Empirical derivation of an electronic clinically useful problem statement system

Problem lists are tools to improve patient management. In the medical recor d, they connect diagnoses to therapy, prognosis, and psychosocial issues. C omputer-based problem lists enhance paper-based approaches by enabling cost -containment and quality assurance applications, but they require clinicall y expressive controlled vocabularies. Because existing controlled vocabular ies do not represent problem statements at a clinically useful level, we de rived a new canonical problem statement vocabulary through semi-automated a nalysis and distillation of provider-entered problem lists collected over 6 years from 74 696 patients. We combined automated and manual methods to co ndense 891 770 problem statements entered by 1961 care providers at Grady M emorial Hospital in Atlanta, Georgia, to 15 534 Canonical Clinical Problem Statement System (CCPSS) terms. The nature and frequency of problem stateme nts were characterized, interrelations among them were enumerated, and a da tabase capturing the epidemiology of problems was created. The authors iden tified 23 503 problem relations (co-occurrences, sign-symptom complexes, an d differential diagnoses) and 22 690 modifier words that further categorize d "canonical" problems, To assess completeness, CCPSS content was compared with that of the 1997 Un ified Medical Language System Metathesaurus (containing terms from 44 clini cal vocabularies). Unified Medical Language System terms expressed 25% of i ndividual CCPSS terms exactly (71% of problems by frequency), 27% partially , and 48% poorly or not at all. Clinicians judged that CCPSS terms complete ly captured their clinical intent for 84% of 686 randomly selected free-tex t problem statements. The CCPSS represents clinical concepts at a level exc eeding that of previous approaches. A similar national approach could creat e a standardized, useful, shared resource for clinical practice.