Can we all speak the same language?

Clinical Terminology

Throughout healthcare the use and need for clinical terminology continues to increase and expand with maturity of electronic communication. In the era of moving from “paper” to “electronic”, terminologies and vocabularies have taken on significant importance yet, the process and outcome has rewards and challenges. To “reuse” the data to convey information and gain wisdom all systems must speak the same language.

With multiple terms describing a given clinical event – acute and long-term care, medications and treatments, managed care, etc., the challenge is to define and collect data to provide consistent clinical information for the delivery of care, reporting and the many functions that occur after the clinical encounter. Both the source and target must speak the same language to integrate clinical findings, standards, systems, and other elements in the delivery of care. In addition to the clinical aspects, billing and reimbursement, research, regulations, repositories, mobile devices, etc. must also be considered in the continuum of care and the business of health.

A plethora of information is available identifying the many coding and classification systems, proprietary and specialized data sets and problem lists, terminologies concepts, vocabularies, etc. One might ponder – “how do I fit in this complex schema?” AHIMA has published many documents to aid the Health Information Professional in their learning and desire to remain current and fluent with the rapid changing healthcare landscape. Review AHIMA's publication – “Clinical Terminology: Expanding Career Pathways for HIM Professionals”.