메뉴 건너뛰기




Volumn 18, Issue 2, 2011, Pages 181-186

Data from clinical notes: A perspective on the tension between structure and flexible documentation

Author keywords

[No Author keywords available]

Indexed keywords

ACCURACY; ARTICLE; CLINICAL ASSESSMENT; COMPUTER SYSTEM; DATA ANALYSIS; ELECTRONIC MEDICAL RECORD; HEALTH CARE PERSONNEL; INFORMATION RETRIEVAL; MEDICAL DOCUMENTATION; PATIENT CARE;

EID: 79953093873     PISSN: 10675027     EISSN: 1527974X     Source Type: Journal    
DOI: 10.1136/jamia.2010.007237     Document Type: Article
Times cited : (262)

References (124)
  • 1
    • 0025620976 scopus 로고
    • The evolution, uses, and present problems of the patient's medical record as exemplified by the records of the New York Hospital from 1793 to the present
    • Engle RL Jr. The evolution, uses, and present problems of the patient's medical record as exemplified by the records of the New York Hospital from 1793 to the present. Trans Am Clin Climatol Assoc 1991;102:182-9.
    • (1991) Trans Am Clin Climatol Assoc , vol.102 , pp. 182-189
    • Engle Jr., R.L.1
  • 2
    • 0014973814 scopus 로고
    • Quality control and the medical record
    • Weed LL. Quality control and the medical record. Arch Intern Med 1971;127:101-5.
    • (1971) Arch Intern Med , vol.127 , pp. 101-105
    • Weed, L.L.1
  • 4
    • 0034170165 scopus 로고    scopus 로고
    • Can history and physical examination be used as markers of quality? An analysis of the initial visit note in musculoskeletal care
    • Solomon DH, Schaffer JL, Katz JN, et al. Can history and physical examination be used as markers of quality? An analysis of the initial visit note in musculoskeletal care. Med Care 2000;38:383-91.
    • (2000) Med Care , vol.38 , pp. 383-391
    • Solomon, D.H.1    Schaffer, J.L.2    Katz, J.N.3
  • 6
    • 0015080824 scopus 로고
    • The problem oriented record as a basic tool in medical education, patient care and clinical research
    • Weed LJ. The problem oriented record as a basic tool in medical education, patient care and clinical research. Ann Clin Res 1971;3:131-4.
    • (1971) Ann Clin Res , vol.3 , pp. 131-134
    • Weed, L.J.1
  • 7
    • 0015516552 scopus 로고
    • Assessing quality of care from the medical record
    • Fessel WJ, Van Brunt EE. Assessing quality of care from the medical record. N Engl J Med 1972;286:134-8.
    • (1972) N Engl J Med , vol.286 , pp. 134-138
    • Fessel, W.J.1    Van Brunt, E.E.2
  • 8
    • 0021338749 scopus 로고
    • Assessing the quality of emergency care: the medical record versus patient outcome
    • Murphy JG, Jacobson S. Assessing the quality of emergency care: the medical record versus patient outcome. Ann Emerg Med 1984;13:158-65.
    • (1984) Ann Emerg Med , vol.13 , pp. 158-165
    • Murphy, J.G.1    Jacobson, S.2
  • 9
    • 0016053352 scopus 로고
    • The importance of medical records
    • Holder AR. The importance of medical records. JAMA 1974;228:118-19.
    • (1974) JAMA , vol.228 , pp. 118-119
    • Holder, A.R.1
  • 10
    • 0024884327 scopus 로고
    • The diagnostic importance of the history and physical examination as determined by the use of a medical decision support system
    • Wagner MM, Bankowitz RA, McNeil M, et al. The diagnostic importance of the history and physical examination as determined by the use of a medical decision support system. SCAMC 1989:139-44.
    • (1989) SCAMC , pp. 139-144
    • Wagner, M.M.1    Bankowitz, R.A.2    McNeil, M.3
  • 12
    • 0019304780 scopus 로고
    • Functional characteristics of a computerized medical record
    • Hammond WE, Stead WW, Straube MJ, et al. Functional characteristics of a computerized medical record. Methods Inf Med 1980;19:157-62.
    • (1980) Methods Inf Med , vol.19 , pp. 157-162
    • Hammond, W.E.1    Stead, W.W.2    Straube, M.J.3
  • 13
    • 0030720495 scopus 로고    scopus 로고
    • Implementation of clinical guidelines using a computer charting system. Effect on the initial care of health care workers exposed to body fluids
    • Schriger DL, Baraff LJ, Rogers WH, et al. Implementation of clinical guidelines using a computer charting system. Effect on the initial care of health care workers exposed to body fluids. JAMA 1997;278:1585-90.
    • (1997) JAMA , vol.278 , pp. 1585-1590
    • Schriger, D.L.1    Baraff, L.J.2    Rogers, W.H.3
  • 14
    • 0034062477 scopus 로고    scopus 로고
    • Implementation of clinical guidelines via a computer charting system: effect on the care of febrile children less than three years of age
    • Schriger DL, Baraff LJ, Buller K, et al. Implementation of clinical guidelines via a computer charting system: effect on the care of febrile children less than three years of age. J Am Med Inform Assoc 2000;7:186-95.
    • (2000) J Am Med Inform Assoc , vol.7 , pp. 186-195
    • Schriger, D.L.1    Baraff, L.J.2    Buller, K.3
  • 15
    • 0035749057 scopus 로고    scopus 로고
    • Usability evaluation of the progress note construction set
    • Brown SH, Hardenbrook S, Herrick L, et al. Usability evaluation of the progress note construction set. Proc AMIA Symp 2001:76-80.
    • (2001) Proc AMIA Symp , pp. 76-80
    • Brown, S.H.1    Hardenbrook, S.2    Herrick, L.3
  • 16
    • 14644417205 scopus 로고    scopus 로고
    • Computer-based documentation: effect on parent and physician satisfaction during a pediatric health maintenance encounter
    • Johnson KB, Serwint JR, Fagan LM, et al. Computer-based documentation: effect on parent and physician satisfaction during a pediatric health maintenance encounter. Arch Pediatr Adolesc Med 2005;159:250-4.
    • (2005) Arch Pediatr Adolesc Med , vol.159 , pp. 250-254
    • Johnson, K.B.1    Serwint, J.R.2    Fagan, L.M.3
  • 17
    • 45849109216 scopus 로고    scopus 로고
    • Preliminary development of the physician documentation quality instrument
    • Stetson PD, Morrison FP, Bakken S, et al. Preliminary development of the physician documentation quality instrument. J Am Med Inform Assoc 2008;15:534-41.
    • (2008) J Am Med Inform Assoc , vol.15 , pp. 534-541
    • Stetson, P.D.1    Morrison, F.P.2    Bakken, S.3
  • 19
    • 33847640918 scopus 로고    scopus 로고
    • Cognitive factors influencing perceptions of clinical documentation tools
    • Rosenbloom ST, Crow AN, Blackford JU, et al. Cognitive factors influencing perceptions of clinical documentation tools. J Biomed Inform 2007;40:106-13.
    • (2007) J Biomed Inform , vol.40 , pp. 106-113
    • Rosenbloom, S.T.1    Crow, A.N.2    Blackford, J.U.3
  • 20
    • 3042765729 scopus 로고    scopus 로고
    • Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians
    • Embi PJ, Yackel TR, Logan JR, et al. Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians. J Am Med Inform Assoc 2004;11:300-9.
    • (2004) J Am Med Inform Assoc , vol.11 , pp. 300-309
    • Embi, P.J.1    Yackel, T.R.2    Logan, J.R.3
  • 21
    • 0031136464 scopus 로고    scopus 로고
    • The barriers to electronic medical record systems and how to overcome them
    • McDonald CJ. The barriers to electronic medical record systems and how to overcome them. J Am Med Inform Assoc 1997;4:213-21.
    • (1997) J Am Med Inform Assoc , vol.4 , pp. 213-221
    • McDonald, C.J.1
  • 22
    • 11144296823 scopus 로고    scopus 로고
    • Factors and forces affecting EHR system adoption: report of a 2004 ACMI discussion
    • Ash JS, Bates DW. Factors and forces affecting EHR system adoption: report of a 2004 ACMI discussion. J Am Med Inform Assoc 2005;12:8-12.
    • (2005) J Am Med Inform Assoc , vol.12 , pp. 8-12
    • Ash, J.S.1    Bates, D.W.2
  • 23
    • 1542327773 scopus 로고    scopus 로고
    • Some unintended consequences of information technology in health care: the nature of patient care information system-related errors
    • Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 2004;11:104-12.
    • (2004) J Am Med Inform Assoc , vol.11 , pp. 104-112
    • Ash, J.S.1    Berg, M.2    Coiera, E.3
  • 24
    • 0032161272 scopus 로고    scopus 로고
    • Physician data entry: providing options is essential
    • 8, 90-2
    • Gilbert JA. Physician data entry: providing options is essential. Health Data Manag 1998;6:84-6, 8, 90-2.
    • (1998) Health Data Manag , vol.6 , pp. 84-86
    • Gilbert, J.A.1
  • 25
    • 4344614397 scopus 로고    scopus 로고
    • Brainstorming about next-generation computer-based documentation: an AMIA clinical working group survey
    • Johnson KB, Ravich WJ, Cowan JA Jr. Brainstorming about next-generation computer-based documentation: an AMIA clinical working group survey. Int J Med Inform 2004;73:665-74.
    • (2004) Int J Med Inform , vol.73 , pp. 665-674
    • Johnson, K.B.1    Ravich, W.J.2    Cowan Jr., J.A.3
  • 26
    • 0031698169 scopus 로고    scopus 로고
    • Is asthma documentation improved by computer-facilitated data entry?
    • Kabir A, Hanson R, Mellis CM, et al. Is asthma documentation improved by computer-facilitated data entry? J Qual Clin Pract 1998;18:187-93.
    • (1998) J Qual Clin Pract , vol.18 , pp. 187-193
    • Kabir, A.1    Hanson, R.2    Mellis, C.M.3
  • 27
    • 3042726399 scopus 로고    scopus 로고
    • Experience in implementing inpatient clinical note capture via a provider order entry system
    • Rosenbloom ST, Grande J, Geissbuhler A, et al. Experience in implementing inpatient clinical note capture via a provider order entry system. J Am Med Inform Assoc 2004;11:310-15.
    • (2004) J Am Med Inform Assoc , vol.11 , pp. 310-315
    • Rosenbloom, S.T.1    Grande, J.2    Geissbuhler, A.3
  • 28
    • 0030695490 scopus 로고    scopus 로고
    • Transition to a computer-based record using scannable, structured encounter forms
    • Shiffman RN, Brandt CA, Freeman BG. Transition to a computer-based record using scannable, structured encounter forms. Arch Pediatr Adolesc Med 1997;151:1247-53.
    • (1997) Arch Pediatr Adolesc Med , vol.151 , pp. 1247-1253
    • Shiffman, R.N.1    Brandt, C.A.2    Freeman, B.G.3
  • 29
    • 77950512034 scopus 로고    scopus 로고
    • Openness of patients' reporting with use of electronic records: psychiatric clinicians' views
    • Salomon RM, Blackford JU, Rosenbloom ST, et al. Openness of patients' reporting with use of electronic records: psychiatric clinicians' views. J Am Med Inform Assoc 2010;17:54-60.
    • (2010) J Am Med Inform Assoc , vol.17 , pp. 54-60
    • Salomon, R.M.1    Blackford, J.U.2    Rosenbloom, S.T.3
  • 30
    • 0032415583 scopus 로고    scopus 로고
    • Thesauri and formal classifications: terminologies for people and machines
    • Rector AL. Thesauri and formal classifications: terminologies for people and machines. Methods Inf Med 1998;37:501-9.
    • (1998) Methods Inf Med , vol.37 , pp. 501-509
    • Rector, A.L.1
  • 31
    • 0025823160 scopus 로고
    • Foundations for an electronic medical record
    • Rector AL, Nowlan WA, Kay S. Foundations for an electronic medical record. Methods Inf Med 1991;30:179-86.
    • (1991) Methods Inf Med , vol.30 , pp. 179-186
    • Rector, A.L.1    Nowlan, W.A.2    Kay, S.3
  • 32
    • 33646503008 scopus 로고    scopus 로고
    • Interface terminologies: facilitating direct entry of clinical data into electronic health record systems
    • Rosenbloom ST, Miller RA, Johnson KB, et al. Interface terminologies: facilitating direct entry of clinical data into electronic health record systems. J Am Med Inform Assoc 2006;13:277-88.
    • (2006) J Am Med Inform Assoc , vol.13 , pp. 277-288
    • Rosenbloom, S.T.1    Miller, R.A.2    Johnson, K.B.3
  • 33
    • 0031744798 scopus 로고    scopus 로고
    • Accuracy of medical records in hip fracture
    • Fox KM, Reuland M, Hawkes WG, et al. Accuracy of medical records in hip fracture. J Am Geriatr Soc 1998;46:745-50.
    • (1998) J Am Geriatr Soc , vol.46 , pp. 745-750
    • Fox, K.M.1    Reuland, M.2    Hawkes, W.G.3
  • 34
    • 0032941832 scopus 로고    scopus 로고
    • Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department
    • Marill KA, Gauharou ES, Nelson BK, et al. Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department. Ann Emerg Med 1999;33:500-9.
    • (1999) Ann Emerg Med , vol.33 , pp. 500-509
    • Marill, K.A.1    Gauharou, E.S.2    Nelson, B.K.3
  • 36
    • 0029899339 scopus 로고    scopus 로고
    • The physician's flexible narrative
    • van Ginneken AM. The physician's flexible narrative. Methods Inf Med 1996;35:98-100.
    • (1996) Methods Inf Med , vol.35 , pp. 98-100
    • van Ginneken, A.M.1
  • 37
    • 0020621356 scopus 로고
    • Critiquing anesthetic management: the 'ATTENDING' computer system
    • Miller PL. Critiquing anesthetic management: the 'ATTENDING' computer system. Anesthesiology 1983;58:362-9.
    • (1983) Anesthesiology , vol.58 , pp. 362-369
    • Miller, P.L.1
  • 40
    • 34250309164 scopus 로고    scopus 로고
    • Information technology comes to medicine
    • Blumenthal D, Glaser JP. Information technology comes to medicine. N Engl J Med 2007;356:2527-34.
    • (2007) N Engl J Med , vol.356 , pp. 2527-2534
    • Blumenthal, D.1    Glaser, J.P.2
  • 41
    • 0018903230 scopus 로고
    • An assessment of a computerized reporting system (SIREP)
    • Jeans WD, Danton RM, Kilburn AR. An assessment of a computerized reporting system (SIREP). Br J Radiol 1980;53:421-7.
    • (1980) Br J Radiol , vol.53 , pp. 421-427
    • Jeans, W.D.1    Danton, R.M.2    Kilburn, A.R.3
  • 42
    • 0014932988 scopus 로고
    • Recording, retrieval and review of medical data by physician-computer interaction
    • Greenes RA, Barnett GO, Klein SW, et al. Recording, retrieval and review of medical data by physician-computer interaction. N Engl J Med 1970;282:307-15.
    • (1970) N Engl J Med , vol.282 , pp. 307-315
    • Greenes, R.A.1    Barnett, G.O.2    Klein, S.W.3
  • 43
    • 0032249025 scopus 로고    scopus 로고
    • Self-documenting structured reports using open information standards
    • Kahn CE Jr. Self-documenting structured reports using open information standards. Medinfo 1998;9:403-7.
    • (1998) Medinfo , vol.9 , pp. 403-407
    • Kahn Jr., C.E.1
  • 44
    • 0034517666 scopus 로고    scopus 로고
    • Snomed RT and SNOMEDCT. Promise of an international clinical terminology
    • Spackman K. ; Snomed RT and SNOMEDCT. Promise of an international clinical terminology. MD Comput 2000;17:29.
    • (2000) MD Comput , vol.17 , pp. 29
    • Spackman, K.1
  • 45
    • 34248510775 scopus 로고    scopus 로고
    • Rates of change in a large clinical terminology: three years experience with SNOMED Clinical Terms
    • Spackman KA. Rates of change in a large clinical terminology: three years experience with SNOMED Clinical Terms. AMIA Annu Symp Proc 2005:714-18.
    • (2005) AMIA Annu Symp Proc , pp. 714-718
    • Spackmn, K.A.1
  • 46
    • 79953086046 scopus 로고    scopus 로고
    • Generating complex clinical documents using structured entry and reporting
    • Rosenbloom ST, Kiepek W, Belletti J, et al. Generating complex clinical documents using structured entry and reporting. Stud Health Technol Inform 2004;107:683-7.
    • (2004) Stud Health Technol Inform , vol.107 , pp. 683-687
    • Rosenbloom, S.T.1    Kiepek, W.2    Belletti, J.3
  • 47
    • 0014029295 scopus 로고
    • A computer-based medical-history system
    • Slack WV, Hicks GP, Reed CE, et al. A computer-based medical-history system. N Engl J Med 1966;274:194-8.
    • (1966) N Engl J Med , vol.274 , pp. 194-198
    • Slack, W.V.1    Hicks, G.P.2    Reed, C.E.3
  • 48
    • 0014209294 scopus 로고
    • A computer-based physical examination system
    • Slack WV, Peckham BM, Van Cura LJ, et al. A computer-based physical examination system. JAMA 1967;200:224-8.
    • (1967) JAMA , vol.200 , pp. 224-228
    • Slack, W.V.1    Peckham, B.M.2    Van Cura, L.J.3
  • 49
    • 0014013773 scopus 로고
    • Computer aids to medical diagnosis
    • Ledley RS. Computer aids to medical diagnosis. JAMA 1966;196:933-43.
    • (1966) JAMA , vol.196 , pp. 933-943
    • Ledley, R.S.1
  • 50
    • 0015351880 scopus 로고
    • Computer-assisted interview of patients with functional headache
    • Stead WW, Heyman A, Thompson HK, et al. Computer-assisted interview of patients with functional headache. Arch Intern Med 1972;129:950-5.
    • (1972) Arch Intern Med , vol.129 , pp. 950-955
    • Stead, W.W.1    Heyman, A.2    Thompson, H.K.3
  • 52
    • 0017638345 scopus 로고
    • Evaluation of an audio mode of the automated medical history
    • Stead WW, Hammond WE, Estes EH. Evaluation of an audio mode of the automated medical history. Methods Inf Med 1977;16:20-3.
    • (1977) Methods Inf Med , vol.16 , pp. 20-23
    • Stead, W.W.1    Hammond, W.E.2    Estes, E.H.3
  • 53
    • 0035002880 scopus 로고    scopus 로고
    • How the past teaches the future: ACMI distinguished lecture
    • Hammond WE. How the past teaches the future: ACMI distinguished lecture. J Am Med Inform Assoc 2001;8:222-34.
    • (2001) J Am Med Inform Assoc , vol.8 , pp. 222-234
    • Hammond, W.E.1
  • 54
    • 0018518642 scopus 로고
    • COSTAR, a computer-based medical information system for ambulatory care
    • Barnett GO. COSTAR, a computer-based medical information system for ambulatory care. Proc IEEE 1979;67:1226-37.
    • (1979) Proc IEEE , vol.67 , pp. 1226-1237
    • Barnett, G.O.1
  • 55
    • 0019975856 scopus 로고
    • The utility for audit of manual and computerized problem-oriented medical record systems
    • Stratmann WC, Goldberg AS, Haugh LD. The utility for audit of manual and computerized problem-oriented medical record systems. Health Serv Res 1982;17:5-26.
    • (1982) Health Serv Res , vol.17 , pp. 5-26
    • Stratmann, W.C.1    Goldberg, A.S.2    Haugh, L.D.3
  • 56
    • 0019473382 scopus 로고
    • Do information systems improve the quality of clinical research? Results of a randomized trial in a cooperative multiinstitutional cancer group
    • Wirtschafter DD, Scalise M, Henke C, et al. Do information systems improve the quality of clinical research? Results of a randomized trial in a cooperative multiinstitutional cancer group. Comput Biomed Res 1981;14:78-90.
    • (1981) Comput Biomed Res , vol.14 , pp. 78-90
    • Wirtschafter, D.D.1    Scalise, M.2    Henke, C.3
  • 57
    • 84907109804 scopus 로고
    • Update on ONCOCIN: a chemotherapy advisor for clinical oncology
    • Shortliffe EH. Update on ONCOCIN: a chemotherapy advisor for clinical oncology. Med Inform (Lond) 1986;11:19-21.
    • (1986) Med Inform (Lond) , vol.11 , pp. 19-21
    • Shortliffe, E.H.1
  • 58
    • 0037229712 scopus 로고    scopus 로고
    • The Stanford Health Assessment Questionnaire: a review of its history, issues, progress, and documentation
    • Bruce B, Fries JF. The Stanford Health Assessment Questionnaire: a review of its history, issues, progress, and documentation. J Rheumatol 2003;30:167-78.
    • (2003) J Rheumatol , vol.30 , pp. 167-178
    • Bruce, B.1    Fries, J.F.2
  • 59
    • 0022625404 scopus 로고
    • Computer-assisted design of studies using routine clinical data. Analyzing the association of prednisone and cholesterol
    • Blum RL. Computer-assisted design of studies using routine clinical data. Analyzing the association of prednisone and cholesterol. Ann Intern Med 1986;104:858-68.
    • (1986) Ann Intern Med , vol.104 , pp. 858-868
    • Blum, R.L.1
  • 60
    • 79953082349 scopus 로고    scopus 로고
    • CORI: Clinical Outcomes Research Initiative Publications List
    • CORI: Clinical Outcomes Research Initiative Publications List http://www.cori.org/?topic=publications.
  • 61
    • 79953068158 scopus 로고    scopus 로고
    • CORI: Clinical Outcomes Research Initiative
    • CORI: Clinical Outcomes Research Initiative. http://www.cori.org.
  • 63
    • 79953069343 scopus 로고    scopus 로고
    • Generating Clinical Notes for Electronic Health Record Systems
    • (accepted 28 Jun 2010)
    • Rosenbloom ST, Stead WW, Denny JC, et al. Generating Clinical Notes for Electronic Health Record Systems. Appl Clin Inform 2010;1:232-43. (accepted 28 Jun 2010).
    • (2010) Appl Clin Inform , vol.1 , pp. 232-243
    • Rosenbloom, S.T.1    Stead, W.W.2    Denny, J.C.3
  • 64
    • 0036482275 scopus 로고    scopus 로고
    • Clictate: a computer-based documentation tool for guideline-based care
    • Johnson KB, Cowan J. Clictate: a computer-based documentation tool for guideline-based care. J Med Syst 2002;26:47-60.
    • (2002) J Med Syst , vol.26 , pp. 47-60
    • Johnson, K.B.1    Cowan, J.2
  • 65
    • 79953126406 scopus 로고    scopus 로고
    • Logician Ambulatory
    • Logician Ambulatory. http://www.gehealthcare.com.
  • 66
    • 79953087729 scopus 로고    scopus 로고
    • Epic Systems Corporation
    • Epic Systems Corporation. http://www.epicsys.com/.
  • 67
    • 79953076833 scopus 로고    scopus 로고
    • Physician Micro Systems, Incorporated: Practice Partner Patient Records
    • Physician Micro Systems, Incorporated: Practice Partner Patient Records
  • 68
    • 0347952486 scopus 로고    scopus 로고
    • VistA-US Department of Veterans Affairs national-scale HIS
    • Brown SH, Lincoln MJ, Groen PJ, et al. VistA-US Department of Veterans Affairs national-scale HIS. Int J Med Inf 2003;69:135-56.
    • (2003) Int J Med Inf , vol.69 , pp. 135-156
    • Brown, S.H.1    Lincoln, M.J.2    Groen, P.J.3
  • 69
    • 1542327773 scopus 로고    scopus 로고
    • Some unintended consequences of information technology in health care: the nature of patient care informations system related errors
    • Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care informations system related errors. J Am Med Inform Assoc 2004.11:104-12.
    • (2004) J Am Med Inform Assoc , vol.11 , pp. 104-112
    • Ash, J.S.1    Berg, M.2    Coiera, E.3
  • 70
    • 57349200714 scopus 로고    scopus 로고
    • The PEN-Ivory project: exploring user-interface design for the selection of items from large controlled vocabularies of medicine
    • Poon AD, Fagan LM, Shortliffe EH. The PEN-Ivory project: exploring user-interface design for the selection of items from large controlled vocabularies of medicine. J Am Med Inform Assoc 1996;3:168-83.
    • (1996) J Am Med Inform Assoc , vol.3 , pp. 168-183
    • Poon, A.D.1    Fagan, L.M.2    Shortliffe, E.H.3
  • 72
    • 0347210459 scopus 로고    scopus 로고
    • Standardized problem list generation, utilizing the Mayo canonical vocabulary embedded within the Unified Medical Language System
    • Elkin PL, Mohr DN, Tuttle MS, et al. Standardized problem list generation, utilizing the Mayo canonical vocabulary embedded within the Unified Medical Language System. Proc AMIA Annu Fall Symp 1997:500-4.
    • (1997) Proc AMIA Annu Fall Symp , pp. 500-504
    • Elkin, P.L.1    Mohr, D.N.2    Tuttle, M.S.3
  • 73
    • 0033258105 scopus 로고    scopus 로고
    • Barriers to the clinical implementation of compositionality
    • McKnight LK, Elkin PL, Ogren PV, et al. Barriers to the clinical implementation of compositionality. Proc AMIA Symp 1999:320-4.
    • (1999) Proc AMIA Symp , pp. 320-324
    • McKnight, L.K.1    Elkin, P.L.2    Ogren, P.V.3
  • 74
    • 0036356447 scopus 로고    scopus 로고
    • A modern optical character recognition system in a real world clinical setting: some accuracy and feasibility observations
    • Biondich PG, Overhage JM, Dexter PR, et al. A modern optical character recognition system in a real world clinical setting: some accuracy and feasibility observations. Proc AMIA Symp 2002:56-60.
    • (2002) Proc AMIA Symp , pp. 56-60
    • Biondich, P.G.1    Overhage, J.M.2    Dexter, P.R.3
  • 75
    • 0033257363 scopus 로고    scopus 로고
    • User satisfaction and frustration with a handheld, pen-based guideline implementation system for asthma
    • Shiffman RN, Liaw Y, Navedo DD, et al. User satisfaction and frustration with a handheld, pen-based guideline implementation system for asthma. Proc AMIA Symp 1999:940-4.
    • (1999) Proc AMIA Symp , pp. 940-944
    • Shiffman, R.N.1    Liaw, Y.2    Navedo, D.D.3
  • 76
    • 0035752429 scopus 로고    scopus 로고
    • Effective mapping of biomedical text to the UMLS Metathesaurus: the MetaMap program
    • Aronson AR. Effective mapping of biomedical text to the UMLS Metathesaurus: the MetaMap program. Proc AMIA Symp 2001:17-21.
    • (2001) Proc AMIA Symp , pp. 17-21
    • Aronson, A.R.1
  • 77
    • 0035741485 scopus 로고    scopus 로고
    • A simple algorithm for identifying negated findings and diseases in discharge summaries
    • Chapman WW, Bridewell W, Hanbury P, et al. A simple algorithm for identifying negated findings and diseases in discharge summaries. J Biomed Inform 2001;34:301-10.
    • (2001) J Biomed Inform , vol.34 , pp. 301-310
    • Chapman, W.W.1    Bridewell, W.2    Hanbury, P.3
  • 78
    • 0347210450 scopus 로고    scopus 로고
    • Towards a comprehensive medical language processing system: methods and issues
    • Friedman C. Towards a comprehensive medical language processing system: methods and issues. Proc AMIA Annu Fall Symp 1997:595-9.
    • (1997) Proc AMIA Annu Fall Symp , pp. 595-599
    • Friedman, C.1
  • 79
    • 0028402861 scopus 로고
    • Natural language processing and the representation of clinical data
    • Sager N, Lyman M, Bucknall C, et al. Natural language processing and the representation of clinical data. J Am Med Inform Assoc 1994;1:142-60.
    • (1994) J Am Med Inform Assoc , vol.1 , pp. 142-160
    • Sager, N.1    Lyman, M.2    Bucknall, C.3
  • 80
    • 0038154028 scopus 로고    scopus 로고
    • 'Understanding' medical school curriculum content using KnowledgeMap
    • Denny JC, Smithers JD, Miller RA, et al. 'Understanding' medical school curriculum content using KnowledgeMap. J Am Med Inform Assoc 2003;10:351-62.
    • (2003) J Am Med Inform Assoc , vol.10 , pp. 351-362
    • Denny, J.C.1    Smithers, J.D.2    Miller, R.A.3
  • 81
    • 50649122567 scopus 로고    scopus 로고
    • Extracting information from textual documents in the electronic health record: a review of recent research
    • Meystre SM, Savova GK, Kipper-Schuler KC, et al. Extracting information from textual documents in the electronic health record: a review of recent research. Yearb Med Inform 2008:128-44.
    • (2008) Yearb Med Inform , pp. 128-144
    • Meystre, S.M.1    Savova, G.K.2    Kipper-Schuler, K.C.3
  • 82
    • 39849088588 scopus 로고    scopus 로고
    • Increased hospital mortality in patients with bedside hippus
    • Denny JC, Arndt FV, Dupont WD, et al. Increased hospital mortality in patients with bedside hippus. Am J Med 2008;121:239-45.
    • (2008) Am J Med , vol.121 , pp. 239-245
    • Denny, J.C.1    Arndt, F.V.2    Dupont, W.D.3
  • 83
    • 33750432529 scopus 로고    scopus 로고
    • Using regular expressions to abstract blood pressure and treatment intensification information from the text of physician notes
    • Turchin A, Kolatkar NS, Grant RW, et al. Using regular expressions to abstract blood pressure and treatment intensification information from the text of physician notes. J Am Med Inform Assoc 2006;13:691-5.
    • (2006) J Am Med Inform Assoc , vol.13 , pp. 691-695
    • Turchin, A.1    Kolatkar, N.S.2    Grant, R.W.3
  • 84
    • 35448931891 scopus 로고    scopus 로고
    • Searching for a needle in a haystack: use of ICD-9-CM codes in drug-induced liver injury
    • Jinjuvadia K, Kwan W, Fontana RJ. Searching for a needle in a haystack: use of ICD-9-CM codes in drug-induced liver injury. Am J Gastroenterol 2007;102:2437-43.
    • (2007) Am J Gastroenterol , vol.102 , pp. 2437-2443
    • Jinjuvadia, K.1    Kwan, W.2    Fontana, R.J.3
  • 85
    • 16844368710 scopus 로고    scopus 로고
    • Improved detection of orthopaedic surgical site infections occurring in outpatients
    • Michelson J. Improved detection of orthopaedic surgical site infections occurring in outpatients. Clin Orthop Relat Res 2005;433:218-24.
    • (2005) Clin Orthop Relat Res , vol.433 , pp. 218-224
    • Michelson, J.1
  • 86
    • 24944470272 scopus 로고    scopus 로고
    • Automation of a problem list using natural language processing
    • Meystre S, Haug PJ. Automation of a problem list using natural language processing. BMC Med Inform Decis Mak 2005;5:30.
    • (2005) BMC Med Inform Decis Mak , vol.5 , pp. 30
    • Meystre, S.1    Haug, P.J.2
  • 87
    • 0942266011 scopus 로고    scopus 로고
    • Evaluation of a deidentification (De-Id) software engine to share pathology reports and clinical documents for research
    • Gupta D, Saul M, Gilbertson J. Evaluation of a deidentification (De-Id) software engine to share pathology reports and clinical documents for research. Am J Clin Pathol 2004;121:176-86.
    • (2004) Am J Clin Pathol , vol.121 , pp. 176-186
    • Gupta, D.1    Saul, M.2    Gilbertson, J.3
  • 89
    • 0031958629 scopus 로고    scopus 로고
    • An experiment comparing lexical and statistical methods for extracting MeSH terms from clinical free text
    • Cooper GF, Miller RA. An experiment comparing lexical and statistical methods for extracting MeSH terms from clinical free text. J Am Med Inform Assoc 1998;5:62-75.
    • (1998) J Am Med Inform Assoc , vol.5 , pp. 62-75
    • Cooper, G.F.1    Miller, R.A.2
  • 90
    • 0032233736 scopus 로고    scopus 로고
    • SAPHIRE International: a tool for cross-language information retrieval
    • Hersh WR, Donohoe LC. SAPHIRE International: a tool for cross-language information retrieval. Proc AMIA Symp 1998:673-7.
    • (1998) Proc AMIA Symp , pp. 673-677
    • Hersh, W.R.1    Donohoe, L.C.2
  • 91
    • 28444477373 scopus 로고    scopus 로고
    • 'Where do we teach what?' Finding broad concepts in the medical school curriculum
    • Denny JC, Smithers JD, Armstrong B, et al. 'Where do we teach what?' Finding broad concepts in the medical school curriculum. J Gen Intern Med 2005;20:943-6.
    • (2005) J Gen Intern Med , vol.20 , pp. 943-946
    • Denny, J.C.1    Smithers, J.D.2    Armstrong, B.3
  • 92
    • 23144436097 scopus 로고    scopus 로고
    • A controlled trial of automated classification of negation from clinical notes
    • Elkin PL, Brown SH, Bauer BA, et al. A controlled trial of automated classification of negation from clinical notes. BMC Med Inform Decis Mak 2005;5:13.
    • (2005) BMC Med Inform Decis Mak , vol.5 , pp. 13
    • Elkin, P.L.1    Brown, S.H.2    Bauer, B.A.3
  • 93
    • 33744793443 scopus 로고    scopus 로고
    • Evaluation of the content coverage of SNOMED CT: ability of SNOMED clinical terms to represent clinical problem lists
    • Elkin PL, Brown SH, Husser CS, et al. Evaluation of the content coverage of SNOMED CT: ability of SNOMED clinical terms to represent clinical problem lists. Mayo Clin Proc 2006;81:741-8.
    • (2006) Mayo Clin Proc , vol.81 , pp. 741-748
    • Elkin, P.L.1    Brown, S.H.2    Husser, C.S.3
  • 94
    • 0035133051 scopus 로고    scopus 로고
    • UMLS concept indexing for production databases: a feasibility study
    • Nadkarni P, Chen R, Brandt C. UMLS concept indexing for production databases: a feasibility study. J Am Med Inform Assoc 2001;8:80-91.
    • (2001) J Am Med Inform Assoc , vol.8 , pp. 80-91
    • Nadkarni, P.1    Chen, R.2    Brandt, C.3
  • 95
    • 4544280638 scopus 로고    scopus 로고
    • Automated encoding of clinical documents based on natural language processing
    • Friedman C, Shagina L, Lussier Y, et al. Automated encoding of clinical documents based on natural language processing. J Am Med Inform Assoc 2004;11:392-402.
    • (2004) J Am Med Inform Assoc , vol.11 , pp. 392-402
    • Friedman, C.1    Shagina, L.2    Lussier, Y.3
  • 96
    • 36749001490 scopus 로고    scopus 로고
    • Extracting drug-drug interaction articles from MEDLINE to improve the content of drug databases
    • Duda S, Aliferis C, Miller R, et al. Extracting drug-drug interaction articles from MEDLINE to improve the content of drug databases. AMIA Annu Symp Proc 2005:216-20.
    • (2005) AMIA Annu Symp Proc , pp. 216-220
    • Duda, S.1    Aliferis, C.2    Miller, R.3
  • 97
    • 0042334852 scopus 로고    scopus 로고
    • Creating a text classifier to detect radiology reports describing mediastinal findings associated with inhalational anthrax and other disorders
    • Chapman WW, Cooper GF, Hanbury P, et al. Creating a text classifier to detect radiology reports describing mediastinal findings associated with inhalational anthrax and other disorders. J Am Med Inform Assoc 2003;10:494-503.
    • (2003) J Am Med Inform Assoc , vol.10 , pp. 494-503
    • Chapman, W.W.1    Cooper, G.F.2    Hanbury, P.3
  • 98
    • 0034987054 scopus 로고    scopus 로고
    • A comparison of classification algorithms to automatically identify chest X-ray reports that support pneumonia
    • Chapman WW, Fizman M, Chapman BE, et al. A comparison of classification algorithms to automatically identify chest X-ray reports that support pneumonia. J Biomed Inform 2001;34:4-14.
    • (2001) J Biomed Inform , vol.34 , pp. 4-14
    • Chapman, W.W.1    Fizman, M.2    Chapman, B.E.3
  • 99
    • 0033036039 scopus 로고    scopus 로고
    • A reliability study for evaluating information extraction from radiology reports
    • Hripcsak G, Kuperman GJ, Friedman C, et al. A reliability study for evaluating information extraction from radiology reports. J Am Med Inform Assoc 1999;6:143-50.
    • (1999) J Am Med Inform Assoc , vol.6 , pp. 143-150
    • Hripcsak, G.1    Kuperman, G.J.2    Friedman, C.3
  • 100
    • 70350788833 scopus 로고    scopus 로고
    • Evaluation of a method to identify and categorize section headers in clinical documents
    • Denny JC, Spickard A 3rd, Johnson KB, et al. Evaluation of a method to identify and categorize section headers in clinical documents. J Am Med Inform Assoc 2009;16:806-15.
    • (2009) J Am Med Inform Assoc , vol.16 , pp. 806-815
    • Denny, J.C.1    Spickard 3rd, A.2    Johnson, K.B.3
  • 101
    • 36749031587 scopus 로고    scopus 로고
    • An electronic health record based on structured narrative
    • Johnson SB, Bakken S, Dine D, et al. An electronic health record based on structured narrative. J Am Med Inform Assoc 2008;15:54-64.
    • (2008) J Am Med Inform Assoc , vol.15 , pp. 54-64
    • Johnson, S.B.1    Bakken, S.2    Dine, D.3
  • 102
    • 0042336002 scopus 로고    scopus 로고
    • Using lexical disambiguation and named-entity recognition to improve spelling correction in the electronic patient record
    • Ruch P, Baud R, Geissbuhler A. Using lexical disambiguation and named-entity recognition to improve spelling correction in the electronic patient record. Artif Intell Med 2003;29:169-84.
    • (2003) Artif Intell Med , vol.29 , pp. 169-184
    • Ruch, P.1    Baud, R.2    Geissbuhler, A.3
  • 104
    • 55549101625 scopus 로고    scopus 로고
    • Word sense disambiguation across two domains: biomedical literature and clinical notes
    • Savova GK, Coden AR, Sominsky IL, et al. Word sense disambiguation across two domains: biomedical literature and clinical notes. J Biomed Inform 2008;41:1088-100.
    • (2008) J Biomed Inform , vol.41 , pp. 1088-1100
    • Savova, G.K.1    Coden, A.R.2    Sominsky, I.L.3
  • 105
    • 78149490620 scopus 로고    scopus 로고
    • Mayo clinical Text Analysis and Knowledge Extraction System (cTAKES): architecture, component evaluation and applications
    • Savova GK, Masanz JJ, Ogren PV, et al. Mayo clinical Text Analysis and Knowledge Extraction System (cTAKES): architecture, component evaluation and applications. J Am Med Inform Assoc 2010;17:507-13.
    • (2010) J Am Med Inform Assoc , vol.17 , pp. 507-513
    • Savova, G.K.1    Masanz, J.J.2    Ogren, P.V.3
  • 106
    • 0003525850 scopus 로고    scopus 로고
    • Committee on Quality of Health Care in America, Using Information Technology. Washington, DC: IOM
    • Committee on Quality of Health Care in America, Using Information Technology. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: IOM, 2001.
    • (2001) Crossing the Quality Chasm: A New Health System for the 21st Century
  • 107
    • 0033427443 scopus 로고    scopus 로고
    • Automated semantic indexing of imaging reports to support retrieval of medical images in the multimedia electronic medical record
    • Lowe HJ, Antipov I, Hersh W, et al. Automated semantic indexing of imaging reports to support retrieval of medical images in the multimedia electronic medical record. Methods Inf Med 1999;38:303-7.
    • (1999) Methods Inf Med , vol.38 , pp. 303-307
    • Lowe, H.J.1    Antipov, I.2    Hersh, W.3
  • 108
    • 39049176044 scopus 로고    scopus 로고
    • Identifying UMLS concepts from ECG Impressions using KnowledgeMap
    • Denny JC, Spickard A 3rd, Miller RA, et al. Identifying UMLS concepts from ECG Impressions using KnowledgeMap. AMIA Annu Symp Proc 2005:196-200.
    • (2005) AMIA Annu Symp Proc , pp. 196-200
    • Denny, J.C.1    Spickard 3rd, A.2    Miller, R.A.3
  • 109
    • 33750722813 scopus 로고    scopus 로고
    • Natural language processing to extract medical problems from electronic clinical documents: performance evaluation
    • Meystre S, Haug PJ. Natural language processing to extract medical problems from electronic clinical documents: performance evaluation. J Biomed Inform 2006;39:589-99.
    • (2006) J Biomed Inform , vol.39 , pp. 589-599
    • Meystre, S.1    Haug, P.J.2
  • 110
    • 77950338000 scopus 로고    scopus 로고
    • Robust replication of genotype-phenotype associations across multiple diseases in an electronic medical record
    • Ritchie MD, Denny JC, Crawford DC, et al. Robust replication of genotype-phenotype associations across multiple diseases in an electronic medical record. Am J Hum Genet 2010;86:560-72.
    • (2010) Am J Hum Genet , vol.86 , pp. 560-572
    • Ritchie, M.D.1    Denny, J.C.2    Crawford, D.C.3
  • 111
    • 36749097784 scopus 로고    scopus 로고
    • Automated acquisition of disease drug knowledge from biomedical and clinical documents: an initial study
    • Chen ES, Hripcsak G, Xu H, et al. Automated acquisition of disease drug knowledge from biomedical and clinical documents: an initial study. J Am Med Inform Assoc 2008;15:87-98.
    • (2008) J Am Med Inform Assoc , vol.15 , pp. 87-98
    • Chen, E.S.1    Hripcsak, G.2    Xu, H.3
  • 112
    • 21544453050 scopus 로고    scopus 로고
    • Automated detection of adverse events using natural language processing of discharge summaries
    • Melton GB, Hripcsak G. Automated detection of adverse events using natural language processing of discharge summaries. J Am Med Inform Assoc 2005;12:448-57.
    • (2005) J Am Med Inform Assoc , vol.12 , pp. 448-457
    • Melton, G.B.1    Hripcsak, G.2
  • 113
    • 0036370590 scopus 로고    scopus 로고
    • A comparison of the Charlson comorbidities derived from medical language processing and administrative data
    • Chuang JH, Friedman C, Hripcsak G. A comparison of the Charlson comorbidities derived from medical language processing and administrative data. Proc AMIA Symp 2002:160-4.
    • (2002) Proc AMIA Symp , pp. 160-164
    • Chuang, J.H.1    Friedman, C.2    Hripcsak, G.3
  • 114
    • 16544378488 scopus 로고    scopus 로고
    • The KnowledgeMap project: development of a concept-based medical school curriculum database
    • Denny JC, Irani PR, Wehbe FH, et al. The KnowledgeMap project: development of a concept-based medical school curriculum database. AMIA Annu Symp Proc 2003:195-9.
    • (2003) AMIA Annu Symp Proc , pp. 195-199
    • Denny, J.C.1    Irani, P.R.2    Wehbe, F.H.3
  • 115
    • 70349437268 scopus 로고    scopus 로고
    • Tracking medical students' clinical experiences using natural language processing
    • Denny JC, Bastarache L, Sastre EA, et al. Tracking medical students' clinical experiences using natural language processing. J Biomed Inform 2009;42:781-9.
    • (2009) J Biomed Inform , vol.42 , pp. 781-789
    • Denny, J.C.1    Bastarache, L.2    Sastre, E.A.3
  • 116
    • 2542419260 scopus 로고    scopus 로고
    • A natural language based search engine for ICD10 diagnosis encoding
    • Baud R. A natural language based search engine for ICD10 diagnosis encoding. Med Arh 2004;58(1 Suppl 2):79-80.
    • (2004) Med Arh , vol.58 , Issue.1 SUPPL. 2 , pp. 79-80
    • Baud, R.1
  • 117
    • 70349460061 scopus 로고    scopus 로고
    • Facilitating cancer research using natural language processing of pathology reports
    • Xu H, Anderson K, Grann VR, et al. Facilitating cancer research using natural language processing of pathology reports. Stud Health Technol Inform 2004;107:565-72.
    • (2004) Stud Health Technol Inform , vol.107 , pp. 565-572
    • Xu, H.1    Anderson, K.2    Grann, V.R.3
  • 118
    • 34250895016 scopus 로고    scopus 로고
    • Electronic medical records for clinical research: application to the identification of heart failure
    • Pakhomov S, Weston SA, Jacobsen SJ, et al. Electronic medical records for clinical research: application to the identification of heart failure. Am J Manag Care 2007;13:281-8.
    • (2007) Am J Manag Care , vol.13 , pp. 281-288
    • Pakhomov, S.1    Weston, S.A.2    Jacobsen, S.J.3
  • 119
    • 73949147563 scopus 로고    scopus 로고
    • eQuality for all: Extending automated quality measurement of free text clinical narratives
    • Brown SH, Elkin PL, Rosenbloom ST, et al. eQuality for all: Extending automated quality measurement of free text clinical narratives. AMIA Annu Symp Proc 2008:71-5.
    • (2008) AMIA Annu Symp Proc , pp. 71-75
    • Brown, S.H.1    Elkin, P.L.2    Rosenbloom, S.T.3
  • 120
    • 38449114048 scopus 로고    scopus 로고
    • Medication reconciliation using natural language processing and controlled terminologies
    • Cimino JJ, Bright TJ, Li J. Medication reconciliation using natural language processing and controlled terminologies. Stud Health Technol Inform 2007;129:679-83.
    • (2007) Stud Health Technol Inform , vol.129 , pp. 679-683
    • Cimino, J.J.1    Bright, T.J.2    Li, J.3
  • 121
    • 35148895006 scopus 로고    scopus 로고
    • Identification of trauma patients at a level 1 trauma center utilizing natural language processing
    • Day S, Christensen LM, Dalto J, et al. Identification of trauma patients at a level 1 trauma center utilizing natural language processing. J Trauma Nurs 2007;14:79-83.
    • (2007) J Trauma Nurs , vol.14 , pp. 79-83
    • Day, S.1    Christensen, L.M.2    Dalto, J.3
  • 122
    • 0030333390 scopus 로고    scopus 로고
    • Identification of suspected tuberculosis patients based on natural language processing of chest radiograph reports
    • Jain NL, Knirsch CA, Friedman C, et al. Identification of suspected tuberculosis patients based on natural language processing of chest radiograph reports. Proc AMIA Annu Fall Symp 1996:542-6.
    • (1996) Proc AMIA Annu Fall Symp , pp. 542-546
    • Jain, N.L.1    Knirsch, C.A.2    Friedman, C.3
  • 123
    • 0028403632 scopus 로고
    • A general natural-language text processor for clinical radiology
    • Friedman C, Alderson PO, Austin JH, et al. A general natural-language text processor for clinical radiology. J Am Med Inform Assoc 1994;1:161-74.
    • (1994) J Am Med Inform Assoc , vol.1 , pp. 161-174
    • Friedman, C.1    Alderson, P.O.2    Austin, J.H.3
  • 124
    • 34748882343 scopus 로고    scopus 로고
    • Creation of structured documentation templates using Natural Language Processing techniques
    • Kashyap V, Turchin A, Morin L, et al. Creation of structured documentation templates using Natural Language Processing techniques. AMIA Annu Symp Proc 2006:977.
    • (2006) AMIA Annu Symp Proc , pp. 977
    • Kashyap, V.1    Turchin, A.2    Morin, L.3


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.