The fundamental challenge in healthcare documentation is local systems have different ways of identifying the same concept. It is crucial shared standards through coding in health information management, in order for users to access, combine, manipulate, and share comparable data with other healthcare organizations or settings. Vocabulary, terminology, and classification systems are key in this function. A vocabulary is a collection of words or phrase with their meanings, that is, a dictionary of those terms. A terminology is a set of terms representing a system of concepts. A classification is a system that arranges or organizes like or related entities. One other related term, ontology, is a common vocabulary organized by meaning that allows for an understanding of structure of descriptive information, which helps to facilitate interoperability.
Functions of Standardized Medical Terminologies / Ontologies:
- Access to complete & accurate clinical data
- Electronic data collection
- Capture detailed clinical data about patient
- Allow different site, different provider sending & receiving medical data
- Practitioner alerts, reminders & decision support systems
- Improve the quality of care through effective use of information in other information management systems
- Allow computer to manipulate standardized data & find information relevant to individual patient to produce automatic reminders & alerts
- Links to Medical Knowledge
- Provides an organized system of data collection and retrieval, resulting in the linkage of published research with clinical care, to improve the quality of care through outcome measurements
- Research & Epidemilogical Studies
- Allows the collection and reporting of basic health statistics
- Ensure a high-quality database for accurate clinical and statistical data
- Healthcare Claims
- Provides data for use in designing payment systems and determining the correct payment for healthcare services
- Indentifies fraudulent or abusive practices
- Public Health
- Provides data for use in monitoring public health and risks
Applications of Standardized Medical Terminologies / Ontologies:
- Electronic medical records
- Physician order entry
- Clinical decision support
- Laboratory reporting
- Case report forms for clinical research
- Surgical procedure masters
- Consumer health information services