Working Toward Automated Coding in General Practice

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Stephen Lean
School of Engineering and Advanced Technology
Massey University
(P35, 16/10/08, Coding stream, 3.50pm)

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Working Toward Automated Coding in General Practice

  1. 1. Working Toward Automated Coding in General Practice A Work in Progress
  2. 2. Background <ul><li>Electronic Medical Record (EMR) coding at PHC level in NZ. </li></ul><ul><ul><li>What is coding and what is used? </li></ul></ul><ul><ul><li>Why is coding carried out? </li></ul></ul><ul><ul><li>How is coding carried out and by who? </li></ul></ul>
  3. 3. Open Problems <ul><li>Two main issues arising from coding. </li></ul><ul><ul><li>It is a purely manual process requiring the GP to spend considerable time reviewing the record and selecting a code to apply. </li></ul></ul><ul><ul><li>Non-standardised approach to coding leads to inconsistencies in the way codes are applied e.g. the same patient visit may be coded differently by two different GP’s. </li></ul></ul>
  4. 4. Open Problems - Consequences <ul><li>Time spent coding by GP’s would be much better spent seeing patients. </li></ul><ul><li>Non-standardised coding leads to a loss in quality of medical records. </li></ul><ul><li>Only increasing requirements from the Ministry of Health for coding so issues, if left unattended, will only be magnified. </li></ul>
  5. 5. Project <ul><li>Use an IT system to analyse the free text content of EMRs with the intention of using NLP techniques to automatically identify potential codes for the record. </li></ul><ul><li>The idea here is to: </li></ul><ul><ul><li>Reduce the time GP’s spend coding. </li></ul></ul><ul><ul><li>Standardise the application of codes. </li></ul></ul>
  6. 6. Main Concept for Development <ul><li>Apply annotations to concepts from the free text. </li></ul><ul><li>Abstract away from the raw text where the proposed system would then operate over a set of annotated concepts. </li></ul><ul><li>Utilise these annotated concepts, or combination thereof. </li></ul>
  7. 7. Annotations - Example
  8. 8. Results <ul><li>Prototype design only implemented to a rudimentary level of functionality. </li></ul><ul><li>Progress and knowledge gained was encouraging and shows promise. </li></ul><ul><li>Probably not feasible to create a set of rules that provide coverage of all potential coding outcomes. </li></ul>
  9. 9. Results <ul><li>Implementation of a logical reaction to the firing of rules, based on pattern recognition within text and patterns from within the graph of annotations, is a very complex issue. </li></ul><ul><li>Issues encountered: </li></ul><ul><ul><li>No direct access to vocabulary of codes. </li></ul></ul><ul><ul><li>Lack of access to actual medical records. </li></ul></ul><ul><ul><li>Time and resources i.e. one person over six months. </li></ul></ul><ul><li>Design decisions were affected by these issues. </li></ul>
  10. 10. Conclusions and Future Work <ul><li>Introduction of SNOMED CT will require a reassessment of the way codes can be implemented within the system. </li></ul><ul><li>Determine what language aspects of EMRs are most problematic. </li></ul><ul><li>Traceability, result representation and assurance. </li></ul>
  11. 11. Questions <ul><li>? </li></ul>

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