• Johanne Krogsgaard Jensen
  • Thea Mentz Sørensen
Introduction: The use of free text documentation supports clinical practice but challenges arise when reusing free text documents. Since it is not possible to reuse all information within healthcare, a focus on preserving the situational context must be retained when handling the challenges. Therefore, the objective of this study was to explore how the situational context can be preserved when extracting and structuring relevant information from free text documents in order to obtain semantic interoperability. Method: Discharge summaries from the N2C2 2010 challenge were used as the data foundation, which together with an implementation context set the scope for the development. HL7 FHIR resources, SNOMED CT expressions, and the NLP system cTAKES, were used to structure, encode, and extract information from the discharge summaries. cTAKES was adjusted using an agile development approach. The focus of the adjustments were to include more contextual information by using post-coordinated expressions from SNOMED CT, and these were tested against a gold standard. Result: The 21 FHIR profiles contained 95.5% of information from the discharge summaries. The adjusted cTAKES had a F-score of 0.120. Conclusion: The situational contextual information from free text documents can be preserved using HL7 FHIR and SNOMED CT. However, automatic information extraction using cTAKES, lack the maturity for clinical use.
Publication dateJun 2021
Number of pages85
ID: 413094238