Medical Terminology in the Digital age

Pamela Marasco MEd., CPC

If Hippocrates and Galen found themselves in the doctor’s lounge of any medical center today they would most certainly feel as if they were on another planet.

Essential Greek and Latin Etymology

• The written and spoken language of healthcare would have some elements (word roots, suffixes and prefixes) they would likely understand

• As the essential Greek and Latin origins and meanings of most medical terms remain the same

• But there would be a whole new vocabulary filled with acronyms, colloquial terms and medical jargon from a variety of sources

Lost in Translation

• Over the last several years there has been a gradual evolution in the circumstances, development and protocol regarding the use (and misuse) of medical terms in every specialty from pediatrics to podiatry

• Patients began to demand a user friendly vocabulary that wasn’t lost in translation

• Students felt that rather than learning “Medical Terminology: The Living Language (the title of a popular medical terminology textbook) they were translating Caesar’s Gallic Wars, studying a dead language from ancient texts

Popular Culture and Medical Terminology

• The gap was often filled by a set of medical terms base on popular culture more entertaining than accurate

• Medical jargon and slang began creeping into the language of medicine trivializing critically important concepts

• Terms like crispy critter (burn victim), deep fry (radiation therapy) and acronyms like FLK (funny looking kid) trivialized the critically important concept that medical terms were meant to be a standardized form of communication among health care professionals rather than street talk

Tower of Babel

A working vocabulary for health care professionals meant to avoid misunderstanding and minimize confusion had become the medical version of the tower of Babel with more than 100,000 plus medical terms currently in use with multiple meanings

Tower of Babel Syndrome

Little Chance of Slowing Down

• New techniques, procedures, research and cultural trends have created an exponential rate of growth in the field of medical terminology that shows little chance of slowing down

We All Need to Speak the Same Language

• With current changes in health care management and data sharing of medical information, physicians and healthcare providers as well as students, researchers, health care administrators, medical billers and coders and government agencies all need to be speaking the same language

Driven By Technology

• Medical terminology is undergoing a transformation to meet the needs of EHR (electronic health records), data mining, quality care improvement and meaningful use

• The jargon and acronyms alone used by the managed care industry requires its own playbook and a recent Google search of medical terminology and the government brought up 3,090,000 results

Common Digital Language

• Teachers, trainers and working professionals all realize the importance of re-standardizing our medical vocabulary

• To develop a common digital language that all stakeholders (healthcare providers, administrators, government agencies, computer programmers and informaticists) understand

• Classical medical terminology translated into a common digital format

Oceans of Data

• Various permutations of standardized medical terminology have already begun. These oceans of data were primarily designed either for medical billing and coding or to facilitate EHR (electronic health records) and computer cross mapping

• Their nomenclature remains scattered and despite their best efforts to address errors and inconsistencies, many errors and inconsistencies do exist

Current Languages in Use Include the Following Vocabularies

• National Institute of Health UMLS, or Unified Medical Language System (UMLS)

• A set of files and software that brings together various health and biomedical vocabularies and standards to enable interoperability between computer systems

Unified Medical Language System

Current Languages in Use Include the Following Vocabularies

• (SNOMED CT) Systematized Nomenclature of Medicine-Clinical Terms

• Described as the most comprehensive, multilingual clinical healthcare terminology in the world.

• Developed in the US by the College of American Pathologists and the National Health Service in the UK. Its design was based on identified user requirements, practical experience and scientific principles based on peer reviewed publications

• Maintained and distributed by the International Health Terminology Standards Development Organization (IHTSDO), a not-for-profit association which is owned and governed by its national members

• SNOMED currently contains more than 311,000 active concepts

SNOMED CT

Current Languages in Use Include the Following Vocabularies

• Kaiser Permanente's Convergent Medical Terminology (CMT)

• Allows clinicians to use familiar language to achieve standard electronic health information exchange

• According to Phil Fasano, Chief Information Officer at Kaiser Permanente, CMT is “designed to be seamless so clinicians see the familiar clinical language on their monitors while other users can see a simpler, translated version”

• In September 2009 Kaiser Permanente donated its CMT to the International Healthcare Terminology Standards Development Organization (IHTSDO) for U.S. distribution through the U.S. Department of Health and Human Services (HHS) to support data exchange between providers

Kaiser Permanente CMT

Provider Friendly Terminology (PFT)

• All represent current efforts to codify the language of healthcare with provider friendly terminology (PFT)

• Look to avoid multiple terms with the same meaning and eliminate redundancy

Havoc in Cyberland

• For example

• Reporting renal failure syndrome as RF, kidney failure, failure of the kidneys

• Reporting an abnormal computed tomography result as abnormal CAT scan, abnormal CT, computerized axial tomography result abnormal, CT scan result abnormal

• Can create havoc in cyber land with multiple terms with the same meaning and unnecessary redundancy

I Don’t Know What My Doctor is Talking About

• In addition a crosswalk vocabulary will bridge the gap between healthcare providers and patients who often complain “I know what my Doctor is talking about”

Why Is This Important?

• Digital data bases encourage the use of standardized medical terms with accurate, relevant data that can be confidently used and shared by professionals to ensure quality care and understood by patients to create a well-informed healthcare consumer

• Statistics can more easily be gathered and used to make decisions on future health care delivery

• Quality of care assessment, patient safety evaluation, public health surveillance and decision support algorithm development depend on reliable data

Usable Medical Vocabulary

• A sustainable data exchange depends on a usable medical vocabulary

• Those of us who are involved in the study and interpretation of medical data see the need for the classical language of medical terminology paired with appropriate colloquial terms to create a language adaptable to medical terminology in the digital age

• Bioinformatics seeks to improve the gathering, storing, organizing and sharing of digital biological and health data

• Analyzing information can lead to better problem solving, decision making and more informed choices about our country’s health care but only if we all speak the same language

Examples of Medical Terms Used in the Digital Age

• EHR - electronic health records also known as EMR (electronic medical records).

• BMI Charts (Body Mass Index Charts) - EMR systems can automatically calculate BMI from inputted height and weight information. BMI is used by an EMR system to generate prompts to clinicians regarding preventive health and disease management protocols.

• Electronic Protected Health Information (ePHI) - protected health information (PHI) which is stored, accessed, transmitted or received electronically.

• E Prescribing (also called electronic prescribing, electronic prescription, e-prescribing or eRX) - the electronic transmission of prescription information to and from the prescriber's computer and a pharmacy computer. It replaces a paper prescription that the patient would otherwise carry or fax to the pharmacy.

• Hospitalist - a physician who practices most of his or her time in hospitals and specializes in medical care to hospitalized patients. Hospital-based providers.

• Health informatics (also called healthcare informatics, biohealth informatics, medical informatics, biomedical informatics) - deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health and biomedicine.

• HITECH - the Health Information Technology for Economic and Clinical Health Act (HITECH Act) -legislation created to stimulate the adoption of electronic health records (EHR) and supporting technology in the United States. President Obama signed HITECH into law on February 17, 2009 as part of the American Recovery and Reinvestment Act of 2009 (ARRA).

• Interoperability - enables data and information generated by one system to be accessed and (re-)used in a meaningful way by another system