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引用次数: 1

摘要

医疗报告标准和结构化报告系统的流行反映了对用结构良好的受控词汇表表示和保存医疗和临床数据的需求日益增长。严格格式化的医疗报告提供了较高的可读性,并促进了进一步的数据处理,例如查询、统计分析和推理,以支持决策。然而,许多医疗报告,如病理报告、护理笔记和医生笔记,都是用自由文本叙述的方式写的。通过填充预定义的数据字段来手动提取自由文本报告既麻烦又容易出错。与此同时,信息提取工具试图自动化这一过程,例如,通过基于机器学习的方法。这种方法通常需要大量人工标注的训练数据集,而这些数据集的获取成本很高。此外,它们也受到准确性(精度和召回率)的限制。为了方便从叙述性医疗报告中提取信息并将提取的数据转换为标准化的结构化表单,我们在本文中提出了一个半自动系统ASLForm,该系统与用户交互,分析自由文本输入并生成规范化答案以实时填充表单。该系统透明地从用户反馈中学习,并逐步建立决策模型。它不需要额外的配置和训练数据集。ASLForm不受任何领域的限制,并且适用于任何格式的自由文本输入。系统的这些特性提供了高可用性和可移植性。它的设计还可以轻松地与现有的报告系统集成。
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Bridging the unstructured and structured worlds: an adaptive self learning medical form generating system
The prevalence of medical report standards and structured reporting systems reflects the increasing demand for representing and preserving medical and clinical data with controlled vocabularies in well structured format. Strictly formatted medical reports offer high human readability and facilitate further data processing, such as querying, statistical analysis, and reasoning to support decision making. However, many medical reports, such as pathology reports, nursing notes and physician's notes, are written in free-text narration. Manually extracting free text reports by filling predefined data fields is cumbersome and error-prone. Meanwhile, information extraction tools try to automate such process, for example, through machine learning based methods. Such methods often require large volumes of training datasets annotated manually by humans, which is expensive to obtain. Furthermore, they are also limited by their accuracy (both precision and recall). To facilitate the process of extracting information from narrative medical reports and transforming extracted data into standardized structured forms, we present in this paper a semi-automatic system, ASLForm, that interacts with users, analyzes free text input and generates normalized answers to populate forms in real-time. This system learns from users' feedback transparently and establishes decision models incrementally. It requires no additional configurations and training datasets. ASLForm is not constrained to any domain, and is adaptable to free text input in any format. These features of the system offer high usability and portability. Its design also enables easy integration with existing reporting systems.
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