From detailed guides to online courses – resources are available to provide you with the knowledge necessary to build and integrate EHR applications.

Terminology Standards

Other types of standards address terminology and other vocabularies used in various clinical contexts, allowing physicians and other health care providers to communicate with each other in predictable ways and to provide consistent results across record sets and jurisdictions. Examples include Logical Observation Identifiers Names and Codes (LOINC) and Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT). HL7 uses external terminology standards like LOINC and SNOMED CT, as well as its own terminology for HL7 v2 and v3.

For example, if a type of lab test is given a different name by other labs in Ontario, errors in searching for and interpreting a health care client’s lab tests can result. It is necessary to determine what the standard set of terminology should be and secure agreement on how to adopt it, while making the required changes in local systems or mapping to the terminology in the EHR.

Standards bodies work with subject matter experts on all aspects of the EHR to assure stakeholders that their needs will be met by the technologies being procured and implemented. This provides a strong channel of planning and communication between system developers and system consumers. The following terminology standards provide some examples.

Logical Observation Identifiers Names and Codes (LOINC)

LOINC is a terminology standard that provides standardized means of identifying medical observations. It has two main parts: laboratory and clinical LOINC. LOINC is often used to provide standardized names for lab tests, which is essential for clinicians and labs to exchange requests for tests and results electronically. Clinical LOINC contains a subdomain of document ontology which captures types of clinical reports and documents. Clinical LOINC codes are sometimes used in Clinical Document Architecture (CDA) implementations to represent the types of sections of a document. Canada Health Infoway maintains a Canadian extension to LOINC called the Pan-Canadian LOINC Observation Code Database (pCLOCD), which OLIS is adopting.

Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT)

SNOMED CT is a reference terminology standard that provides standard codes, descriptions and synonyms for over 311,000 clinical concepts. A clinical concept is a representation of clinical idea, which can range from body parts and drugs to services such as medical procedures and assessments. The clinical concepts are organized into groups called hierarchies. Medical procedures, clinical findings, body structure, and pharmaceutical products are examples of SNOMED CT hierarchies. Each concept is given a unique code to support functions such as algorithms for clinical decision support, alerts and reminders. Each concept has a description (a human-readable explanation) and a precise name (a fully specified name), as well as synonyms which can be other commonly used names. The use of fully specified names and synonyms helps with situations where a user wants to see a particular name in their application that is different from its fully specified name.

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