&lt;title&gt;Technical challenges, past and future, in implementing THERESA: a one million patient, one billion item computer-based patient record and decision support system&lt;/title&gt;

Camp, Henry N.

doi:10.1117/12.231664

Health Care Information Infrastructure

1996

DOI: 10.1117/12.231664

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<title>Technical challenges, past and future, in implementing THERESA: a one million patient, one billion item computer-based patient record and decision support system</title>

Henry N. Camp¹

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“…19 In the private sector, Kaiser Permanente is deploying its clinical information system for encounter documentation across its eight regions. Numerous other organizations have made a commitment to computer-based patient record systems 10,[20][21][22][23][24][25][26][27] in hopes of improving information access.…”

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confidence: 99%

Derivation and Evaluation of a Document-naming Nomenclature

Brown¹,

Lincoln²,

Hardenbrook³

et al. 2001

Journal of the American Medical Informatics Association

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Derivation and Evaluation of a Document-naming Nomenclature

Brown¹,

Lincoln²,

Hardenbrook³

et al. 2001

Journal of the American Medical Informatics Association

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Empirical Derivation of an Electronic Clinically Useful Problem Statement System

et al. 1999

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Problem lists are tools to improve patient management. In the medical record, they connect diagnoses to therapy, prognosis, and psychosocial issues. Computer-based problem lists enhance paper-based approaches by enabling cost-containment and quality assurance applications, but they require clinically expressive controlled vocabularies. Because existing controlled vocabularies do not represent problem statements at a clinically useful level, we derived a new canonical problem statement vocabulary through semi-automated analysis and distillation of provider-entered problem lists collected over 6 years from 74,696 patients. We combined automated and manual methods to condense 891,770 problem statements entered by 1961 care providers at Grady Memorial Hospital in Atlanta, Georgia, to 15,534 Canonical Clinical Problem Statement System (CCPSS) terms. The nature and frequency of problem statements were characterized, interrelations among them were enumerated, and a database capturing the epidemiology of problems was created. The authors identified 23,503 problem relations (co-occurrences, sign-symptom complexes, and differential diagnoses) and 22,690 modifier words that further categorized "canonical" problems. To assess completeness, CCPSS content was compared with that of the 1997 Unified Medical Language System Metathesaurus (containing terms from 44 clinical vocabularies). Unified Medical Language System terms expressed 25% of individual CCPSS terms exactly (71% of problems by frequency), 27% partially, and 48% poorly or not at all. Clinicians judged that CCPSS terms completely captured their clinical intent for 84% of 686 randomly selected free-text problem statements. The CCPSS represents clinical concepts at a level exceeding that of previous approaches. A similar national approach could create a standardized, useful, shared resource for clinical practice.

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<title>Technical challenges, past and future, in implementing THERESA: a one million patient, one billion item computer-based patient record and decision support system</title>

Cited by 2 publications

References 0 publications

Derivation and Evaluation of a Document-naming Nomenclature

Derivation and Evaluation of a Document-naming Nomenclature

Empirical Derivation of an Electronic Clinically Useful Problem Statement System

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