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Just-in-time coding of the problem list in a clinical environment
J J Warren1, J Collins, C Sorrentino
1University of Nebraska Medical Center, Omaha, USA.
Proceedings. AMIA Symposium
|February 3, 1999
Summary
Standardizing clinical problem lists is crucial for electronic health records. UNMC developed a dynamic lexicon, mapped to standard classifications, to improve clinical terminology and data consistency.
Area of Science:
- Health Informatics
- Clinical Terminology
- Electronic Health Records
Background:
- Standardized problem lists are vital for Comprehensive Patient Records (CPR).
- A significant challenge in healthcare is establishing a unified clinical terminology.
- The University of Nebraska Medical Center (UNMC) addressed this by creating a specialized lexicon.
Purpose of the Study:
- To describe the development and ongoing maintenance of a clinical lexicon at UNMC.
- To support the creation of clinically useful problem lists within the CPR.
- To standardize medical terms for improved clinical communication and data management.
Main Methods:
- A just-in-time coding strategy was employed for lexicon maintenance.
- The lexicon was prospectively developed and extended within a dynamic clinical setting.
- Terms were systematically mapped to established classification schemes: ICD-9-CM, NANDA, and SNOMED International.
Main Results:
- The UNMC lexicon currently comprises approximately 12,000 terms.
- The lexicon facilitates standardized clinical problem list entries.
- The methodology supports a dynamic and evolving clinical vocabulary.
Conclusions:
- The developed lexicon provides a standardized terminology for clinical problem lists.
- Prospective maintenance using a just-in-time strategy ensures lexicon relevance.
- Mapping to multiple classification systems enhances interoperability and data utility.