Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.
Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.
Appl Clin Inform. 2019 Mar;10(2):189-198. doi: 10.1055/s-0039-1679927. Epub 2019 Mar 20.
When a paucity of clinical information is communicated from ordering physicians to radiologists at the time of radiology order entry, suboptimal imaging interpretations and patient care may result.
Compare documentation of relevant clinical information in electronic health record (EHR) provider note to computed tomography (CT) order requisition, prior to ordering of head CT for emergency department (ED) patients presenting with headache.
In this institutional review board-approved retrospective observational study performed between April 1, 2013 and September 30, 2014 at an adult quaternary academic hospital, we reviewed data from 666 consecutive ED encounters for patients with headaches who received head CT. The primary outcome was the number of concept unique identifiers (CUIs) relating to headache extracted via ontology-based natural language processing from the history of present illness (HPI) section in ED notes compared with the number of concepts obtained from the imaging order requisition.
Our analysis was conducted on cases where the HPI note section was completed prior to image order entry, which occurred in 23.1% (154/666) of encounters. For these 154 encounters, the number of CUIs specific to headache per note extracted from the HPI (median = 3, interquartile range [IQR]: 2-4) was significantly greater than the number of CUIs per encounter obtained from the imaging order requisition (median = 1, IQR: 1-2; Wilcoxon signed rank < 0.0001). Extracted concepts from notes were distinct from order requisition indications in 92.9% (143/154) of cases.
EHR provider notes are a valuable source of relevant clinical information at the time of imaging test ordering. Automated extraction of clinical information from notes to prepopulate imaging order requisitions may improve communication between ordering physicians and radiologists, enhance efficiency of ordering process by reducing redundant data entry, and may help improve clinical relevance of clinical decision support at the time of order entry, potentially reducing provider burnout from extraneous alerts.
当医嘱医师在放射科医嘱录入时向放射科医师传达的临床信息不足时，可能会导致影像学解读和患者护理效果不佳。
比较电子病历（EHR）提供者记录与计算机断层扫描（CT）医嘱申请中与头痛急诊患者头部 CT 检查相关的临床信息的记录情况。
在这项 2013 年 4 月 1 日至 2014 年 9 月 30 日在一家成人四级学术医院进行的机构审查委员会批准的回顾性观察研究中，我们对 666 例因头痛而接受头部 CT 检查的急诊患者连续就诊数据进行了回顾。主要结局是通过基于本体的自然语言处理从急诊就诊记录的现病史（HPI）部分提取与头痛相关的概念唯一标识符（CUI）的数量与从影像学医嘱申请中获得的概念数量进行比较。
我们的分析是在图像订单录入之前完成 HPI 记录部分的情况下进行的，这种情况发生在 23.1%（154/666）的就诊中。对于这 154 例就诊者，从 HPI 中提取的每份记录中特定于头痛的 CUI 数量（中位数=3，四分位距[IQR]：2-4）显著大于从影像学医嘱申请中获得的就诊者数量（中位数=1，IQR：1-2；Wilcoxon 符号秩检验，<0.0001）。在 92.9%（143/154）的病例中，从记录中提取的概念与医嘱申请的指示明显不同。
EHR 提供者记录是影像学检查医嘱时获取相关临床信息的有价值的来源。从记录中自动提取临床信息以预填充影像学医嘱申请可以改善医嘱医师和放射科医师之间的沟通，通过减少冗余的数据录入提高医嘱录入流程的效率，并有助于在医嘱录入时提高临床决策支持的临床相关性，可能减少因无关警报导致的提供者倦怠。
