Dataset Information

Formal representation of patients' care context data: the path to improving the electronic health record.

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.

SUBMITTER: Colicchio TK

PROVIDER: S-EPMC7671623 | biostudies-literature | 2020 Nov

REPOSITORIES: biostudies-literature

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Publications

Formal representation of patients' care context data: the path to improving the electronic health record.

Colicchio Tiago K TK Dissanayake Pavithra I PI Cimino James J JJ

Journal of the American Medical Informatics Association : JAMIA 20201101 11

<h4>Objective</h4>To develop a collection of concept-relationship-concept tuples to formally represent patients' care context data to inform electronic health record (EHR) development.<h4>Materials and methods</h4>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 an ...[more]

PMID: 32935127

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Dataset Information

Formal representation of patients' care context data: the path to improving the electronic health record.

Objective

Materials and methods

Results

Conclusions

Publications

Formal representation of patients' care context data: the path to improving the electronic health record.

Similar Datasets

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