Methodology to ease the construction of a terminology of problems

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. (c) 2005 Elsevier Ireland Ltd. All rights reserved.