J Biomed Inform - Summarization of clinical information: a conceptual model.

Tópicos

{ record(1888) medic(1808) patient(1693) }
{ research(1085) discuss(1038) issu(1018) }
{ framework(1458) process(801) describ(734) }
{ medic(1828) order(1363) alert(1069) }
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{ design(1359) user(1324) use(1319) }
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{ structur(1116) can(940) graph(676) }
{ general(901) number(790) one(736) }
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{ howev(809) still(633) remain(590) }
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{ patient(2837) hospit(1953) medic(668) }
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{ bind(1733) structur(1185) ligand(1036) }
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{ signal(2180) analysi(812) frequenc(800) }
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{ detect(2391) sensit(1101) algorithm(908) }

Resumo

CKGROUND: To provide high-quality and safe care, clinicians must be able to optimally collect, distill, and interpret patient information. Despite advances in text summarization, only limited research exists on clinical summarization, the complex and heterogeneous process of gathering, organizing and presenting patient data in various forms.OBJECTIVE: To develop a conceptual model for describing and understanding clinical summarization in both computer-independent and computer-supported clinical tasks.DESIGN: Based on extensive literature review and clinical input, we developed a conceptual model of clinical summarization to lay the foundation for future research on clinician workflow and automated summarization using electronic health records (EHRs).RESULTS: Our model identifies five distinct stages of clinical summarization: (1) Aggregation, (2) Organization, (3) Reduction and/or Transformation, (4) Interpretation and (5) Synthesis (AORTIS). The AORTIS model describes the creation of complex, task-specific clinical summaries and provides a framework for clinical workflow analysis and directed research on test results review, clinical documentation and medical decision-making. We describe a hypothetical case study to illustrate the application of this model in the primary care setting.CONCLUSION: Both practicing physicians and clinical informaticians need a structured method of developing, studying and evaluating clinical summaries in support of a wide range of clinical tasks. Our proposed model of clinical summarization provides a potential pathway to advance knowledge in this area and highlights directions for further research.

Resumo Limpo

ckground provid highqual safe care clinician must abl optim collect distil interpret patient inform despit advanc text summar limit research exist clinic summar complex heterogen process gather organ present patient data various formsobject develop conceptu model describ understand clinic summar computerindepend computersupport clinic tasksdesign base extens literatur review clinic input develop conceptu model clinic summar lay foundat futur research clinician workflow autom summar use electron health record ehrsresult model identifi five distinct stage clinic summar aggreg organ reduct andor transform interpret synthesi aorti aorti model describ creation complex taskspecif clinic summari provid framework clinic workflow analysi direct research test result review clinic document medic decisionmak describ hypothet case studi illustr applic model primari care settingconclus practic physician clinic informatician need structur method develop studi evalu clinic summari support wide rang clinic task propos model clinic summar provid potenti pathway advanc knowledg area highlight direct research

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