Using Narrative Data to Enrich the Online Medical Record

描述（由申请人提供）：

DESCRIPTION (provided by applicant): Narrative information is vital to health care, because it enables physicians to synthesize the raw facts and provide a context and interpretation for them. Electronic medical record systems contain a wealth of clinical data, but typically lack the clinical narrative found in paper records, e.g., the patient history and progress notes. Numerous barriers prevent the timely acquisition of narrative data, and most computer systems are unable to use such information productively. Current approaches offer a tradeoff, capture of rich clinical data that lacks structure (using transcription services or speech technology), versus entry of structured data that lacks flexibility and expressiveness (using template systems). Natural language processing can integrate these approaches by allowing physicians full freedom of expression while producing structured documents that preserve the richness and enable further computer processing. This proposal seeks to capture and structure narrative in the online medical record in order to improve entry time, completeness, information content and consistency of clinical documentation. The specific aims of this proposal are: 1) Maintain the continuity of the medical record; a lengthy medical record requires significant time to review and digest. Many facts from past narratives remain true in the present or persist with minor changes. By automatically bringing these facts forward into the current narrative, the system can reduce the time to enter the document, and improve the completeness of documentation by maintaining continuity of what is known about a patient; 2) Integrate the medical record: Electronic medical records contain a vast amount of data. However, most of these data are raw facts. By helping the physician to connect, interpret and summarize these facts, the system can improve the usefulness of the information in the record, and reduce the time to enter documents by performing some syntheses automatically; and 3) Harmonize the medical record; the multidisciplinary nature of health care creates the potential for the differing perspectives and interpretations in the medical record, and even contradictions. By bringing possible discrepancies to the attention of the physician, the system can help resolve the inconsistencies.