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 |
Volume | 75 |
Issue | 8 |
Pagination | 624-32 |
Date Published | 2006 Aug |
ISSN | 1386-5056 |
Keywords | Medical Records, Problem-Oriented, Terminology as Topic |
Abstract | 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. |
DOI | 10.1016/j.ijmedinf.2005.08.011 |
Alternate Journal | Int J Med Inform |
PubMed ID | 16219485 |