner, more years of work have to be done. Obviously, this gets too expensive.
The solution then is to instead have each hospital EHR system map to an international set of reference data and values. Then the data can be sent unambiguously. These international sets of values are referred to as standardized Reference Terminologies. SNOMED CT is one famous and widely used international clinical terminology. LOINC is another terminology used to assign codes for laboratory tests. MED-RT is a terminology for prescription drugs and is organized by drug names and classes.
The LOINC terminology standard is governed by the Regenstrief Institute a dynamic, people-centered research organization.
We envision a world where better information empowers people to improve healthcare. LOINC is driven by a mission to connect and innovate for better health. They report that “Regulated clinical research is carried out and supported across multiple sectors including academic medical centers, biopharmaceutical companies, biotechnology companies, clinical research organizations, federal agencies, information technology vendors and others." Source: Regenstrief Institute.
