Synchronization of Codification of Unspecified Schizophrenia Againts Back-Referral System of Mirit Public Health Center

Background: The disease classification system is a grouping of diseases following the International Statistical Classification of Diseases and Related Health Problems Tenth Revisions ICD-10. The coding application must be in accordance with ICD-10 to obtain a valid code in disease indexing, national, international reporting of morbidity and mortality, analysis of health care costs, and epidemiological and clinical research. The diagnosis of schizoaffective disorder is made if schizophrenia and affective disorder are symptoms based on the ICD-10 diagnostic criteria. This study aims to determine the synchronization of the codification of unspecified schizophrenia and determine the factors that influence it against the back-referral system at the Mirit Health Center. Method: This research is qualitative research with a descriptive approach. Respondents were four officers, i.e. one doctor, one medical record officer, one person holding a mental program, one pharmacy officer. The number of observed medical record documents was 96 data with research indicators of accuracy and completeness of the diagnosis code in patients referred from First Level Health Facilities (FKTP) to Advanced Health Facilities (FKTL). Result: The results showed 30 referrals, with nine referrals having the accuracy of the patient referral diagnosis code. The back-referral program (PRB) for mental illness at the Mirit Health Center, in collaboration with Mbah Marsio's mental health rehabilitation center, was carried out well. However, the implementation of the Chronic Disease Management program (Prolanis) for mental health was still not good. Conclusion: There are many unsynchronized codifications. It is recommended to conduct an evaluation where they communicate with each other about the patient's condition to supervise the implementation of Referback Patients, especially to specialists who write the back-referral form

Pemodelan Text Mining dalam Pengkodean Penyakit Pasien Berdasar Kode ICD 10

Pengkodean penyakit yang lazim dilakukan oleh Rumah Sakit adalah menggunakan 2 metode, yang pertama adalah klinisi/ dokter menuliskan numenklatur penyakit berdasarkan kode ICD-10 dengan panduan kamus ICD-10 yang dapat berupa elektronik maupun buku. Metode kedua adalah klinisi/ dokter menulis secara free-text kemudian petugas koding dari rekam medis yang memberikan kode penyakit berdasar kode ICD-10 dan apabila ada hal yang sekiranya diragukan, petugas koding akan mengkonfirmasi ke dokter yang merawat pasien. Dari kebanyakan diagnosis medis yang berupa deskripsi free-text, kemiripan makna serta istilah medis yang memiliki kekhususan daripada istilah umum akan menjadi tantangan tersendiri dalam mengekstrak informasi yang berada di dalamnya. Hal ini yang mendorong penulis untuk membuat pendekatan koding penyakit dengan pememodelkan Text Mining dalam membantu pengkodean penyakit tersebut melalui data diagnosis dokter sehingga diharapkan proses pengkodean penyakit menjadi lebih cepat dan mengurangi aspek human error khususnya untuk penyakit di Indonesia. Metode pendekatan yang diterapkan adalah Clinical Text Mining dengan Natural Language Processing dimana metode ini dirasa paling tepat untuk mengekstraksi informasi dari diagnosis dokter yang tidak terstruktur. Data diambil dari Rumah Sakit bagian poliklinik penyakit dalam sejumlah 3787 data dengan 5 kategori kode ICD 10 yakni E11.9 Type 2 diabetes mellitus without complications, I10 Essential (primary) hypertension, I11.9 Hypertensive heart disease without (congestive) heart failure, K21.9 Gastro-oesophageal reflux disease without oesophagitis, K30 Functional dyspepsia  dengan pembagian komposisi data untuk training dan testing adalah 70:30 proses ekstraksi melalui tahapan case folding, contraction untuk pencocokan dengan kamus singkatan, tokenization, stop word removal dan menggunakan word2vec untuk proses konversi kata yang berupa karakter alphanumeric kedalam bentuk vector dari hasil pemodelan menggunakan Neural Network didapatkan nilai performa model cukup baik yakni memiliki akurasi 86.8%

Linking free text documentation of functioning and disability to the ICF with natural language processing

Background: Invaluable information on patient functioning and the complex interactions that define it is recorded in free text portions of the Electronic Health Record (EHR). Leveraging this information to improve clinical decision-making and conduct research requires natural language processing (NLP) technologies to identify and organize the information recorded in clinical documentation. Methods: We used natural language processing methods to analyze information about patient functioning recorded in two collections of clinical documents pertaining to claims for federal disability benefits from the U.S. Social Security Administration (SSA). We grounded our analysis in the International Classification of Functioning, Disability, and Health (ICF), and used the Activities and Participation domain of the ICF to classify information about functioning in three key areas: mobility, self-care, and domestic life. After annotating functional status information in our datasets through expert clinical review, we trained machine learning-based NLP models to automatically assign ICF categories to mentions of functional activity. Results: We found that rich and diverse information on patient functioning was documented in the free text records. Annotation of 289 documents for Mobility information yielded 2,455 mentions of Mobility activities and 3,176 specific actions corresponding to 13 ICF-based categories. Annotation of 329 documents for Self-Care and Domestic Life information yielded 3,990 activity mentions and 4,665 specific actions corresponding to 16 ICF-based categories. NLP systems for automated ICF coding achieved over 80% macro-averaged F-measure on both datasets, indicating strong performance across all ICF categories used. Conclusions: Natural language processing can help to navigate the tradeoff between flexible and expressive clinical documentation of functioning and standardizable data for comparability and learning. The ICF has practical limitations for classifying functional status information in clinical documentation but presents a valuable framework for organizing the information recorded in health records about patient functioning. This study advances the development of robust, ICF-based NLP technologies to analyze information on patient functioning and has significant implications for NLP-powered analysis of functional status information in disability benefits management, clinical care, and research

Extreme multi-label deep neural classification of Spanish health records according to the International Classification of Diseases

111 p.Este trabajo trata sobre la minería de textos clínicos, un campo del Procesamiento del Lenguaje Natural aplicado al dominio biomédico. El objetivo es automatizar la tarea de codificación médica. Los registros electrónicos de salud (EHR) son documentos que contienen información clínica sobre la salud de unpaciente. Los diagnósticos y procedimientos médicos plasmados en la Historia Clínica Electrónica están codificados con respecto a la Clasificación Internacional de Enfermedades (CIE). De hecho, la CIE es la base para identificar estadísticas de salud internacionales y el estándar para informar enfermedades y condiciones de salud. Desde la perspectiva del aprendizaje automático, el objetivo es resolver un problema extremo de clasificación de texto de múltiples etiquetas, ya que a cada registro de salud se le asignan múltiples códigos ICD de un conjunto de más de 70 000 términos de diagnóstico. Una cantidad importante de recursos se dedican a la codificación médica, una laboriosa tarea que actualmente se realiza de forma manual. Los EHR son narraciones extensas, y los codificadores médicos revisan los registros escritos por los médicos y asignan los códigos ICD correspondientes. Los textos son técnicos ya que los médicos emplean una jerga médica especializada, aunque rica en abreviaturas, acrónimos y errores ortográficos, ya que los médicos documentan los registros mientras realizan la práctica clínica real. Paraabordar la clasificación automática de registros de salud, investigamos y desarrollamos un conjunto de técnicas de clasificación de texto de aprendizaje profundo

Using machine learning for automated de-identification and clinical coding of free text data in electronic medical records

The widespread adoption of Electronic Medical Records (EMRs) in hospitals continues to increase the amount of patient data that are digitally stored. Although the primary use of the EMR is to support patient care by making all relevant information accessible, governments and health organisations are looking for ways to unleash the potential of these data for secondary purposes, including clinical research, disease surveillance and automation of healthcare processes and workflows. EMRs include large quantities of free text documents that contain valuable information. The greatest challenges in using the free text data in EMRs include the removal of personally identifiable information and the extraction of relevant information for specific tasks such as clinical coding. Machine learning-based automated approaches can potentially address these challenges. This thesis aims to explore and improve the performance of machine learning models for automated de-identification and clinical coding of free text data in EMRs, as captured in hospital discharge summaries, and facilitate the applications of these approaches in real-world use cases. It does so by 1) implementing an end-to-end de-identification framework using an ensemble of deep learning models; 2) developing a web-based system for de-identification of free text (DEFT) with an interactive learning loop; 3) proposing and implementing a hierarchical label-wise attention transformer model (HiLAT) for explainable International Classification of Diseases (ICD) coding; and 4) investigating the use of extreme multi-label long text transformer-based models for automated ICD coding. The key findings include: 1) An end-to-end framework using an ensemble of deep learning base-models achieved excellent performance on the de-identification task. 2) A new web-based de-identification software system (DEFT) can be readily and easily adopted by data custodians and researchers to perform de-identification of free text in EMRs. 3) A novel domain-specific transformer-based model (HiLAT) achieved state-of-the-art (SOTA) results for predicting ICD codes on a Medical Information Mart for Intensive Care (MIMIC-III) dataset comprising the discharge summaries (n=12,808) that are coded with at least one of the most 50 frequent diagnosis and procedure codes. In addition, the label-wise attention scores for the tokens in the discharge summary presented a potential explainability tool for checking the face validity of ICD code predictions. 4) An optimised transformer-based model, PLM-ICD, achieved the latest SOTA results for ICD coding on all the discharge summaries of the MIMIC-III dataset (n=59,652). The segmentation method, which split the long text consecutively into multiple small chunks, addressed the problem of applying transformer-based models to long text datasets. However, using transformer-based models on extremely large label sets needs further research. These findings demonstrate that the de-identification and clinical coding tasks can benefit from the application of machine learning approaches, present practical tools for implementing these approaches, and highlight priorities for further research