Bmc Medical Informatics and Decision Making Development and Evaluation of an Open Source Software Tool for Deidentification of Pathology Reports
Bmc Medical Informatics and Decision Making Development and Evaluation of an Open Source Software Tool for Deidentification of Pathology Reports
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通讯作者：
B. Beckwith;Rajeshwarri Mahaadevan;U. Balis;F. Kuo;Rajeshwarri
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作者：
B. Beckwith;Rajeshwarri Mahaadevan;U. Balis;F. Kuo;Rajeshwarri
背景：电子病历，包括病理报告，经常用于研究目的。目前，几乎没有可自由使用的程序来删除识别符，同时保持病理报告文本的其余部分不变。我们的目标是生成一个开源的、符合健康保险携带和责任法案(HIPAA)的、为病理报告量身定做的身份识别工具。我们设计了一个去除潜在识别符的三步流程。第一步是查找已知与患者相关的识别符，如姓名、病历编号、病理登录号等。接下来，一系列模式匹配寻找可能代表识别数据的可预测模式；例如日期、登录号和地址以及患者、机构和医生的姓名。最后，将单个单词与专有名称和地理位置的数据库进行比较。来自三个机构的病理报告被用来设计和测试算法。该软件在训练集上进行了迭代改进，直到表现出良好的性能。然后处理了1800份新的病理报告。在取消识别之前和之后，手动审查每一份报告，以对所有标识进行分类，并注意未删除的标识。
Background: Electronic medical records, including pathology reports, are often used for research purposes. Currently, there are few programs freely available to remove identifiers while leaving the remainder of the pathology report text intact. Our goal was to produce an open source, Health Insurance Portability and Accountability Act (HIPAA) compliant, deidentification tool tailored for pathology reports. We designed a three-step process for removing potential identifiers. The first step is to look for identifiers known to be associated with the patient, such as name, medical record number, pathology accession number, etc. Next, a series of pattern matches look for predictable patterns likely to represent identifying data; such as dates, accession numbers and addresses as well as patient, institution and physician names. Finally, individual words are compared with a database of proper names and geographic locations. Pathology reports from three institutions were used to design and test the algorithms. The software was improved iteratively on training sets until it exhibited good performance. 1800 new pathology reports were then processed. Each report was reviewed manually before and after deidentification to catalog all identifiers and note those that were not removed.