Musen M A, Wieckert K E, Miller E T, Campbell K E, Fagan L M
Section on Medical Informatics, Stanford University School of Medicine, CA, USA.
Methods Inf Med. 1995 Mar;34(1-2):85-95.
The creation of controlled medical terminologies is a central challenge in the development of electronic patient records. In the T-Helper patient-record system, designed for the care of patients with HIV disease, the IVORY module allows health-care workers to compose textual progress notes by making selections from menus generated automatically from a controlled medical terminology. Construction of this IVORY terminology required extensive design sessions with a team of computer scientists and an expert physician. Refinement of the terminology was only possible when the design team could envision how the completed T-Helper system would be used in the context of clinical practice. Development of controlled medical terminologies is a significant problem in knowledge acquisition. Techniques used to acquire and represent clinical concepts for the purpose of building decision-support systems also are appropriate for the construction of controlled terminologies such as the one in T-Helper.
创建受控医学术语是电子病历发展中的一项核心挑战。在专为艾滋病患者护理设计的T-Helper患者记录系统中，IVORY模块允许医护人员通过从由受控医学术语自动生成的菜单中进行选择来撰写文本病程记录。构建此IVORY术语需要与一组计算机科学家和一位专家医生进行广泛的设计会议。只有当设计团队能够设想完整的T-Helper系统在临床实践中如何使用时，术语的完善才有可能。受控医学术语的开发是知识获取中的一个重大问题。为构建决策支持系统而用于获取和表示临床概念的技术也适用于构建诸如T-Helper中的受控术语。
