Development of a controlled medical terminology: knowledge acquisition and knowledge representation

Area of Science:

• Medical Informatics
• Health Information Technology
• Knowledge Representation

Background:

• Electronic patient records (EPRs) require controlled medical terminologies for data standardization.
• Developing these terminologies presents a significant knowledge acquisition challenge.
• The T-Helper system addresses HIV patient care using a novel approach.

Purpose of the Study:

• To describe the development of the IVORY module's controlled medical terminology for the T-Helper EPR system.
• To illustrate the process of constructing and refining clinical terminologies for practical application.
• To highlight the importance of user-centered design in medical informatics.

Main Methods:

• Collaborative design sessions involving computer scientists and physicians.
• Iterative refinement of the terminology based on envisioned clinical practice.
• Leveraging knowledge acquisition techniques for clinical concept representation.

Main Results:

• Successful creation of the IVORY controlled medical terminology for the T-Helper system.
• Demonstrated feasibility of menu-driven progress note composition for healthcare workers.
• Established a methodology for terminology development applicable to decision-support systems.

Conclusions:

• Controlled medical terminologies are crucial for effective EPR systems.
• Interdisciplinary collaboration and clinical context are vital for successful terminology development.
• The methods used for IVORY are transferable to building other controlled terminologies and decision-support tools.