In 2003, the National Committee on Vital and Health Statistics (NCVHS) recommended the first set of clinical terminologies as national standards: Snomed CT, RxNorm, and LOINC. At that time the use of these reference terminology standards was voluntary, as it officially still is.

Medicomp, however, has long taken the approach that reporting and compliance based on these standards will become mandatory by 2015. The requirements to demonstrate Meaningful Use (MU) and to track PQRS standards are just the beginning.

Up to this point, the use of clinical terminologies has focused on reporting, such as tracking a certain number of measures for Stage 1 MU reporting. Later MU stages will likely call for providers to submit the detailed data in reference terminology format. The number of mappings required to support this functionality is currently more than 500,000 and will eventually be in the millions as the number of PQRS measures increase.

While the use of standards offers numerous benefits, the implementation of clinical terminologies adds a layer of complexity to the documentation and reporting process. These complexities only increase with the introduction of new care models that require the exchange of clinical data and even more reporting requirements.

Several new models, for example, require that all persons involved in the care of a patient coordinate their efforts. This includes physicians, nurses, allied health professionals, home caregivers, and even patients themselves. Currently different types of providers use different data definitions: physicians employ terminology such as ICD-10, ICD-9, Snomed CT, RxNorm, LOINC, DSM-IV, and CPTs, while nurses use terms like NANDA, NIC, NOC, ICNP, PNDS, and CCC. Creating an integrated picture of patient care can be quite challenging when terminology is inconsistent.

The proliferation of Health Information Exchanges (HIEs) will also impact the use of terminology standards. Within five years providers will be expected to routinely receive and update their records based on an increasing volume of incoming transactions from other providers and HIEs. This exchange of clinical data has the potential to greatly improve the care process, but only if the information is easily discernible at the point of care, and not just as an array of data points in Snomed, RxNorm, LOINC, and ICD formats.

Medicomp understand the challenges associated with inconsistent terminology. That is why we continue to expand on the hundreds of thousands of intelligent links we have already created between the reference terminology standards and the MEDCIN concepts that providers use at the point of care. Currently our mappings cover more than 99% of the volume of all transactions in each domain, and within the next year Medicomp’s Coding Service will include the ability to do “reverse-lookups” from any supported reference code (such as SNOMED) to MEDCIN, and then filter incoming codes using the MEDCIN diagnostic index.

Medicomp is also working to create new functionality that integrates physician/nursing/allied health documentation and care planning. We have spent the last five years designing utilities that integrate physician and nurse documentation and offer the ability to quickly and intuitively input clinical information at the point of care. We will launch the results of these efforts later this year in a module that ties nursing actions with detailed protocols. These protocols will link with the same MEDCIN concepts that have been tied to physician documentation in our previous MEDCIN offerings, including the MEDCIN prompting engine.