Health Data Standards and Terminologies A Tutorial

2: Terminology Standards and Tools

Characteristics of a Standardized Terminology


A standardized medical terminology is a structured and systematically organized set of terms, concepts, and codes used in health care to describe clinical conditions, procedures, medications, and other healthcare-related topics in a consistent and uniform manner. These and other types of terminologies often use unique identifiers, have concepts or terms, and frequently include synonyms and relationships.

Standardized terminologies may have some or all of the following characteristics:

At the core of a standardized terminology are the concepts. A concept is a unique and unambiguous idea. These concepts are carefully defined and organized to cover the breadth and depth of the subject matter. Each concept has a unique identifier (i.e. code) and may include attributes such as synonyms and definitions.

Standardized terminologies typically assign unique codes or identifiers to each concept and its components, enabling efficient storage, retrieval, and exchange of data. These codes serve as shorthand references to concepts and facilitate interoperability across different systems and applications.

Each concept in a standardized terminology is accompanied by a description. A description is a human-readable phrase (term) that is assigned to an unambiguous concept. Each description may be assigned a unique identifier.
  • Terms - A term is a human readable text description that can act as the anchor meaning for the concept. A term is associated with a unique identifier using a data model in order to represent a concept.
  • Synonyms and Variants - Standardized terminologies often include synonyms or variant forms of terms to account for linguistic variations and diverse user preferences. Synonyms help ensure that users can find relevant information even if they use different terminology to describe the same concept.

A definition provides users with a precise understanding of the intended meaning of each term, reducing ambiguity and ensuring consistent interpretation across users and applications.

Standardized terminologies may define various types of relationships between concepts, beyond hierarchical relationships. These relationships can include associative relationships or other types of semantic connections between terms. For example, certain diseases occur in specific parts of the body. Therefore, the disease and part of the body are related but not in a hierarchical way.

Many standardized terminologies organize concepts into a hierarchical structure or taxonomy. This hierarchy establishes relationships between concepts, with broader concepts at the top and more specific concepts nested beneath them. Hierarchical organization facilitates navigation and categorization of concepts, enabling systematic retrieval from information systems and allowing users to explore related terms and find relevant information efficiently.

Overall, the anatomy of a standardized terminology is designed to provide a robust framework for representing and organizing knowledge within a specific domain, facilitating communication, semantic interoperability, and consistency across users and systems.

Reference vs. Interface Terminologies

Icon showing a laptop with health information

Terminologies have different purposes in different settings. In the clinical world, it is important to know the difference between a reference terminology and an interface terminology.

A reference terminology is a set of well-defined concepts and relationships that provide a common reference point for comparison and aggregation of data about the entire healthcare process. Reference terminologies can be used in healthcare for billing, insurance, data analysis and research, and decision support systems. SNOMED CT is a good example of a reference terminology.

Interface terminologies, also called application or entry terminologies, are systematic collections of healthcare-related phrases (terms) that support clinicians' entry of patient-related information into computer programs, like EHRs. Interface terminologies can be mapped to reference terminologies for storage, management, and analysis of clinical data.

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