Data Mining Medical Documentation
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1 Data Mining Medical Documentation Rick Holtmeier President, Berdy Medical Systems, Inc. Board of Directors, CPRI Executive Committee, HOST Original intent NIST/ATP Grant Technology NIST/ATP grant model evolution Data mining intent Challenges Process Current Status 1
2 Original Purpose Populate SmartClinic with spoken data as a means to get data into an electronic medical record. Speaker SmartVoice NIST/ATP Grant Original Model Closed system New records only Spoken records only SmartGist SmartClinic Data Store 2
3 Speaker SmartVoice SmartGist NIST/ATP Grant Second Model HL7 Encoder Closed input system Open output system New records only Spoken Records only SmartClinic Any HL7 Capable EMR Speaker SmartVoice SmartGist Text (Any Process) NIST/ATP Grant Final Model HL7 Encoder Open system Old and new records Spoken and non-spoken SmartClinic Any HL7 Capable EMR 3
4 Data Mining Intent SmartGist is key technology Text becomes data Most medical information is text Enables EMR without direct physician use TEXT SmartGist Data Data Mining Intent Populate Electronic Medical Records with textual medical documentation from any source with any content organization 4
5 Data Mining Intent Results reporting Drug utilization Drug recalls Longitudinal history Medical research Medical decision making Variety of text formats MS-Word Corel WordPerfect Straight Text Requires normalizer Data Mining Challenges 5
6 Records not electronic Paper Requires Scan/OCR Images Requires OCR Data Mining Challenges Records not usable Cursive Pure image Data Mining Challenges 6
7 Data Mining Challenges Same Concept expressed many ways Problem List... History of Assessment Diagnosis Requires Natural Language Processing Grammar Inference Data Mining Process Voice Recognizers Transcription Word Processing TEXT 7
8 Doctorname, M.D. 211 South 9th Street Suite 300 RE: lastname Dear Dr. Doctorname Lastname was seen by me on July 1, 1998 with the chief complaint of vertigo. H.P.I. severe in nature, positional also in type, of three weeks duration. There has been no hearing loss and no other neurological deficits. Over the past several days, he felt that the dizziness is getting gradually better. He also denies any epistaxis.physical Examination of the nasal passages was clear with no epistaxis. The ears were clear. My impression was benign positional vertigo with nystagmus and I have advised him this is a benign condition which should gradually recover. I have told the patient that if the symptoms persist beyond six weeks, I would like to see him here and go ahead with further testing. The patient had a CT scan of his skull about three months earlier which was within normal range. Thank you again for this referral. Kindest regards. Sincerely yours, Doctorname, M.D. Data Mining Process TEXT Normalizer 8
9 Lastname was seen by me on July one nineteen ninety eight with the chief complaint of vertigo H.P.I. severe in nature positional also in type of three weeks duration There has been no hearing loss and no other neurological deficits Over the past several days he felt that the dizziness is getting gradually better He also denies any epistaxis Physical Examination of the nasal passages was clear with no epistaxis The ears were clear My impression was benign positional vertigo with nystagmus and I have advised him this is a benign condition which should gradually recover I have told the patient that if the symptoms persist beyond six weeks I would like to see him here and go ahead with further testing The patient had a C.T. scan of his skull about three months earlier which was within normal range Data Mining Process Inference Rules TEXT Preprocessor SmartGist Grammar 9
10 Chief Complaint:LASTNAME WAS SEEN BY ME ON JULY 1st 1998 WITH THE CHIEF COMPLAINT OF VERTIGO; Present Illness:SEVERE IN NATURE POSITIONAL ALSO IN TYPE OF 3 WEEKS DURATION THERE HAS BEEN NO HEARING LOSS AND NO OTHER NEUROLOGICAL DEFICITS OVER THE PAST SEVERAL DAYS HE FELT THAT THE DIZZINESS IS GETTING GRADUALLY BETTER HE ALSO DENIES ANY EPISTAXIS; Ears Px:EARS WERE CLEAR; Nose Px:NASAL PASSAGES WAS CLEAR WITH NO EPISTAXIS; Problem:BENIGN POSITIONAL VERTIGO WITH NYSTAGMUS; Plan: AND I HAVE ADVISED HIM THIS IS A BENIGN CONDITION WHICH SHOULD GRADUALLY RECOVER I HAVE TOLD THE PATIENT THAT IF THE SYMPTOMS PERSIST BEYOND 6 WEEKS I WOULD LIKE TO SEE HIM HERE AND GO AHEAD WITH FURTHER TESTING THE PATIENT HAD A CT SCAN OF HIS SKULL ABOUT 3 MONTHS EARLIER WHICH WAS WITHIN NORMAL RANGE ; Data Mining Process TEXT Normalizer SmartGist HL7 10
11 MSH ^~\& ADT^A P 2.3 EVN PID Ri 354 Firstname^Lastname^^^L O O PV1 O OBX ST ^Chief Complaint^AS4 LASTNAME WAS SEEN BY ME ON JULY 1ST 1998 WITH THE CHIEF COMPLAINT OF VERTIGO F OBX ST ^Present Illness^AS4 SEVERE IN NATURE POSITIONAL ALSO IN TYPE OF 3 WEEKS DURATION THERE HAS BEEN NO HEARING LOSS AND NO OTHER NEUROLOGICAL DEFICITS OVER THE PAST SEVERAL DAYS HE FELT THAT THE DIZZINESS IS GETTING GRADUALLY BETTER HE ALSO DENIES ANY EPISTAXIS F OBX ST ^Ears Px^AS4 EARS WERE CLEAR F OBX ST ^Nose Px^AS4 NASAL PASSAGES WAS CLEAR WITH NO EPISTAXIS F MSH ^~\& PPR^PC P 2.3 PID Ri 354 Firstname^Lastname^^^L O O PRB UP ^BENIGN POSITIONAL VERTIGO WITH NYSTAGMUS Ri ^SmartClinic^8664^Random ^ AND I HAVE ADVISED HIM THIS IS A BENIGN CONDITION WHICH SHOULD GRADUALLY RECOVER I HAVE TOLD THE PATIENT THAT IF THE SYMPTOMS PERSIST BEYOND 6 WEEKS I WOULD LIKE TO SEE HIM HERE AND GO AHEAD WITH FURTHER TESTING THE PATIENT HAD A CT SCAN OF HIS SKULL ABOUT 3 MONTHS EARLIER WHICH WAS WITHIN NORMAL RANGE 11
12 Data Mining Process TEXT Preprocessor SmartGist HL7 HL7 Capable EMR 12
13 Launched January, 1999 Inference rules Grammar rules Successfully mines data from Major Universities Transcription companies Hospitals Large clinics Data Mining Current Status See our web pages Data Mining Current Status 13
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