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Unstructured clinical documentation reflecting cognitive and behavioral dysfunction: toward an EHR-based phenotype
Andrea L Gilmore-Bykovskyi1,2,3, Laura M Block1, Lily Walljasper1
1University of Wisconsin-Madison School of Nursing, Madison, Wisconsin, USA.
Summary
Cognitive impairment (CI) symptoms are often missed in hospitals. This study found that clinicians use specific terms in unstructured electronic health records to describe CI symptoms, which can help improve detection.
Area of Science:
- Medical Informatics
- Geriatric Medicine
- Neurology
Background:
- Cognitive impairment (CI) is under-detected in hospitalized patients, despite increased risks.
- Under-diagnosis of etiologies like dementia limits automated electronic health record (EHR)-based CI detection.
- Unstructured EHR data may contain valuable information on CI symptoms.
Purpose of the Study:
- To examine unstructured EHR data for symptoms of cognitive impairment in hospitalized patients with dementia.
- To characterize terminology used by clinicians to describe CI symptoms in narrative EHR fields.
Main Methods:
- Review of unstructured EHR data from hip and stroke fracture patients with dementia at two hospitals.
- Clinician reviewers identified and classified CI symptoms using standardized criteria.
- Descriptive characterization and terminology evaluation of relevant narrative text.
Main Results:
- 90% of patient EHRs contained narrative text reflecting cognitive/behavioral dysfunction common in CI.
- Classifications of CI symptoms were reliable (κ = 0.82).
- Most descriptions were vague, lacking specific diagnostic terminology.
Conclusions:
- Clinicians utilize specific terminology in unstructured EHRs to describe CI symptoms.
- This terminology can inform the development of EHR-based phenotypes for improved CI detection.
- Further investigation in diverse patient samples is warranted.
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