- Consistent clinical terminology is essential for clean, reusable healthcare data.
- Editorial governance helps reduce ambiguity and improve interoperability.
- IMO Health combines terminology standards with the flexibility clinicians need.
- Terminology precision supports data quality, patient safety, and compliance.
- Decades of terminology expertise help advance AI-ready healthcare data.
The blueprint for IMO Health’s clinical terminology
Documenting patient care is kind of like ordering a salad (stay with me). The more elements or customizations you include, the greater the chance something gets lost along the way.
Now imagine that kind of inconsistency occurring across millions of healthcare data records every day. Small wording differences can snowball once information starts moving between systems, teams, and workflows.
When clinicians document patient care, every word matters. The way a diagnosis is phrased, the placement of a modifier, or even the use of an abbreviation can shape how healthcare data is interpreted, exchanged, analyzed, and reused later. Understandably, most providers aren’t thinking about the editorial side of clinical terminology while they’re documenting care, but that behind-the-scenes work has a huge impact on whether healthcare data ends up useful or just messy and inconsistent.
At IMO Health, that editorial work has always been critical. For years, we have maintained an extensive internal editorial policy framework that guides how terminology is created, reviewed, structured, and maintained across its clinical content offerings. Customers never actually see these policies, though they influence every piece of terminology IMO Health delivers.
As Julie Glasgow, MD, Senior Staff Clinical Terminologist at IMO Health, puts it, these guidelines are the “hidden superpower” behind our terminology quality and central to why our content is known across the industry for its consistency and reliability.
Why editorial consistency matters in healthcare
Healthcare organizations generate huge amounts of clinical data every day, but much of it becomes difficult to reuse when documentation is inconsistent. Freeform, or unstructured, documentation can introduce:
- Misspellings and typos
- Ambiguous abbreviations
- Inconsistent phrasing and duplicate terminology
- Formatting differences that create interoperability challenges later on
Glasgow points to acronyms as a simple example of how quickly ambiguity can show up in healthcare documentation.
The acronym AMA could mean “advanced maternal age,” “against medical advice,” or even the “American Medical Association,” depending on the context. A clinician may know exactly what they mean in the moment, but once that data moves elsewhere in the healthcare system, its meaning can become unclear quickly.
Without strong editorial governance, healthcare organizations can end up with data that is fragmented and difficult to standardize.
“Data will be only as good as the least careful documenter,” Glasgow said.
Read our eBook, Specificity in clinical documentation: 5 considerations for revenue optimization, to go deeper into the value of precise documentation.
A living framework built for precision
IMO Health’s editorial policy is not just a static style guide collecting dust in a drawer. It’s a living dictionary that evolves alongside medical standards, coding systems, customer needs, and new clinical use cases. The policies cover every clinical domain within IMO Health’s terminology offerings, including diagnoses, procedures, medications, surgical terminology, and specialty-specific content areas.
Each domain has its own rules and nuances, while broader standards help keep everything consistent across the board. Those standards cover things like capitalization, punctuation, abbreviations, pluralization, and clinical terminology phrasing.
One thing Glasgow emphasized is the level of rigor involved – IMO Health documents nearly every editorial decision, even when it seems minor. Over time, that approach has created a very detailed editorial knowledge base that supports consistency across millions of terminology records.
“Using the word obsessive probably is not an overstatement,” she joked.
Supporting both consistency and flexibility
One of the trickier parts of terminology management is balancing standardization with how clinicians naturally document care.
IMO Health handles that through an internal structure built around concepts and lexicals, known as IMO IDs. A concept represents a single unit of clinical meaning, while multiple IMO IDs can exist beneath that concept to reflect different ways clinicians may phrase the same idea.
Each concept includes:
- A primary “default” description that follows our strictest editorial requirements
- Alternate descriptions that support more familiar or flexible phrasing
- Additional flexibility for common misspellings and terminology variations
For instance, the default description “acute febrile mucocutaneous lymph node syndrome” has a default description that may be more familiar to clinicians: “Kawasaki disease.” This structure enables us to support alternate phrasing while still preserving the consistency underneath it all, explained Glasgow.
Editorial rigor that supports patient safety
The impact of editorial consistency goes beyond cleaner data. In some situations, terminology precision can directly support safer care.
Glasgow highlighted the importance of carefully managing the use of “and” versus “or” in terminology descriptions, as ambiguity between the two can pose a meaningful clinical risk. IMO Health’s editorial standards explicitly govern how conjunctions are used so clinical terminology stays as clear as possible, even if the phrasing occasionally sounds less natural.
“We will word something a little bit awkwardly just to make sure the ‘and’ or the ‘or’ is crystal clear,” Glasgow said.
The editorial framework also includes policies designed to minimize the use of offensive or stigmatizing terminology whenever possible, while still maintaining compliance with required standards such as ICD-10-CM.
Building a stronger foundation for interoperability and AI
As healthcare organizations continue to invest in interoperability, analytics, and AI, the value of structured, reusable clinical data continues to grow.
According to Glasgow, the decades IMO Health has spent documenting editorial decisions are now creating new opportunities for AI-assisted workflows. Because those editorial standards are so clearly defined and consistently applied, AI systems can operate with greater accuracy and reliability when informed by that framework.
“It’s allowing us to turbocharge our AI efforts,” she said.
Most healthcare organizations simply do not have the resources or expertise to maintain this level of terminology governance internally, which is one reason why IMO Health has remained so valuable in the ecosystem.
By maintaining a centralized, highly governed terminology framework, IMO Health helps healthcare organizations produce cleaner, more interoperable, and more trustworthy clinical data without forcing clinicians to become terminology experts themselves. These efforts are now a springboard for what comes next: advancing the next generation of clinical data capabilities with the same rigor, reliability, and trust that have always defined IMO Health’s content.
“We’re happy to take on the role of being the total perfectionist, so our customers don’t have to,” Glasgow said.
Learn more about IMO IDs, a critical element of our terminology framework.
Looking for more specific use cases? Schedule a demo here.
