Automatic Application of Health Care Criteria to Narrative Patient Records

This paper describes an experimental computer program for the application of health care review criteria to hospital discharge summaries. The use of the computer in this process would make it possible to speed up the routine screening of patient records; it could also facilitate experimental evaluation of alternate proposed audit criteria. The computer program has two components. The first component creates a structured form of the information contained in natural language medical records. It maps the words of each sentence into labelled columns of a table (or information format) according to the type of medical information contained in each word. This structured information is suitable for use as a data base in many areas of clinical research. The second component consists of a set of retrieval routines, each of which corresponds to a criterion of the health care evaluation form, e.g., was the patient afebrile at discharge? The retrieval component is built up in modular fashion, so that basic routines can be used in other applications. The application of this program to a sample hospital discharge summary is presented and compared to the results obtained by a physician reviewer.