On Mon, 13 Feb 2006 16:13, Dr Nigel Brown wrote:
> The real test is, of course, not case notes but how it interfaces with a
> real-time consultation process in a busy practice. It may be that a system
> that learns each doctor's quirks and helps them with the case note process
> while deducing the SNOMED-CT coding as an epiphenomenon will be the final
> goal.

That is exactly what I had implemented in our hospital in Norway.
Sort of an auto-completing combo box allowing new entries (we called it a self 
learning thesaurus).

If one or more terms matches whetever the doctor starts typing, these terms 
are presented in a pick list, most commonly used term *by the logged in user* 
presented first. The doctor either selects a term (enter +/- arrow keys) or 
just keeps typing

If a term doesn't exist yet, it is added to the list of terms.
Dedicated staff kept mapping terms against the coding system the hospital used 
(ICD-10 at that time) and after a few months running the system there were at 
the most one or two terms per week that had to be mapped manually. All 
doctors could keep using their preferred terms, typing was reduced to a 
minimum, and everybody was happy, even the hospital bean counters

Horst
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