Clinical Vocabulary/Terminology Standard

A Clinical Vocabulary/Terminology Standard is a domain-specific vocabulary standard that is a clinical data standard that represents health and clinical concepts in the form of structured vocabularies, terminologies, code sets and classification systems.

• Example(s):
  • AMA Current Procedural Terminology (CPT) Code Set,
  • CDISC Controlled-Terminology Standard,
  • ICD-10, ICD-11,
  • LOINC Standard,
  • FDA National Drug Code (NDC),
  • Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT).
  • RadLex,
  • RxNorm.
  • MEDCIN,
  • MedDRA,
  • Omaha System.
  • …
• Counter-Example(s):
  • CDISC Foundation Standard,
  • Clinical Content Standard,
  • Clinical Transport Standard,
  • Clinical Privacy and Security Standard.
• See: Interoperability Standard, Clinical Trial, Clinical Research, Standard-Developing Organization (SDO), American National Standards Institute (ANSI), International Organization for Standardization (ISO), Clinical Trial Data, United States Food And Drug Administration (FDA), World Health Organization.

---

---

References

2022

• (HIMSS, 2022b) ⇒ https://www.himss.org/resources/interoperability-healthcare#Part2 Retrieved:2022-02-27.
  • QUOTE: Vocabulary/terminology standards address the ability to represent concepts in an unambiguous manner between a sender and receiver of information, a fundamental requirement for effective communication. Health information systems that communicate with each other rely on structured vocabularies, terminologies, code sets and classification systems to represent health concepts. Some common vocabulary standards currently used in the marketplace include:
    • Current Procedural Terminology (CPT): A code set, maintained by the American Medical Association (AMA), used to bill outpatient and office procedures.
    • Healthcare Common Procedure Coding System: A set of healthcare procedure codes based on CPT that is used for Medicare reimbursement.
    • ICD-10 and ICD-11: The International Statistical Classification of Diseases and Related Health Problems (ICD) is a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. The 11th revision will replace the ICD-10 in January 2022.
    • Logical Observation Identifiers Names and Codes (LOINC): A universal code system for identifying health measurements, observations and documents. These codes represent the “question” for a test or measurement. LOINC codes can be grouped into laboratory and clinical tests, measurements and observations.
    • National Drug Code (NDC): Maintained by the U.S. Food and Drug Administration, NDC provides a list of all drugs manufactured, prepared, propagated, compounded or processed for commercial distribution.
    • RadLex: A unified language of radiology terms for standardized indexing and retrieval of radiology information resources, managed by the Radiological Society of North America. It unifies and supplements other lexicons and standards, such as SNOMED-Clinical Terms and DICOM.
    • RxNorm: A terminology used to normalize names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software. By providing links between these vocabularies, RxNorm can mediate messages between systems not using the same software and vocabulary.
    • Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT): A comprehensive clinical health terminology product. It enables the consistent, processable representation of clinical content in electronic health records (EHRs). These codes often represent the “answer” for a test or measurement to the LOINC “question” code.
    • The Centers for Disease Control and Prevention (CDC) provide a number of code sets for vaccines (Vaccines Administered (CVX)) and manufacturers (Manufacturers of Vaccines (MVX)). These codes can be used in immunization messages.
    • The Unified Code for Units of Measure: A code system intended to include all units of measures used in international science, engineering and business to facilitate unambiguous electronic communication of quantities together with their units.

---