Empirical derivation of an electronic clinically useful problem statement system.

Problem lists are tools to improve patient management. In the medical record, they connect diagnoses to therapy, prognosis, and psychosocial issues. Computer-based problem lists enhance paper-based approaches by enabling cost-containment and quality assurance applications, but they require clinically expressive controlled vocabularies. Because existing controlled vocabularies do not represent problem statements at a clinically useful level, we derived a new canonical problem statement vocabulary through semi-automated analysis and distillation of provider-entered problem lists collected over 6 years from 74,696 patients. We combined automated and manual methods to condense 891,770 problem statements entered by 1961 care providers at Grady Memorial Hospital in Atlanta, Georgia, to 15,534 Canonical Clinical Problem Statement System (CCPSS) terms. The nature and frequency of problem statements were characterized, interrelations among them were enumerated, and a database capturing the epidemiology of problems was created. The authors identified 23,503 problem relations (co-occurrences, sign-symptom complexes, and differential diagnoses) and 22,690 modifier words that further categorized "canonical" problems. To assess completeness, CCPSS content was compared with that of the 1997 Unified Medical Language System Metathesaurus (containing terms from 44 clinical vocabularies). Unified Medical Language System terms expressed 25% of individual CCPSS terms exactly (71% of problems by frequency), 27% partially, and 48% poorly or not at all. Clinicians judged that CCPSS terms completely captured their clinical intent for 84% of 686 randomly selected free-text problem statements. The CCPSS represents clinical concepts at a level exceeding that of previous approaches. A similar national approach could create a standardized, useful, shared resource for clinical practice.

Changes in the internal medicine internship from 1967 to 1987: explanations for decreasing interest in the discipline?

We compared the schedules and responsibilities of medical interns at an urban university hospital in 1967 with those in 1987. We analyzed admissions, length of stay, diagnostic problems, demographic data on interns, changes in diagnostic and therapeutic options, and number and type of consultations. The intern in 1987 spent less time in the hospital but had more admissions, more interruptions, more clerical responsibilities, and more therapeutic and diagnostic options, and was more dependent on senior colleagues with special expertise. For these reasons the intern in 1987 had less time with individual patients and less autonomy than his 1967 counterpart. Recognition and modification of the negative aspects of medicine interns' experience will increase the attractiveness of internal medicine residencies.

Grady Memorial's integrated database improves speed, accuracy and cost containment.

No one at Grady knows exactly how many lives THERESA has saved since it went online in 1983. It is certain that the computerized medical information system has speeded medical care delivery, improved diagnosis accuracy and cut costs at the third largest hospital in the United States.

Terry's nails: revised definition and new correlations.

The fingernails of 512 consecutive hospital inpatients were examined and Terry's nails (by criteria modified slightly from those of Terry) were found in 25.2%. The nail abnormality was associated with the presence of cirrhosis, chronic congestive heart failure, and adult-onset diabetes mellitus, and was also associated with age. In younger patients the nail disorder was associated with an increased risk of systemic disease. Tissue biopsy showed that the nail abnormality was due to distal telangiectasias.