Efficient Standardization of Clinical Notes using Large Language Models

Fuente: arXiv
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Main Authors: Hier, Daniel B., Carrithers, Michael D., Do, Thanh Son, Obafemi-Ajayi, Tayo
Format: Preprint
Published: 2024
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author Hier, Daniel B.
Carrithers, Michael D.
Do, Thanh Son
Obafemi-Ajayi, Tayo
author_facet Hier, Daniel B.
Carrithers, Michael D.
Do, Thanh Son
Obafemi-Ajayi, Tayo
contents Clinician notes are a rich source of patient information but often contain inconsistencies due to varied writing styles, colloquialisms, abbreviations, medical jargon, grammatical errors, and non-standard formatting. These inconsistencies hinder the extraction of meaningful data from electronic health records (EHRs), posing challenges for quality improvement, population health, precision medicine, decision support, and research. We present a large language model approach to standardizing a corpus of 1,618 clinical notes. Standardization corrected an average of $4.9 +/- 1.8$ grammatical errors, $3.3 +/- 5.2$ spelling errors, converted $3.1 +/- 3.0$ non-standard terms to standard terminology, and expanded $15.8 +/- 9.1$ abbreviations and acronyms per note. Additionally, notes were re-organized into canonical sections with standardized headings. This process prepared notes for key concept extraction, mapping to medical ontologies, and conversion to interoperable data formats such as FHIR. Expert review of randomly sampled notes found no significant data loss after standardization. This proof-of-concept study demonstrates that standardization of clinical notes can improve their readability, consistency, and usability, while also facilitating their conversion into interoperable data formats.
format Preprint
id arxiv_https___arxiv_org_abs_2501_00644
institution arXiv
publishDate 2024
record_format arxiv
spellingShingle Efficient Standardization of Clinical Notes using Large Language Models
Hier, Daniel B.
Carrithers, Michael D.
Do, Thanh Son
Obafemi-Ajayi, Tayo
Computation and Language
Artificial Intelligence
92
J.3; I.2
Clinician notes are a rich source of patient information but often contain inconsistencies due to varied writing styles, colloquialisms, abbreviations, medical jargon, grammatical errors, and non-standard formatting. These inconsistencies hinder the extraction of meaningful data from electronic health records (EHRs), posing challenges for quality improvement, population health, precision medicine, decision support, and research. We present a large language model approach to standardizing a corpus of 1,618 clinical notes. Standardization corrected an average of $4.9 +/- 1.8$ grammatical errors, $3.3 +/- 5.2$ spelling errors, converted $3.1 +/- 3.0$ non-standard terms to standard terminology, and expanded $15.8 +/- 9.1$ abbreviations and acronyms per note. Additionally, notes were re-organized into canonical sections with standardized headings. This process prepared notes for key concept extraction, mapping to medical ontologies, and conversion to interoperable data formats such as FHIR. Expert review of randomly sampled notes found no significant data loss after standardization. This proof-of-concept study demonstrates that standardization of clinical notes can improve their readability, consistency, and usability, while also facilitating their conversion into interoperable data formats.
title Efficient Standardization of Clinical Notes using Large Language Models
topic Computation and Language
Artificial Intelligence
92
J.3; I.2
url https://arxiv.org/abs/2501.00644