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SittingonPinsandNeedles:
CharacterizationofSymptomDescriptionsinClinicalNotes
TylerB.Forbush,CRT
SaltLakeCityVAHealthCareSystem
DepartmentofInternalMedicine,UniversityofUtah
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Background
TheVAcontinuestostudymedicallyunexplainedsyndromessuchasChronicFatigue,Fibromyalgia,andIrritableBowelSyndromeandtheirsymptoms.
MUSarecommonintheveteranpopulation.
MUShavemuchincommonwithotherchronicmulti-symptomillnesses,likegulfwarsyndrome.
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Symptoms
Importantfordiagnosis,assessmentofseverityandresponsetotreatment,therapeuticdecisionmaking,phenotypic
classification.
*Bothatthetimeofpatientcare,andforretrospectiveresearch
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StudyAims
Giventhatyourstudyrequiressymptomdata,howcouldyougetitonalargescale?
Useexistingcodedata(ICD-9-CM) NLP
Anoff-the-shelfsystemthatusesterminologiesAcustomsystemthattakesallyourtime/money
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Howaresymptomsrecorded?
SymptomTerms:writteninmedicalterminology
SubjectiveSymptomExpressions:QuotesorcapturepatientsvoiceFiguresofspeechIdiomsLayterms
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Methods
CohortincludedallpatientsseenintheVAin2009.
750documentswererandomlyselectedfromalltextnotesforthesepatientsandgroupedintoMentalhealth/socialwork,andPrimary/Specialty
4healthcareproviderswithannotationexperienceconducteda2layerreview.
ReviewersweretrainedforeachlayeruntilastableIAA>.80wasachieved.
2reviewersannotatedeachnoteindependently,disagreementswereadjudicatedbya3rd.
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Methods
Layer1:Annotateallsymptomsandsubjectivesymptomexpressions.
Layer2:ReviewSSEannotationstoClassifyintosymptomtypesDetermineifthesymptomwascodeDetermineifSSEwasalsomentionedinwordsthatcouldbemappedtoaterminology.i.e.symptomterm
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Classification
Somatic:LossofsomaticfunctionUnpleasantoralteredsensationSomatic,non-sensory,notfunctional
Cognitive/Behavioral/MentalCognitiveDysfunctionFalsePerceptions/beliefsEmotionalDistressHarmtoself/othersBehavioralDysfunction
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ICD9-CMCoding
ICD9-CMcodingfortheencounterwasreviewedtoseeiftheSSEwascodedIftheSSEwascoded,itwasconsideredexplicitlycoded
Feelslikeaviceonmyhead=CodeforHeadache
IftheSSEwasaplausiblemanifestationofthecode,itwasconsideredcontainedby
IdontevenwanttogetoutofbedcontainedbyMajorDepressioncode
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RestatedinSymptomTerm
TheSSEwerecomparedtoSymptomTermsinthesamenote.IftheSSEwasalsorestatedinasymptomterm,itmaybefeasibletouseanNLPpipelinethatutilizesstandardterminologiesordictionaries.
Icantkeepfooddownrestatedasvomiting
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Results
5,031SymptomTermsand543SSE Only170notescontainedSSE
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Results-Classification
Emotionaldistress,behavioraldysfunction,andlossofsomaticfunctionwerecommon.
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ResultsICD9-CM
Only2SSEwereexplicitlycoded,bothwereheadache,andbothwererestated.
79werecontainedbybutnotrestated
36%ofSSEisthebestyoucoulddousingcodingifyouacceptimprecision.
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Results-Restated
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Limitations
176ofthedocumentshadnocodingfortheencounter.
Insomesettings,codingmaybemoreinclusiveofsomesymptoms
TheVAusesICD-9-CM,ICD-10mayofferbetterresults
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Conclusions
Codingwonthelpyoumuch.OnlyheadachesweretrulycodedThebestyoucouldgetis36%
NLPsystemsthatextractsymptomtermsgetsyou55%.
Therestwillrequiremorework.
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TheFullStory
Thesesubjectivesymptomexpressionscontainadepthofinformationnotfoundinmedicalterms.
69y/opatientwasreferredforSuicidalIdeation.
thinkingabouthisdeceasedwife,heputaguntohisheadforaminute,thenwenttobed
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TheFullStory
SSEcommunicatethenatureandseverityofsymptoms.Mykneedoesntfeelright
IwishIcouldjustcutmylegoff
Theyoftenindicatetheimpactofthesymptomonthepatient.
FunctionalstatusandQualityoflifemeasuresInevermakeittothebathroomintimeIhaventleftmyroominweeks,Imsofreakedout
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FutureWork
UsingNLPtolocatephrasesthatmaybeaSubjectiveSymptomExpressionandreferringthemoutforhumanclassification,
thenfeedingthesebacktothesystem.
PreliminaryuseofthesesymptomexpressionsinPTSDandfunctionalstatusstudies
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QuestionsandComments?
AdiV.Gundlapalli,MDPhD,MilandN.Palmer,MPHRHIA,ShuyingShen,MStat,BrettR.SouthMS,GuyDivitaMS,MarjorieCarter,MPH,AndrewReddPhD,Jorie
M.ButlerPhD,MatthewSamore,MD
ThisworkwassupportedbytheDepartmentofVeteransAffairs,OfficeofResearchandDevelopment,HealthServicesResearchandDevelopment,ProWATCH:EpidemiologyofMedicallyUnexplainedSyndromesproject#HIR10-001.
