Clinical terms, while not as vast as the grains of sand on a beach, are certainly plentiful.
In fact, IMO supports healthcare organizations by managing the complexity of 5 million clinical terms and mappings to all major global coding systems. However, this article isn’t about the volume of terms and phrases out there. Rather, its goal is to answer one simple question:
How does a single new clinical term get created?
We asked Patrick McCormick, MD – a clinical terminologist at IMO – to help pull back the curtain of clinical terminology and provide some insight.
Question: Let’s start from the beginning. What prompts a new clinical term request?
Answer: Let’s say a healthcare organization can’t find a diagnosis term within their electronic health record (EHR) system that’s needed for documentation at the point of care. If an EHR is supported by IMO’s foundational clinical terminology, a request for a new term can be submitted and routed to an IMO clinical team member for assessment. The team evaluates the term to make sure all the pertinent clinical details are understood, and if there are questions we’ll message the client back asking for clarification.
It is important to note that all terms in a clinical terminology must stand on their own. In other words, we can’t depend on context other than the knowledge that our terminology will be used in the patient’s medical record in the EHR. For instance, we can’t assume additional information will be available to help a user clarify the acronym MS – which could mean anything from multiple sclerosis, to mitral stenosis, to mass spectroscopy.
Q: What if a new term request already exists?
A: Once IMO’s clinical team is confident that we fully understand the request, we check to make sure we don’t already have that term available.
We may have a synonym for that term that the client didn’t look for, so we can either point the customer to that synonym or we can add the desired term as an additional description to enhance searchability for users.
Q: Let’s say IMO doesn’t have a term requested by the customer. Then what?
A: Assuming the request represents a clinical term that is conceptually distinct from everything else in the terminology database, it is time to craft the new term.
We have developed an extensive body of editorial policies over the years to ensure terminology is written in a way that is consistent, clear, and clinically intuitive to a clinician. We check similar terms to see if there is an outline we can use to mirror the new term’s formatting. We also look at articles in medical journals to check the language of a new term is consistent with the vernacular and phraseology particular to a given specialty.
Q: Okay, so once you determine that a new term does need to be created, what does that process look like?
A: I would break it down into 3 sections:
Crafting the term
One author is assigned the task of making the initial attempt at crafting this new term. Then, a second author must validate the new term in the new concept review step. This reviewer evaluates the new term in a similar fashion to the first but with the advantage of a fresh set of eyes. After that, the new term is given a lexical ID – a unique identification number in IMO’s database – but there’s more work ahead.
Adding coding to the term
Based on the term’s domain – such as procedure, organism, or allergen, to name a few – various metadata components are attached to the new term. Generally, at this stage, our clients are most interested in mapping to standardized code sets. For instance, IMO’s clinical team adds SNOMED CT® maps to almost all new concepts created, along with LOINC® maps if applicable. Meanwhile, a dedicated mapping team adds crucial administrative and billing codes depending on the domain and geographic location of the EHR user.
Tagging new terms with reliable and accurate codes from standardized code sets ensures regulatory compliance and helps optimize billing. It also supports crucial downstream clinical workflows and data analytics.
At the end of the process, we have the final review stage. All new terms are reviewed by an IMO clinical team member. Conformance to editorial guidelines is checked again by the most senior clinical team members. If any errors are found, the term may be sent back to the beginning of the “terminology assembly line.”
Additionally, previously added metadata components are reviewed to ensure nothing was added in error. Then, after one more review of the SNOMED CT maps, the new term is finally deemed worthy of inclusion in one of IMO’s upcoming clinical terminology release packages.
Q: Such a thorough process! Are there any automated quality checks?
A: I’m glad you asked. In the background of this process, we have queries running to ensure all new terms meet specific product requirements and quality standards. Some of these quality assurance checks ensure all the proper codes are added to a term. Others look for editorial non-compliance issues like unnecessary white spaces. These jobs must be resolved before every release.
Q: Patrick, thanks for walking us through the “terminology assembly line.” Any final wisdom to share?
A: I think I would just stress that adding a new term involves far more than just adding a fresh entry to the IMO database. All new terms are channeled through a rigorous process consisting of extensive manual and automated review to ensure compliance with editorial policy. We also check that a new term is appropriately mapped to standardized terminologies, and that any product-specific requirements are met before the term goes live.
To learn more about why granular clinical terminology is the key to data quality success, check out our white paper, Specificity is the new black: A guide to greater reimbursement.
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