What Does Standardized Terminology Mean in Healthcare?

Health information includes any data that supports the delivery, management and improvement of healthcare services, ranging from patient records to population health management. In today’s interconnected healthcare ecosystem, standardization of health information plays a pivotal role in ensuring accurate data exchange, enhancing patient safety and improving healthcare delivery. In this context, clinical terminologies are also one of the crucial aspects of health information that need to be standardized. 

Clinical terminology standards such as SNOMED CT, ICD 10-11, LOINC and RxNorm are the fundamental building blocks for standardizing health information, enabling seamless and accurate data exchange across different healthcare systems. Standardized terms and codes enhance the efficiency of healthcare systems beyond just improving patient care outcomes. Standardized terminology in healthcare also promotes epidemiological analyses, quality and research, clinical decision support systems and administrative functions effectively.  

As emphasized by the Healthcare Information and Management Systems Society (HIMSS), the usage of standardized clinical terminology is a fundamental and rational step in healthcare IT because standardization mitigates ambiguity between the communicating parties. This process mainly aims to transform clinical information into a structured format, with a preference for a coded version. 

At Tiga Healthcare Technologies, we highlight the importance of standardized clinical terminology, specifically through the Terminology Server we developed. This solution eases the understanding and sharing of health data by constructing structures that align with the National and International Clinical Terminology standards. As leaders in the healthcare IT landscape, we tide over the difficulties related to the use of different information systems, differences in data management and diversities in terminologies and we convert the entire system into a comprehensive interoperable one. In this blog, we answer the question of ‘’What is standardized terminology in healthcare?’’ by exploring standardized clinical terminologies’ benefits and applications.  

What is Standardized Clinical Terminology? 

Just as every sector has its own unique standardizations, healthcare has its specific terminologies—such as prescription codes, diagnostic codes and disease classifications—that need to be standardized to enable seamless integration and functionality within health information systems. These terms are regulated through standardization, a process of developing and implementing coding standards to establish consistency, compatibility and interoperability across systems. This process brings standardized clinical terminology that refers to an established comprehensive set of recommended terms and codes, assuring a shared understanding among all stakeholders.  

Standardized clinical terminologies bring a common language, valuing both healthcare professionals and patients. As a structured set of data concepts, it improves communication and data exchange between professionals while supporting healthcare authorities and providers. Authorities and providers collect regulated information for population health disease surveillance, monitor public health trends, ensure compliance with reporting standards and manage health policy development through standardized terminologies. In addition to the consistency in information flows, these terminologies facilitate the documentation of clinical information. By reducing unstructured texts and natural language subject to interpretation, they prevent misunderstandings for patients. Furthermore, they enable key information required by electronic health record (EHR) systems, enhancing patient care outcomes.  

There are different clinical terminology standards used in health information systems, building a meaningful path for health data and research by supporting the communication competence of two or more healthcare professionals, providers and national health systems. While ICD 10-11, SNOMED CT, LOINC and RxNorm are among the most widely adopted clinical terminology standards in health information systems, they are not the only ones. Numerous other standards cater to specific use cases and regional requirements. In this blog, we will focus on these four globally recognized standards to provide a comprehensive understanding of their importance and applications. The following sections delve into ICD 10-11, SNOMED CT, LOINC and RxNorm.  

SNOMED CT 

SNOMED CT, standing for Systematized Nomenclature of Medicine—Clinical Terms, is an extensive clinical health terminology product which encodes clinical data in patients’ records, offering a consistent and processable representation of clinical content in EHR systems. It is widely used to indicate diseases, symptoms, medical procedures, treatment plans and other healthcare information.  

This multilingual system is known as a coding system of diagnosis. For example, this terminology represents a diagnosis of ‘type 2 diabetes’ with a specific code. Additionally, it includes other types of clinical findings such as signs and symptoms. This terminology, comprising tens of thousands of surgical, therapeutic and diagnostic procedures, also involves observables like heart rate and concepts demonstrating body structures, organisms, substances, pharmaceutical products, physical objects, physical forces and specimens. This comprehensive system offers easier data sharing between systems and improves the coordination of patient care across different healthcare facilities at local, national and international levels.  

ICD 10-11  

ICD 10, known as the International Statistical Classification of Diseases and Related Health Problems, is a standardized system designed by the World Health Organization (WHO) for classifying and coding diseases, conditions and other health-related issues. Healthcare providers, researchers and policymakers use this system for documenting, reporting and analyzing health data worldwide.  

ICD 10 involves codes for a wide variety of diseases, conditions, injuries and causes of death. For example, it represents ‘cholera’ and ‘acute myocardial infarction’ with different codes. With its hierarchical structure, this system has various chapters based on the body system or condition type. Each chapter is subdivided into categories, subcategories and more specific codes. ICD 10 allows for comparison of data across different regions and health systems by providing a common language.  

ICD 11 is a more comprehensive and modernized version of ICD 10 with greater flexibility, adaptability and detail for current and future healthcare needs. This medical classification system comprises codes for diseases, symptoms, abnormal findings, complaints, social situations and external causes of diseases or injuries, standardizing the way health conditions are documented.  

ICD-11 supports effective disease tracking, public health management and research. This system is used for reporting of causes of death, morbidity coding and reporting, assessing and monitoring the safety, efficacy and quality of care, coding traditional medicine conditions, researching and performing clinical trials and epidemiological studies and assessing functioning. For example, it provides unique codes for conditions like ‘hypertension’, ‘COVID-19’ and ‘heart disease’, allowing healthcare professionals worldwide to diagnose, treat and report these conditions consistently and efficiently.  

LOINC 

LOINC, recognized as Logical Observation Identifiers Names and Codes, is a universal code system describing health measurements, observations and documents. This database identifies medical laboratory and clinical observations, making sending clinical data electronically from laboratories and other data producers to hospitals, physicians’ offices and payers who utilize the data for clinical care and management purposes easier.  

As a rich catalog of measurements, LOINC has mainly two parts; Laboratory LOINC includes laboratory tests and microbiology tests while Clinical LOINC involves non-lab concepts like ECG concepts, anthropometric measures and obstetric ultrasound. There are two sub-parts in Clinical LOINC; ‘clinical documents’ sub-part includes concepts for different types of clinical reports like discharge summary and well-child visit note. On the other hand, ‘survey instruments’ sub-part has concepts for standardized surveys such as Glasgow Coma Scale and PHQ-9 depression scale. For example, LOINC codes are used for blood sugar tests, cholesterol tests and PCR tests while covering clinical observations such as blood pressure, body temperature and heart rate. Different health systems can exchange data related to test results and clinical measurements seamlessly with this code system.   

RxNorm 

RxNorm is a standardized nomenclature for clinical drugs that links drug names to widely used drug vocabularies in pharmacy management and drug interaction software. It offers a uniform way to present drug names, strengths and dosages across different systems.  

This system which is used for generic and branded drugs supports semantic interoperation between drug terminologies and pharmacy knowledge base systems. It provides normalized names and unique identifiers for medicines and drugs to making the communication between hospitals, pharmacies and other organizations using different computer systems with different sets of drug names easier. For example, RxNorm codes identify specific drugs like acetylsalicylic acid-based 100 mg medication, representing drugs across electronic health systems consistently and preventing medication errors. 

Benefits of Standardized Clinical Terminology within Healthcare 

Standardized clinical terminology provides a common language across different healthcare settings, bringing key aspects of the industry various advantages. This section focuses on how standardized terminologies improve key areas such as healthcare interoperability, communication, data analysis and research, visibility, evaluation and patient safety. 

Benefits of Standardized Clinical Terminology to Healthcare Interoperability 

Healthcare interoperability means the ability of different healthcare systems, devices and software to seamlessly use, interpret and exchange health data. This allows patient information like medical history, test results and prescriptions to be shared across different healthcare providers, organizations, professionals and platforms. For more coordinated patient care, fewer errors and optimized healthcare workflows, healthcare professionals, providers and authorities should perceive the crucial role of interoperability.  

Standardized clinical terminologies conserve the same meaning when exchanging health data between different settings. This property prevents unclear information flows between relevant stakeholders, directly supporting healthcare interoperability. Shared and consistent health data from standardized terminologies contribute to strategic and clinical decision-making which is an essential part of interoperability.  

Benefits of Standardized Clinical Terminology to Communication 

Healthcare authorities, providers, professionals and patients are always in touch with each other to exchange health data and address other circumstances. During the communication between these parties, different words can be used according to various countries and departments’ languages. Because of this situation, misunderstandings about health information can emerge; for example, a professional can describe a patient’s condition as ‘chronic kidney disease stage 3’ while another one can identify the condition as ‘moderate renal insufficiency’ and this inconsistency could lead to misinterpretation of the patient’s condition and improper treatment. To avoid encountering real-world cases similar to this example, health-related terms should be aligned across different healthcare providers and systems.  

Standardized terminology in healthcare creates a uniform interpretation of terms across systems and stakeholders to reduce ambiguity. Furthermore, a shared understanding of clinical words keeps information exchange clear and precise while accelerating data sharing and decision-making. Overall, standardized terminologies contribute to efficiency in dialogues, multidisciplinary collaboration and patient safety. 

Benefits of Standardized Clinical Terminology to Data Analysis & Research 

Healthcare researchers and analysts regularly exchange data during general research practices. Standardized clinical terminologies leverage the exchange by creating a consistent and accurate atmosphere across datasets.  

Standardization in healthcare terms improves sector-specific research findings’ reliability by reducing errors in data interpretation. It guarantees that words used in patient records and clinical trials are consistent, making comparing data across studies easier. Additionally, standardized clinical terminology facilitates the integration of diverse data sources like electronic health record systems and research databases. Furthermore, standardization contributes to the reproducibility of research studies, which is a key aspect of scientific validity.  

Benefits of Standardized Clinical Terminology to Monitoring and Evaluation 

Monitoring and evaluation are crucial parts of quality improvement within healthcare settings. Monitoring includes continuously or periodically observing patients, clinical environments and systems to collect data on health status, treatment effectiveness and operational efficiency. During evaluation, periodic analyses of the monitored data are performed to detect the impact of interventions and programs. For better monitoring and evaluation procedures, healthcare professionals, providers and authorities should embrace a shared understanding.  

Standardized terms in healthcare systems support these two interrelated processes; standardized clinical codes enable accurate and real-time tracking of patient outcomes and offer precise reporting of these outcomes, making assessing treatments and processes’ effectiveness easier. Additionally, standardization reduces errors and misinterpretations in monitoring databases to ensure that evaluations are based on reliable data. Cross-system comparison is another advantage; standardized clinical terminologies allow comparison of health data like treatment efficacy, disease prevalence and vaccination coverage from different institutions and regions by creating universally recognized terms, helping to determine best practices and areas for development.  

Benefits of Standardized Clinical Terminology to Patient Safety 

The WHO describes patient safety as ‘the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum.’ According to this definition, identifying and eliminating avoidable risks in patient care processes, reducing exposure to unnecessary treatments and monitoring patient conditions continuously are vital steps. All of these can be achieved through the implementation of standardization.  

Standardized clinical terminology minimizes misunderstandings and misinterpretations in diagnoses, treatment plans and medication orders. For example, standardized pharmaceutical names and dosages avoid medication errors. Additionally, standardization builds clear communication channels by ensuring that healthcare professionals adopt the same understanding among themselves and their connections with patients, preventing inappropriate treatments. Furthermore, standardized data provides easier tracking of patients’ conditions and adverse events, supporting early identification of potential safety risks.  

Standardized terms and codes in health information systems leverage interoperability, increase data accuracy and contribute to patient safety. Healthcare authorities, providers and professionals from different systems and regions can eliminate ambiguity, reduce errors and communicate effectively by using the same language. These benefits shape the various aspects of healthcare, from clinical applications to the integration of medical devices. Hence, authorities, providers and professionals should consider the importance of standardization of coding for creating a more accurate and secure healthcare ecosystem. 

At Tiga Healthcare Technologies, we highlight the vital role of standardized clinical terminology in driving better healthcare solutions with a focus on our Terminology Server, which is compatible with ICD 10-11, SNOMED CT, LOINC and RxNorm. This innovative product makes understanding and sharing of clinical data more manageable and efficient in different systems, which supports an interoperable ecosystem. We aim to contribute to a future where healthcare information is not only accurate, reliable and consistent but also supports more informed decision-making for relevant stakeholders with the Terminology Server.  

Let’s continue to shape a more secure, coherent, errorless and collaborative future together, as always!