Providing a standardised health language in Norway
Successful interoperability between the various health and care services is essential for ensuring proper treatment for patients. This standardised health language can be described as an ecosystem of health-related terminology, with medical classifications and variables in context.
Bellow you find the english summary of the document Common health language.
Download the document Felles språk i helse- og omsorgssektoren Målbilde versjon 1.0 (PDF, Norwegian)
Successful interoperability between the various actors in health and care services is essential for ensuring proper treatment for patients. Successful interoperability also provides significant socio-economic benefits. Interoperability across administrative sectors and between the parties involved in health and care services is however, still deficient. In order to ensure good interaction in the sector, interoperability must be established in several areas. The European Interoperability Framework (EIF) divides interoperability into the following four layers: legal, organisational, semantic and technical.
The vision Common health language contributes to increased semantic interoperability. The vision expands on the objective of an ecosystem for terminology and code lists. It also reinforces interoperability in the health and care services sector by helping ensure that all parties involved understand the information correctly. We are currently at a stage where terminology (ontologies) and new generations of healthcare solutions will give entirely new opportunities. This vision describes the direction for development and the level of ambition we must assume if we are to exploit these opportunities. The Norwegian Directorate of eHealth (NDE) shall work on the basis of experience and obtain new experience during the process.
The purpose of this document is to describe the vision that paves the way for semantic interoperability within the health and care services sector via Common health language. It will not be possible to realise the benefits on a large scale unless Common health language is appropriately utilised in eHealth systems. The vision expands on the objective of Common health language – an ecosystem for terminology and classifications. The foundations have been laid for this vision through a program for health classifications and terminology. This vision is based on the study of the SNOMED CT terminology and the review of current challenges and future opportunities. The vision is in line with international trends in the field. These trends are monitored carefully.
Our citizens require access to simple and secure digital services. They also require access to updated and necessary health information, irrespective of where they have received medical assistance previously. Citizens and patients also need to be able to understand the information they receive from the health and care services.
Healthcare professionals need data to be recorded once only, in a clinically relevant language and with the correct level of accuracy. They also need data to be collected automatically where possible. It has to be possible for health information to be documented, communicated, understood and utilised unambiguously by all parties involved, both for the purpose of documenting clinical activities and for administrative follow-up of patient treatment. We need a common understanding of information shared between those who meet people weather they are patients or dependents. With Common health language, we can help ensure that data is understood and follows a patient throughout a treatment cycle.
Common health language
We define Common health language as an ecosystem of health-related terminology, classifications and variables in context. These shall be used in structured documentation of information in the health sector's ICT systems (like the electronic health record system (EHR)– for example, the information entered by a doctor in a journal after meeting a patient. Common health language does not take into account which information is to be structured or how this is performed. Electronic health records (EHR) will still include free text as an important element for documentation. However, where structure has been or will be introduced in EHRs, the contents of the structure shall be registered using Common health language.
Common health languag also includes the relationships that link a term, and a code, to other code lists, classifications, and registry variables. The goal is to ensure that information utilised during patient treatment can be reused after having been recorded one time only. Furthermore, the various terminologies and code lists will be used for the purpose for which they are designed, e.g. statistical and reimbursement purposes. Common language consists of terminologies, administrative code lists, medical classifications and health registry variables. With Common health language, these elements are interconnected.
Health-related termsmay have one or more synonyms. Different terms can be used to describe the same concept in different contexts. A GP may choose to describe a concept with a different term than that used by a specialist, or with the term a patient can understand.
This document has been compiled for the decision-makers within the health and care services sector who are responsible for digitalisation, technology and eHealth. The document may also be useful for those who plan, coordinate or facilitate guidelines and codes for patient records or patient-related administrative data. Examples of the above are individuals responsible for coding and documentation in clinical practice or persons responsible for health registries, quality work or research. The document may also be useful for persons responsible for planning architecture, ICT support and data management in the health and care services sector.