Why Standardising Clinical Terminology is Necessary: A Guide for Digital Health Leaders

Digital transformation in healthcare isn’t just about implementing new systems—it’s about ensuring that the information flowing through those systems is accurate, meaningful, and safe. At the heart of this challenge lies a deceptively simple question:

Do we all speak the same clinical language?

For most organisations, the honest answer is not really.
Different departments, systems, and clinicians often use different words to describe the same thing. Free‑text documentation, local codes, inconsistent abbreviations, and legacy terminology all contribute to a fragmented data landscape.

This is why standardising clinical terminology is not optional—it is foundational. For digital health leaders, it is one of the most important strategic investments you can make.

What Do We Mean by “Clinical Terminology”?

Clinical terminology refers to the structured, coded language used to represent clinical concepts such as:

• diagnoses
• symptoms
• procedures
• medications
• allergies
• observations
• social determinants of health

Example standardised terminologies can include:

• SNOMED CT – the core clinical terminology
• LOINC – laboratory and observation identifiers
• ICD‑10‑AM – statistical classification
• AMT – Australian Medicines Terminology

These standards ensure that clinical information is represented consistently across systems.

Why Standardisation Matters: The Case for Digital Health Leaders

1. Patient Safety Depends on Clear, Unambiguous Data

When clinicians document using free text or inconsistent terms, systems cannot reliably:

• trigger decision support
• detect allergies
• identify risks
• surface relevant history
• support clinical handover

Standardised terminology ensures that “heart attack,” “MI,” and “myocardial infarction” all map to the same precise concept. This reduces clinical risk and supports safer care.

2. Interoperability Fails Without Standard Terminology

You can build the best FHIR APIs in the world, but if the underlying data is inconsistent, the exchange will still be complex and not easily scaled.

Standard terminology is what makes interoperability clinically useful—not just technically possible.

It ensures that:

• EMRs can talk to each other
• pathology and imaging results integrate cleanly
• primary care and hospital systems align
• national programs (e.g., My Health Record) receive usable data

Without terminology standardisation, interoperability becomes a patchwork of mappings, workarounds, and manual fixes.

3. Data Quality Is a Strategic Asset

High‑quality data is essential for:

• analytics and reporting
• population health management
• risk stratification
• quality improvement
• AI and machine learning
• research and registries

Poor terminology = poor data.
Poor data = poor decisions.

Digital health leaders who prioritise terminology governance unlock the full value of their data assets.

4. Clinical Decision Support Relies on Structured Terminology

Decision support tools—alerts, reminders, order sets, risk scores—depend on coded data.

If a diagnosis is entered as free text (“chest infection?”), the system cannot:

• detect deterioration
• recommend guidelines
• check medication interactions
• identify contraindications

Standardised terminology makes decision support reliable, safe, and scalable.

5. Standardisation Reduces Duplication and Variation

Without terminology governance, organisations accumulate:

• multiple names for the same concept
• inconsistent problem lists
• duplicated codes
• local “workarounds”
• legacy terms that no longer reflect best practice

This creates clinical confusion and administrative burden.

Standardisation simplifies the ecosystem and reduces waste.

6. It Future‑Proofs Your Digital Transformation

As healthcare moves toward:

• virtual care
• remote monitoring
• AI‑driven insights
• precision medicine
• national interoperability frameworks

…standardised terminology becomes even more critical.

It ensures your organisation can adopt new technologies without costly rework or data cleansing.

What Happens When Terminology Isn’t Standardised?

Digital health leaders can often see the symptoms before they recognise the cause:

• inconsistent problem lists
• failed integrations
• unreliable dashboards
• mismatched codes between systems
• manual data reconciliation work
• poor performing decision support
• poor quality data
• safety incidents linked to digital workflows

These are not always technology failures—they are can also be atributed to terminology failures.

How to Lead Terminology Standardisation in Your Organisation

1. Establish a Terminology Governance Framework

This includes:

• a terminology committee
• clear decision‑making processes
• change control
• version management
• alignment with national standards

2. Adopt National Standards

Use recommended terminologies:

• SNOMED CT‑AU for clinical concepts
• LOINC for observations
• AMT for medicines

3. Integrate Terminology Into System Design

Ensure terminology is embedded in:

• EMR configuration
• FHIR profiles
• templates and forms
• decision support rules
• data models

4. Invest in Clinical Engagement

Clinicians must understand:

• why terminology matters
• how to use structured documentation
• how it improves safety and workflow

5. Monitor Data Quality

Use dashboards to track:

• completeness
• accuracy
• consistency
• mapping errors
• terminology drift

6. Build Capability in Clinical Informatics

Clinical informaticians are essential for:

• modelling clinical concepts
• designing workflows
• ensuring usability
• aligning terminology with practice
  

Final Thoughts

Standardising clinical terminology is not a technical exercise—it is a clinical safety strategy, a data quality strategy, and a digital transformation strategy.

For digital health leaders, it is one of the most powerful levers you have to improve care, reduce risk, and unlock the value of your digital investments.