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J Am Med Inform Assoc. 2011 Nov-Dec;18(6):859-67. doi: 10.1136/amiajnl-2011-000121. Epub 2011 May 25.

A method and knowledge base for automated inference of patient problems from structured data in an electronic medical record.

Author information

1
Department of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA. awright5@partners.org

Abstract

BACKGROUND:

Accurate knowledge of a patient's medical problems is critical for clinical decision making, quality measurement, research, billing and clinical decision support. Common structured sources of problem information include the patient problem list and billing data; however, these sources are often inaccurate or incomplete.

OBJECTIVE:

To develop and validate methods of automatically inferring patient problems from clinical and billing data, and to provide a knowledge base for inferring problems.

STUDY DESIGN AND METHODS:

We identified 17 target conditions and designed and validated a set of rules for identifying patient problems based on medications, laboratory results, billing codes, and vital signs. A panel of physicians provided input on a preliminary set of rules. Based on this input, we tested candidate rules on a sample of 100,000 patient records to assess their performance compared to gold standard manual chart review. The physician panel selected a final rule for each condition, which was validated on an independent sample of 100,000 records to assess its accuracy.

RESULTS:

Seventeen rules were developed for inferring patient problems. Analysis using a validation set of 100,000 randomly selected patients showed high sensitivity (range: 62.8-100.0%) and positive predictive value (range: 79.8-99.6%) for most rules. Overall, the inference rules performed better than using either the problem list or billing data alone.

CONCLUSION:

We developed and validated a set of rules for inferring patient problems. These rules have a variety of applications, including clinical decision support, care improvement, augmentation of the problem list, and identification of patients for research cohorts.

PMID:
21613643
PMCID:
PMC3197992
DOI:
10.1136/amiajnl-2011-000121
[Indexed for MEDLINE]
Free PMC Article

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