University of Wisconsin-Madison School of Nursing, Madison, Wisconsin, USA.
Division of Geriatrics, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA.
J Am Med Inform Assoc. 2018 Sep 1;25(9):1206-1212. doi: 10.1093/jamia/ocy070.
Despite increased risk for negative outcomes, cognitive impairment (CI) is greatly under-detected during hospitalization. While automated EHR-based phenotypes have potential to improve recognition of CI, they are hindered by widespread under-diagnosis of underlying etiologies such as dementia-limiting the utility of more precise structured data elements. This study examined unstructured data on symptoms of CI in the acute-care EHRs of hip and stroke fracture patients with dementia from two hospitals. Clinician reviewers identified and classified unstructured EHR data using standardized criteria. Relevant narrative text was descriptively characterized and evaluated for key terminology. Most patient EHRs (90%) had narrative text reflecting cognitive and/or behavioral dysfunction common in CI that were reliably classified (κ 0.82). The majority of statements reflected vague descriptions of cognitive/behavioral dysfunction as opposed to diagnostic terminology. Findings from this preliminary derivation study suggest that clinicians use specific terminology in unstructured EHR fields to describe common symptoms of CI. This terminology can inform the design of EHR-based phenotypes for CI and merits further investigation in more diverse, robustly characterized samples.
尽管认知障碍（CI）的不良预后风险增加，但在住院期间却大大未被发现。虽然基于电子病历的自动表型具有提高 CI 识别能力的潜力，但由于痴呆等潜在病因的广泛误诊，这限制了更精确的结构化数据元素的应用。本研究检查了来自两家医院的痴呆髋部和卒中骨折患者的急性护理电子病历中的 CI 症状的非结构化数据。临床医生审查员使用标准化标准对非结构化电子病历数据进行了识别和分类。对相关叙述性文本进行了描述性特征描述，并评估了关键术语。大多数患者的电子病历（90%）都有反映 CI 常见认知和/或行为功能障碍的叙述性文本，这些文本可通过可靠的分类（κ 0.82）进行分类。大多数陈述反映的是对认知/行为功能障碍的模糊描述，而不是诊断术语。这项初步推导研究的结果表明，临床医生在非结构化电子病历字段中使用特定术语来描述 CI 的常见症状。该术语可为基于电子病历的 CI 表型设计提供信息，并值得在更多样化、特征更明确的样本中进一步研究。
