|Title||Methodology to ease the construction of a terminology of problems.|
|Publication Type||Journal Article|
|Year of Publication||2006|
|Authors||Fabry, P, Baud, R, Ruch, P, Despont-Gros, C, Lovis, C|
|Journal||International journal of medical informatics|
|Date Published||2006 Aug|
|Keywords||Medical Records, Problem-Oriented, Terminology as Topic|
INTRODUCTION: Problem lists summarize an aspect of the patient's medical history and provide an important way to implement entry points for clinical pathways and guideline-oriented care. However, in order to automate processes based on problem lists, the use of controlled vocabularies is required. We developed a methodology to extract a collection of standardized problem-related terms from medical documents entered in free text by physicians.
METHODS: We extracted a corpus of sentences describing problems from a randomized selection of admission notes collected at the University Hospitals of Geneva. Theses sentences underwent manual and automatic normalization processes, and a statistical clustering, in order to build a set of terms.
RESULTS: We obtained 17,805 sentences from 5000 admission notes. We refined them into 1546 terms, 88.6% of which could be related to a relevant problem statement.
DISCUSSION: A clinically relevant problems terminology was derived from clinical admission notes in free-text using a few methodical steps with a reasonable investment of human resources. Such an approach will ease the development and the use of problem lists better suited to user needs.
|Alternate Journal||Int J Med Inform|