Health Language Blog

How a Terminology Platform Can Support an EHR

Posted on 02/05/13

terminology_server

Vocabulary standards are playing a key force in enabling interoperability of patient data. Meaningful Use may be accomplishing what hasn’t happened before – a set of rules everyone will follow to allow patient data to flow between EHR systems, delivery networks and regional organizations.  Whether the vocabulary standard is a classification system, terminology, controlled vocabulary, or nomenclature, a terminology server can provide a range of services to use and manage these complex entities. 

Vocabularies named to achieve Meaningful Use have been thought of as fairly fixed and simple entities needing little care and feeding. As organizations begin to implement these vocabularies, the complexities of the concepts and relationships become apparent. 

To achieve interoperability within and across disparate healthcare IT systems, both free text and structured clinical information need to be synchronized across various applications. A terminology platform delivers a set of services and functions to map, manage, mediate, and manipulate terminologies for use and re-use in clinical applications.

A terminology platform supports sharing within applications as well as across applications. A terminology platfrom can map

  • between standard vocabularies
  • between locally created content and standard vocabularies
  • between sets of locally created content

This mapping supports standardized descriptions of clinical findings, patient observations, diagnoses, and interventions allowing consistently entered information across care settings and by care providers.  The EHR benefits by having a terminology platform that can ensure valid coded terms have been used. 

The standardized content can be used in 

  • Clinical Decision Support
  • Order Entry
  • Interface Engines
  • HL7 Messaging
  • Clinical Documentation Standardization
  • Search Expansion and Improvement
  • Natural Language Processing

Terminology Platforms meet the complex terminology needs of today’s EHRs. A single source of terminology truth r is a powerful integration tool to provide open systems needed in today’s healthcare marketplace.

Classic terminology server articles
Desiderata for a Clinical Terminology Server
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2232621/pdf/procamiasymp00004-0079.pdf

A Terminology Server for Integrating Clinical Information Systems: The GALEN Approach
http://www.ncbi.nlm.nih.gov/pubmed/9082124

 

 meaningful use stage 2 guide for ehr product managers

Topics: Meaningful use, clinical documentation, Analytics

About the Author

Soraya Assar