Can Automated Retrieval of Data from Emergency Department Physician Notes Enhance the Imaging Order Entry Process?Funding This study was funded in part by the Boston-Area Research Training Program in Biomedical Informatics grant T15LM007092 from the National Library of Medicine. The authors thank Shawn Murphy, Henry Chueh, and the study institution's Research Patient Data Registry group for facilitating use of their database, and Laura E. Peterson for editorial assistance with the manuscript.
24 August 2018
18 January 2019
20 March 2019 (online)
Background 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.
Objectives 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.
Methods 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.
Results 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 p < 0.0001). Extracted concepts from notes were distinct from order requisition indications in 92.9% (143/154) of cases.
Conclusion 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.
Keywordselectronic health records - computerized physician order entry - natural language processing - emergency medicine - radiology
Protection of Human and Animal Subjects
This study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and was reviewed by Brigham and Women's Hospital Institutional Review Board protocol 2015P002169.
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