Abstract

Objective

To develop a collection of concept-relationship-concept tuples to formally represent patients’ care context data to inform electronic health record (EHR) development.

Materials and Methods

We reviewed semantic relationships reported in the literature and developed a manual annotation schema. We used the initial schema to annotate sentences extracted from narrative note sections of cardiology, urology, and ear, nose, and throat (ENT) notes. We audio recorded ENT visits and annotated their parsed transcripts. We combined the results of each annotation into a consolidated set of concept-relationship-concept tuples. We then compared the tuples used within and across the multiple data sources.

Results

We annotated a total of 626 sentences. Starting with 8 relationships from the literature, we annotated 182 sentences from 8 inpatient consult notes (initial set of tuples = 43). Next, we annotated 232 sentences from 10 outpatient visit notes (enhanced set of tuples = 75). Then, we annotated 212 sentences from transcripts of 5 outpatient visits (final set of tuples = 82). The tuples from the visit transcripts covered 103 (74%) concepts documented in the notes of their respective visits. There were 20 (24%) tuples used across all data sources, 10 (12%) used only in inpatient notes, 15 (18%) used only in visit notes, and 7 (9%) used only in the visit transcripts.

Conclusions

We produced a robust set of 82 tuples useful to represent patients’ care context data. We propose several applications of our tuples to improve EHR navigation, data entry, learning health systems, and decision support.

中文翻译：

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病人护理环境数据的正式表示：改善电子健康记录的途径。

摘要

目的

开发概念-关系-概念元组的集合，以正式表示患者的护理环境数据，以告知电子健康记录（EHR）的发展。

材料和方法

我们回顾了文献中报道的语义关系，并开发了手动注释方案。我们使用初始模式来注释从心脏病学，泌尿科以及耳鼻喉科（ENT）的叙述性注释部分中提取的句子。我们记录了ENT访问的录音，并注释了他们的已解译成绩单。我们将每个注释的结果合并为一组概念，关系，概念，元组。然后，我们比较了多个数据源内部和之间使用的元组。

结果

我们总共注释了626个句子。从文献中的8个关系开始，我们注释了8个住院咨询记录中的182个句子（初始元组= 43）。接下来，我们注释了来自10个门诊就诊记录的232个句子（增强的元组= 75）。然后，我们从5次门诊的笔录中注释了212个句子（最后一组元组= 82）。访问记录中的元组涵盖了103个（74％）概念，这些概念记录在其各自访问的注释中。在所有数据源中使用了20个（24％）元组，仅在住院记录中使用了10个（12％），仅在访问记录中使用了15个（18％），仅在访问记录中使用了7个（9％）。

结论

我们生成了一组可靠的82个元组，可用于表示患者的护理环境数据。我们提出元组的几种应用程序，以改善EHR导航，数据输入，学习健康系统和决策支持。