Using Narrative Data to Enrich the Online Medical Record

描述(由申请人提供)： 叙述性信息对医疗保健至关重要，因为它使医生能够综合原始事实，并为它们提供背景和解释。电子病历系统包含丰富的临床数据，但通常缺乏纸质病历中的临床叙述，例如患者病史和进展笔记。许多障碍阻碍了叙事数据的及时获取，而大多数计算机系统无法有效地使用这些信息。当前的方法提供了一种权衡，即捕获缺乏结构的丰富临床数据(使用转录服务或语音技术)，与输入缺乏灵活性和表现力的结构化数据(使用模板系统)。自然语言处理可以通过允许医生充分表达自由来整合这些方法，同时生成保持丰富性并允许进一步的计算机处理的结构化文档。 这项建议旨在捕获和组织在线病历中的叙述，以改进输入时间、完整性、信息内容和临床记录的一致性。这项建议的具体目的是：1)保持病历的连续性；一份冗长的病历需要相当长的时间进行审查和消化。过去的叙述中的许多事实在现在仍然是正确的，或者经过微小的改变仍然存在。通过自动将这些事实提前到当前的叙述中，系统可以减少输入文档的时间，并通过保持有关患者的已知信息的连续性来提高文档的完整性；2)集成病历：电子病历包含大量数据。然而，这些数据大多是原始事实。通过帮助医生连接、解释和总结这些事实，系统可以提高记录中信息的有用性，并通过自动执行一些合成来减少输入文件的时间；以及3)协调病历；医疗保健的多学科性质创造了病历中不同视角和解释的可能性，甚至是矛盾。通过将可能的差异引起医生的注意，该系统可以帮助解决不一致。

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.