Overview of Terminology and Classification Systems

Expectations are that numerous terminology and classification systems, working together in concert, would be required to support an efficient and effective clinical information system and handle a healthcare organization’s administrative needs. For example, SNOMED-CT® (with nearly 1 million terms) is designed for use in the underlying clinical information system to identify and tag data at the point of care. Whereas ICD, with its ability to aggregate data (with tens of thousands of terms), is more suitable for claims processing.

The terminology and classification systems used are determined, in part, by regulatory requirements. The Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) required the Department of Health and Human Services (HHS) to establish national standards, some of which were specific to code sets and electronic transactions.

Other commonly used terminology and classification systems include:

• MEDCIN: proprietary clinical terminology, owned by Medicomp Systems, Inc., developed as a point-of-care tool for electronic medical record (EMR) documentation at the time and place of patient care
• The Logical Observation Identifiers, Names, and Codes (LOINC): An emerging medical informatics standard to facilitate the exchange and pooling of laboratory results. LOINC codes can be used as universal identifiers for laboratory and other clinical observations in the world of electronic health records (EHRs) and in transactions in clinical computing environments. LOINC is a voluntary effort housed in the Regenstrief Institute, an internationally-recognized informatics and healthcare researchorganization.
• The Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT®): A controlled medical terminology with comprehensive coverage of diseases, clinical findings, etiologies, and procedures and outcomes used by physicians, dentists, nurses, allied health professionals, veterinarians, and others. The College of American Pathologists first developed SNOMED. However, intellectual property rights were transferred to the SNOMED SDO in the formal creation of the IHTSDO. SNOMED CT® is designed to uniquely identify clinical information, consistently and in great detail.
• The International Classification of Functioning, Disability, and Health (ICF): A classification of health and health-related domains describing body functions and structures, activities, and participation. ICF has been accepted by nearly 200 countries as the international standard for describing and measuring health and disability. The World Health Organization (WHO) is developer of ICF.