Processing of Short-Form Content in Clinical Narratives: Systematic Scoping Review

BACKGROUND

Clinical narratives are essential components of electronic health records. The adoption of electronic health records has increased documentation time for hospital staff, leading to the use of abbreviations and acronyms more frequently. This brevity can potentially hinder comprehension for both professionals and patients.

OBJECTIVE

This review aims to provide an overview of the types of short forms found in clinical narratives, as well as the natural language processing (NLP) techniques used for their identification, expansion, and disambiguation.

METHODS

In the databases Web of Science, Embase, MEDLINE, EBMR (Evidence-Based Medicine Reviews), and ACL Anthology, publications that met the inclusion criteria were searched according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for a systematic scoping review. Original, peer-reviewed publications focusing on short-form processing in human clinical narratives were included, covering the period from January 2018 to February 2023. Short-form types were extracted, and multidimensional research methodologies were assigned to each target objective (identification, expansion, and disambiguation). NLP study recommendations and study characteristics were systematically assigned occurrence rates for evaluation.

RESULTS

Out of a total of 6639 records, only 19 articles were included in the final analysis. Rule-based approaches were predominantly used for identifying short forms, while string similarity and vector representations were applied for expansion. Embeddings and deep learning approaches were used for disambiguation.

CONCLUSIONS

The scope and types of what constitutes a clinical short form were often not explicitly defined by the authors. This lack of definition poses challenges for reproducibility and for determining whether specific methodologies are suitable for different types of short forms. Analysis of a subset of NLP recommendations for assessing quality and reproducibility revealed only partial adherence to these recommendations. Single-character abbreviations were underrepresented in studies on clinical narrative processing, as were investigations in languages other than English. Future research should focus on these 2 areas, and each paper should include descriptions of the types of content analyzed.

Prevalence and Risk Factors for Dangerous Abbreviations in Malaysian Electronic Clinical Notes

Medical abbreviations can be misinterpreted and endanger patients' lives. This research is the first to investigate the prevalence of abbreviations in Malaysian electronic discharge summaries, where English is widely used, and elicit the risk factors associated with dangerous abbreviations. We randomly sampled and manually annotated 1102 electronic discharge summaries for abbreviations and their senses. Three medical doctors assigned a danger level to ambiguous abbreviations based on their potential to cause patient harm if misinterpreted. The predictors for dangerous abbreviations were determined using binary logistic regression. Abbreviations accounted for 19% (33,824) of total words; 22.6% (7640) of those abbreviations were ambiguous; and 52.3% (115) of the ambiguous abbreviations were labelled dangerous. Increased risk of danger occurs when abbreviations have more than two senses (OR = 2.991; 95% CI 1.586, 5.641), they are medication-related (OR = 6.240; 95% CI 2.674, 14.558), they are disorders (OR = 7.771; 95% CI 2.054, 29.409) and procedures (OR = 3.492; 95% CI 1.376, 8.860). Reduced risk of danger occurs when abbreviations are confined to a single discipline (OR = 0.519; 95% CI 0.278, 0.967). Managing abbreviations through awareness and implementing automated abbreviation detection and expansion would improve the quality of clinical documentation, patient safety, and the information extracted for secondary purposes.

Deciphering clinical abbreviations with a privacy protecting machine learning system

Physicians write clinical notes with abbreviations and shorthand that are difficult to decipher. Abbreviations can be clinical jargon (writing "HIT" for "heparin induced thrombocytopenia"), ambiguous terms that require expertise to disambiguate (using "MS" for "multiple sclerosis" or "mental status"), or domain-specific vernacular ("cb" for "complicated by"). Here we train machine learning models on public web data to decode such text by replacing abbreviations with their meanings. We report a single translation model that simultaneously detects and expands thousands of abbreviations in real clinical notes with accuracies ranging from 92.1%-97.1% on multiple external test datasets. The model equals or exceeds the performance of board-certified physicians (97.6% vs 88.7% total accuracy). Our results demonstrate a general method to contextually decipher abbreviations and shorthand that is built without any privacy-compromising data.

Structure, content, unsafe abbreviations, and completeness of discharge summaries: A retrospective analysis in a University Hospital in Austria

RATIONALE AND OBJECTIVE

The discharge summary (DS) is one of the most important instruments to transmit information to the treating general physician (GP). The objective of this study was to analyse important components of DS, structural characteristics as well as medical and general abbreviations.

METHOD

One hundred randomly selected DS from five different clinics were evaluated by five independent reviewers regarding content, structure, abbreviations and conformity to the Austrian Electronic Health Records (ELGA) using a structured case report form. Abbreviations of all 100 DS were extracted. All items were scored on a 4-point Likert-type scale ranging from "strongly agree" to "strongly disagree" (or "not relevant"). Subsequently, the results were discussed among reviewers to achieve a consensus decision.

RESULTS

The mandatory fields, reason for admission and diagnosis at discharge were present in 80% and 98% of DS. The last medication was fully scored in 48% and the recommended medication in 94% of 100 DS. There were significant overall differences among clinics for nine mandatory items. In total, 750 unexplained abbreviations were found in 100 DS.

CONCLUSIONS

In conclusion, DS are often lacking important items. Particularly important are a detailed medication history and recommendations for further medication that should always be listed in each DS. It is thus necessary to design and implement changes that improve the completeness of DS. An important quality improvement can be achieved by avoiding the use of ambiguous abbreviations.

Danger in discharge summaries: Abbreviations create confusion for both author and recipient

BACKGROUND

The transition from hospital inpatient care to medical care in the community is a high-risk period for adverse events. Inadequate communication, including low quality or unavailable discharge summaries, has been shown to impact patient care.

AIMS

Assess use of abbreviations in clinical handover documents from inpatient hospital teams to general practitioners (GPs), and the interpretation of these abbreviations by GPs and hospital-based junior doctors.

METHODS

Retrospective audit of 802 discharge summaries completed during a one-week period in 2017 by a Queensland regional health service. GPs and local junior doctors then attempted interpretation of twenty relevant abbreviations.

RESULTS

99% (794) discharge summaries included abbreviations. 1612 different abbreviations were used on 16 327 occasions. The median number of abbreviations per discharge summary was 17 (range 0-86). 254 GPs and 62 junior doctors responded to a survey which found that no abbreviation was interpreted the same by all respondents. GPs and junior doctors were unable to offer any interpretation in 17.9% and 15.2% of cases respectively. GPs offered a greater range of interpretations than junior doctors, with a median of 9 and 3 different interpretations per abbreviation respectively. 94% (239) of GPs felt that the use of abbreviations in discharge summaries had the potential to impact patient care. 152 (60%) GPs felt that time spent clarifying abbreviations in discharge summaries could be excessive.

CONCLUSIONS

Abbreviations are often used in discharge summaries, yet poorly understood. This has the potential to impact patient care in the transition period after hospitalisation This article is protected by copyright. All rights reserved.

A deep database of medical abbreviations and acronyms for natural language processing

The recognition, disambiguation, and expansion of medical abbreviations and acronyms is of upmost importance to prevent medically-dangerous misinterpretation in natural language processing. To support recognition, disambiguation, and expansion, we present the Medical Abbreviation and Acronym Meta-Inventory, a deep database of medical abbreviations. A systematic harmonization of eight source inventories across multiple healthcare specialties and settings identified 104,057 abbreviations with 170,426 corresponding senses. Automated cross-mapping of synonymous records using state-of-the-art machine learning reduced redundancy, which simplifies future application. Additional features include semi-automated quality control to remove errors. The Meta-Inventory demonstrated high completeness or coverage of abbreviations and senses in new clinical text, a substantial improvement over the next largest repository (6–14% increase in abbreviation coverage; 28–52% increase in sense coverage). To our knowledge, the Meta-Inventory is the most complete compilation of medical abbreviations and acronyms in American English to-date. The multiple sources and high coverage support application in varied specialties and settings. This allows for cross-institutional natural language processing, which previous inventories did not support. The Meta-Inventory is available at https://bit.ly/github-clinical-abbreviations.

Measurement(s)	Controlled Vocabulary • Linguistic Form
Technology Type(s)	digital curation • data combination
Sample Characteristic - Location	United States of America

Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.14068949

The Readability of Outpatient Plastic Surgery Clinic Letters: Are We Adhering to Plain English Writing Standards?

The readability of letters sent to patients plays a pivotal role in facilitating joint decision making and positive health outcomes. Guidance suggests that all correspondence should be directed to patients. Covid-19 led to an increase in direct-to-patient communication. This study aims to determine the quantity and quality of plastic surgery clinic letters sent to patients before and during the Covid-19 pandemic. A total of 127 pre-Covid clinic letters from November to December 2019 and 103 peri-Covid clinic letters from April to May 2020 were identified and assessed for readability. Text was analyzed using a standardized set of commonly used readability formulae, including SMOG, Flesch Reading Ease, and the Coleman-Liao Index. A total of 100 pre-Covid and 58 peri-Covid letters were suitable for inclusion. Median results for formulae that output a U.S. grade score ranged between 9 and 12.9 for letters written prior to Covid-19 and 9 and 13.2 for those written during Covid-19. Eight percent of letters were sent to patients pre-Covid, increasing to 28% during the pandemic. Letters sent to patients had a median grade score of between 8 and 12 prior to Covid-19 and 8 and 10.6 during Covid-19. Letters sent to clinicians ranged between 9 and 13 and 9 and 13.3, respectively. Outpatient plastic surgery letters are written at a readability level too high to facilitate understanding among the general population. The increase in direct-to-patient contact during the Covid-19 outbreak has not led to a significant improvement in the readability of clinic letters. The authors suggest an increase in letter standardization and raising awareness of readability when writing clinic letters.

Attitudes of physicians towards target groups and content of the discharge summary: a cross-sectional analysis in Styria, Austria

OBJECTIVES

The discharge summary (DS) represents one of the most important instruments to ensure a safe patient discharge from the hospital. They sometimes have poor quality in content and often include medical jargon, which the patient and their relatives cannot easily understand. Therefore, many risks for patient safety exist. This study investigated the questions for whom the DS is and which contents are necessary to ensure a safe treatment.

DESIGN

Cross-sectional analysis.

SETTING

Styria, Austria.

PARTICIPANTS

3948 internal and external physicians were consulted.

INTERVENTIONS

An online survey consisting of 24 questions was conducted. The survey was distributed to physicians working in the province of Styria, Austria, in 2018 over a period of 6 months.

MAIN OUTCOMES AND MEASURES

Attitudes of internal and external physicians in terms of target group, content and health literacy.

RESULTS

In total, 1060 physicians participated in the survey. The DS is considered as a communication tool among physicians (97.9%) and the patients are also indicated as addressees (73.5%). Furthermore, there is a high level of agreement that understandable information in the DS leads to fewer questions of the patients (67.9%).

CONCLUSION

In conclusion, the DS is not only seen as a document for the further treating physician but is also relevant for the patient. Incorporating the patient into their treatment at all levels may possibly strengthen the individual health literacy of the patient and their caring relatives.

Analysis of abbreviations used by residents in admission notes and discharge summaries

BACKGROUND

There are abbreviations that are used daily such as BP for blood pressure and ECG for electrocardiogram, but many of the abbreviations found in medical documents are unclear.

AIM

The purpose of this study was to assess the frequency, type and comprehension of abbreviations in admission notes and discharge letters composed by orthopedic surgery and medical residents.

METHODS

Abbreviations were extracted from discharge letters and admission notes composed by residents from orthopedic surgery and medical wards. The frequency of use of the abbreviations was determined. Additionally, the fifty commonest abbreviations from each specialty were graded by three medical and three orthopedic surgery senior physicians as 1. understandable or 2. Ambiguous or unknown.

RESULTS

The number of abbreviations found in the documents composed by medical and orthopedic surgery residents was 1525 with 80 different abbreviations and 493 with 51 different abbreviations respectively (9.3% and 4.9% of the total word number respectively). Analysis revealed that 14% of the abbreviations from medical ward documents were graded as ambiguous or unknown by medical senior physicians compared with 25% by senior orthopedic surgeons. When abbreviations from orthopedic surgery documents were presented to both groups, senior orthopedic surgeons graded 8% as ambiguous or unknown compared with 21% by the medical senior physicians.

CONCLUSION

In order to prevent impairment of patient care, only standard abbreviations should be used in medical documents. Measures should be taken to decrease the use of non standard abbreviations such as the incorporation of authorized abbreviations to the electronic medical record.

Mutual comprehension of urological abbreviations

Objective:

To establish the comprehension of urological abbreviations by non-urologists, and evaluate the awareness of urologists to this issue.

Subjects and methods:

This study involved complimentary surveys to non-urologists and urologists in the same area. The non-urologist survey was distributed to three groups: medical students, junior doctors, GPs and GP trainees. It assessed the comprehension of 24 commonly used urological abbreviations. The urologists’ survey assessed the urologists’ expectations of comprehension by each of the non-urologist groups. A total of 196 non-urologists (19 medical students, 35 junior doctors and 142 GPs and GP trainees), and 11 urologists and urological trainees participated.

Results:

On average the junior doctors and GPs understood approximately the same number of abbreviations (9.86 and 9.62 correct, respectively), with the medical students understanding fewer (7.89 correct). While this difference was statistically significant (F2,193df=3.875, P=0.022), gender, number of years post-graduation and completion of a urology term were not shown to have an impact on the comprehension of urological abbreviations. Of the 24 abbreviations, nine were correctly understood by more than 50% of non-urologists. The urologists did not expect non-urologists to understand a majority of the abbreviations; however, most also reported not using abbreviations routinely in communications with non-urologists.

Conclusions:

These results suggest that caution must be used when using abbreviations in communication with non-urologists as there is a high chance of the recipient not understanding the abbreviations. This is particularly pertinent given the current rollout of electronic medical records across Australia.