Identifying Falls Risk Screenings Not Documented with Administrative Codes Using Natural Language Processing.
Year: 2017
Type: article
Abstract: Quality reporting that relies on coded administrative data alone may not completely and accurately depict providers' performance. To assess this concern with a test case, we developed and evaluated a natural language processing (NLP) approach to identify falls risk screenings documented in clinical notes of patients without coded falls risk screening data. Extracting information from 1,558 clinical notes (mainly progress notes) from 144 eligible patients, we generated a lexicon of 38 keywords relevant to falls risk screening, 26 terms for pre-negation, and 35 terms for post-negation. The NLP algorithm identified 62 (out of the 144) patients who falls risk screening documented only in clinical notes and not coded. Manual review confirmed 59 patients as true positives and 77 patients as true negatives. Our NLP approach scored 0.92 for precision, 0.95 for recall, and 0.93 for F-measure. These results support the concept of utilizing NLP to enhance healthcare quality reporting.
Source: PubMed Central
Authors: Vivienne J Zhu, Tina D Walker, Robert W Warren, Peggy B Jenny, Stephane Meystre, Leslie A Lenert
Institution: Medical University of South Carolina
Language: English
Subfield: Health Information Management
Field: Health Professions
Domain: Health Sciences
Open Access status: green
Funder: National Institutes of Health
OpenAlex ID: W2785406638
