改善从临床文本中提取信息的研究报告质量:制定基于共识的报告准则的议定书
Daniel Reichenpfader1,2, Henning Müller3,4, Kerstin Denecke1
1Institute for Patient-Centered Digital Health, Department of Engineering and Computer Science, Bern University of Applied Sciences, Quellgasse 21, Biel, 2502, Switzerland, 41 31 848 60 93.
JMIR research protocols
|September 24, 2025
概括
制定临床信息提取 (CINEX) 准则有助于改善临床信息提取研究的报告. 这份经过专家验证的指南确保了医疗保健人工智能研究的透明度和可重复性.
科学领域:
- 医疗信息学 医疗信息学
- 医疗保健中的人工智能
- 临床自然语言处理 临床自然语言处理
背景情况:
- 临床信息提取 (IE) 研究中不一致的报告实践阻碍了医疗保健的进步.
- 现有的指导方针不足以解决IE研究的独特挑战,导致报告异质性.
- 医疗保健框架中的当前人工智能经常忽视基于文本的IE,而是专注于预测建模或临床试验.
研究的目的:
- 制定临床信息提取 (CINEX) 指南,为临床IE研究制定基于共识的报告标准.
- 为满足临床IE研究的具体需求,提高研究报告的质量和一致性.
主要方法:
- 进行了一项涉及领域专家的3轮电子Delphi (eDelphi) 研究.
- 在MEDINFO 2025的混合共识会议上,最终确定了报告项目.
- 准则的制定遵循了既定方法,并预先定义了共识值.
主要成果:
- 起草了一套初步的28个报告项目,跨越5个维度 (信息模型,架构,数据,注释,结果).
- 在eDelphi过程中,这些项目得到了改进,以达到专家的共识.
- 该指南旨在技术不可知,涵盖各种IE方法.
结论:
- CINEX指南为报告临床IE研究提供了结构化,经专家验证的指导.
- 实施CINEX将提高医疗保健IE研究的透明度,可复制性和可比性.
- 传播将包括一个解释性文件,以支持广泛采用.
相关概念视频
Introduction to Documentation and Reporting
2.9K
Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
2.9K
Clinical Trials
10.1K
Clinical trials are prospective experimental studies conducted on humans to determine the safety and efficacy of treatments, drugs, diet methods, and medical devices. Using statistics in clinical trials enables researchers to derive reasonable and accurate conclusions from the collected data, allowing them to make wise decisions in uncertain situations. In medical research, statistical methods are crucial for preventing errors and bias.
There are four phases in a clinical trial. A phase one...
There are four phases in a clinical trial. A phase one...
10.1K
Types of Reports III: Telephone and Verbal Reports
985
Telephone and Verbal Reports in healthcare settings are two communication methods for conveying therapeutic instructions from healthcare providers to nurses or other healthcare staff.
Here's an overview of each type:
Telephone Orders
Here's an overview of each type:
Telephone Orders
985
Clinical Trials: Overview
4.6K
Clinical development focuses on how the drug will interact with the human body and encompasses four key phases of clinical trials, each serving a specific purpose in assessing the safety and effectiveness of new drugs. These phases overlap and build upon one another. Phase I involves a small group of healthy volunteers (typically 20-80 individuals) or, in cases where significant toxicity is expected, patients with the targeted disease, such as cancer or AIDS. The volunteers are tested for...
4.6K
Guidelines for Writing Outcome
3.6K
When developing expected outcomes for a patient care plan, the nurse should adhere to the following recommendations:
Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care...
Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care...
3.6K
Guidelines for Nursing Documentation II
1.6K
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
1.6K


