Department of Medical Informatics, Osaka University Graduate School of Medicine, Osaka, Japan.
Department of Transformative System for Medical Information, Osaka University Graduate School of Medicine, Osaka, Japan.
Stud Health Technol Inform. 2024 Aug 22;316:1795-1799. doi: 10.3233/SHTI240779.
Radiology reports are an essential communication method for ensuring smooth workflow in healthcare. However, many of these reports are described in free text, and findings documented by radiologists may not be adequately addressed. In this study, focusing on pulmonary nodules, we evaluated whether cases in which radiologists described follow-up as recommended were receiving appropriate treatment. Reports recommending follow-up for pulmonary nodules were automatically extracted using natural language processing. In our evaluation, out of 10,507 reports, 1,501 cases (14.3%) were classified as "reports recommending follow-up for pulmonary nodules." Among these, 958 cases underwent additional imaging tests within 400 days. From the remaining 543 cases, we randomly sampled 42 cases and conducted chart reviews by clinicians to confirm patient care status. Our assessment found that follow-up was not documented in 17 of the 42 cases (40.5%), indicating a high likelihood that appropriate care was not provided.
放射学报告是确保医疗保健流程顺畅的重要沟通方式。然而，许多报告都是以自由文本的形式描述的，放射科医生记录的发现可能没有得到充分的关注。在这项针对肺结节的研究中，我们评估了放射科医生建议进行随访的病例是否接受了适当的治疗。使用自然语言处理自动提取了建议对肺结节进行随访的报告。在我们的评估中，在 10507 份报告中，有 1501 例（14.3%）被归类为“建议对肺结节进行随访的报告”。在这些病例中，有 958 例在 400 天内接受了额外的影像学检查。在剩下的 543 例中，我们随机抽取了 42 例，并由临床医生进行了图表审查，以确认患者的护理状况。我们的评估发现，42 例中有 17 例（40.5%）未记录随访情况，这表明极有可能没有提供适当的护理。
