Categorization of free-text problem lists: an effective method of capturing clinical data

Abstract

Problem lists assist in organizing patient information in computer based medical records. However, in order to use problem lists for billing, research, decision support and standardization, a categorization of the problems entered is required. We describe the problem list component of our computerized patient record, the On-line Medical Record (OMR), which combines a free-text entry mechanism with a categorization scheme, using a dictionary containing 846 terms. All 118,040 problems entered during the system's six years of use have been analyzed, 477 clinicians have entered a mean +/- S.D. of 238 +/- 604 problems into 22,311 patient records. The average number of problems in each patient's file was 5.1 +/- 3.9. Comments were typed for 80,281 (68%) of the problems, ranging in length from 1 to 2456 characters, with a mean length of 98 +/- 110 characters. Half the problems were entered on the day of the encounter with the patient. Overall, 66% of all problems were categorized in relation to terms from the problem dictionary. Lexical analysis of all problem names showed that 80% could be mapped to Meta 1.4, Snomed 3.0 or a pre-release version of Read 3.0. We conclude that a problem list entry scheme combining free-text entry and optional categorization using a dictionary can result in a high proportion of problems being categorized as desired. Improvement of the system by elimination of unused dictionary terms and addition of 1000 terms identified by the lexical analysis is likely to result in even higher categorization rates.