Unstructured clinical documentation reflecting cognitive and behavioral dysfunction: toward an EHR-based phenotype for cognitive impairment

This study examined unstructured data on symptoms of CI in the acute-care EHRs of hip and stroke fracture patients with dementia from two hospitals. Clinician reviewers identified and classified unstructured EHR data using standardize d criteria. Relevant narrative text was descriptively characterized and evaluated for key terminology. Most patient EHRs (90%) had narrative text reflecting cognitive and/or behavioral dysfunction common in CI that were reliably classified (κ 0.82). The majority of statements reflected vague descri ptions of cognitive/behavioral dysfunction as opposed to diagnostic terminology. Findings from this preliminary derivation study suggest that clinicians use specific terminology in unstructured EHR fields to describe common symptoms of CI. This terminology can inform the design of EHR-based phenotyp es for CI and merits further investigation in more diverse, robustly characterized samples.
Source: Journal of the American Medical Informatics Association - Category: Information Technology Source Type: research