title: Creation of structured documentation templates using Natural Language Processing techniques.
abstract: Structured Clinical Documentation is a fundamental component of the healthcare enterprise, linking both clinical (e.g., electronic health record, clinical decision support) and administrative functions (e.g., evaluation and management coding, billing). One of the challenges in creating good quality documentation templates has been the inability to address specialized clinical disciplines and adapt to local clinical practices. A one-size-fits-all approach leads to poor adoption and inefficiencies in the documentation process. On the other hand, the cost associated with manual generation of documentation templates is significant. Consequently there is a need for at least partial automation of the template generation process. We propose an approach and methodology for the creation of structured documentation templates for diabetes using Natural Language Processing (NLP).
authors.affiliation: Clinical Informatics Research and Development, Partners Healthcare System, Wellesley, MA, USA.
authors.forename: Vipul
authors.initials: V
authors.lastname: Kashyap
authors.forename: Alexander
authors.initials: A
authors.lastname: Turchin
authors.forename: Laura
authors.initials: L
authors.lastname: Morin
authors.forename: Frank
authors.initials: F
authors.lastname: Chang
authors.forename: Qi
authors.initials: Q
authors.lastname: Li
authors.forename: Tonya
authors.initials: T
authors.lastname: Hongsermeier
mesh_terms: D003920:Diabetes Mellitus; D004282:Documentation / Q000379:methods*; D006801:Humans; D009323:Natural Language Processing; D018875:Vocabulary, Controlled