Clinical text data in machine learning: Systematic review

Background: Clinical narratives represent the main form of communication within healthcare providing a personalized account of patient history and assessments, offering rich information for clinical decision making. Natural language processing (NLP) has repeatedly demonstrated its feasibility to unlock evidence buried in clinical narratives. Machine learning can facilitate rapid development of NLP tools by leveraging large amounts of text data. Objective: The main aim of this study is to provide systematic evidence on the properties of text data used to train machine learning approaches to clinical NLP. We also investigate the types of NLP tasks that have been supported by machine learning and how they can be applied in clinical practice. Methods: Our methodology was based on the guidelines for performing systematic reviews. In August 2018, we used PubMed, a multi-faceted interface, to perform a literature search against MEDLINE. We identified a total of 110 relevant studies and extracted information about the text data used to support machine learning, the NLP tasks supported and their clinical applications. The data properties considered included their size, provenance, collection methods, annotation and any relevant statistics. Results: The vast majority of datasets used to train machine learning models included only hundreds or thousands of documents. Only 10 studies used tens of thousands of documents with a handful of studies utilizing more. Relatively small datasets were utilized for training even when much larger datasets were available. The main reason for such poor data utilization is the annotation bottleneck faced by supervised machine learning algorithms. Active learning was explored to iteratively sample a subset of data for manual annotation as a strategy for minimizing the annotation effort while maximizing predictive performance of the model. Supervised learning was successfully used where clinical codes integrated with free text notes into electronic health records were utilized as class labels. Similarly, distant supervision was used to utilize an existing knowledge base to automatically annotate raw text. Where manual annotation was unavoidable, crowdsourcing was explored, but it remains unsuitable due to sensitive nature of data considered. Beside the small volume, training data were typically sourced from a small number of institutions, thus offering no hard evidence about the transferability of machine learning models. The vast majority of studies focused on the task of text classification. Most commonly, the classification results were used to support phenotyping, prognosis, care improvement, resource management and surveillance. Conclusions: We identified the data annotation bottleneck as one of the key obstacles to machine learning approaches in clinical NLP. Active learning and distant supervision were explored as a way of saving the annotation efforts. Future research in this field would benefit from alternatives such as data augmentation and transfer learning, or unsupervised learning, which does not require data annotation

Temporal disambiguation of relative temporal expressions in clinical texts using temporally fine-tuned contextual word embeddings.

Temporal reasoning is the ability to extract and assimilate temporal information to reconstruct a series of events such that they can be reasoned over to answer questions involving time. Temporal reasoning in the clinical domain is challenging due to specialized medical terms and nomenclature, shorthand notation, fragmented text, a variety of writing styles used by different medical units, redundancy of information that has to be reconciled, and an increased number of temporal references as compared to general domain texts. Work in the area of clinical temporal reasoning has progressed, but the current state-of-the-art still has a ways to go before practical application in the clinical setting will be possible. Much of the current work in this field is focused on direct and explicit temporal expressions and identifying temporal relations. However, there is little work focused on relative temporal expressions, which can be difficult to normalize, but are vital to ordering events on a timeline. This work introduces a new temporal expression recognition and normalization tool, Chrono, that normalizes temporal expressions into both SCATE and TimeML schemes. Chrono advances clinical timeline extraction as it is capable of identifying more vague and relative temporal expressions than the current state-of-the-art and utilizes contextualized word embeddings from fine-tuned BERT models to disambiguate temporal types, which achieves state-of-the-art performance on relative temporal expressions. In addition, this work shows that fine-tuning BERT models on temporal tasks modifies the contextualized embeddings so that they achieve improved performance in classical SVM and CNN classifiers. Finally, this works provides a new tool for linking temporal expressions to events or other entities by introducing a novel method to identify which tokens an entire temporal expression is paying the most attention to by summarizing the attention weight matrices output by BERT models

Real-time classifiers from free-text for continuous surveillance of small animal disease

A wealth of information of epidemiological importance is held within unstructured narrative clinical records. Text mining provides computational techniques for extracting usable information from the language used to communicate between humans, including the spoken and written word. The aim of this work was to develop text-mining methodologies capable of rendering the large volume of information within veterinary clinical narratives accessible for research and surveillance purposes. The free-text records collated within the dataset of the Small Animal Veterinary Surveillance Network formed the development material and target of this work. The efficacy of pre-existent clinician-assigned coding applied to the dataset was evaluated and the nature of notation and vocabulary used in documenting consultations was explored and described. Consultation records were pre-processed to improve human and software readability, and software was developed to redact incidental identifiers present within the free-text. An automated system able to classify for the presence of clinical signs, utilising only information present within the free-text record, was developed with the aim that it would facilitate timely detection of spatio-temporal trends in clinical signs. Clinician-assigned main reason for visit coding provided a poor summary of the large quantity of information exchanged during a veterinary consultation and the nature of the coding and questionnaire triggering further obfuscated information. Delineation of the previously undocumented veterinary clinical sublanguage identified common themes and their manner of documentation, this was key to the development of programmatic methods. A rule-based classifier using logically-chosen dictionaries, sequential processing and data-masking redacted identifiers while maintaining research usability of records. Highly sensitive and specific free-text classification was achieved by applying classifiers for individual clinical signs within a context-sensitive scaffold, this permitted or prohibited matching dependent on the clinical context in which a clinical sign was documented. The mean sensitivity achieved within an unseen test dataset was 98.17 (74.47, 99.9)% and mean specificity 99.94 (77.1, 100.0)%. When used in combination to identify animals with any of a combination of gastrointestinal clinical signs, the sensitivity achieved was 99.44% (95% CI: 98.57, 99.78)% and specificity 99.74 (95% CI: 99.62, 99.83). This work illustrates the importance, utility and promise of free-text classification of clinical records and provides a framework within which this is possible whilst respecting the confidentiality of client and clinician