Lin R, Lenert L, Middleton B, Shiffman S
Division of Clinical Pharmacology, Stanford University, School of Medicine.
Proc Annu Symp Comput Appl Med Care. 1991:843-7.
The task of gathering detailed patient information from free-text medical records presents a significant barrier to clinical research. In this paper, we describe a prototype system for extracting physical examination findings from dictated admission summaries. Our computer program applies a concept-based free-text processing algorithm that identifies user-selected target physical examination findings. We are using the extraction system to enrich an existing clinical database. The system was evaluated by comparing the physical examination findings extracted by our computer program with findings extracted by an independent investigator. Our prototype system was able to recall 92 percent (sensitivity) of the relevant physical findings, with a precision of 96 percent (positive predictive value).
从自由文本的医疗记录中收集详细的患者信息这一任务，对临床研究构成了重大障碍。在本文中，我们描述了一个用于从口述的入院摘要中提取体格检查结果的原型系统。我们的计算机程序应用了一种基于概念的自由文本处理算法，该算法可识别用户选择的目标体格检查结果。我们正在使用该提取系统来充实现有的临床数据库。通过将我们计算机程序提取的体格检查结果与独立调查员提取的结果进行比较，对该系统进行了评估。我们的原型系统能够召回92%（敏感性）的相关体格检查结果，精确率为96%（阳性预测值）。
