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Background: International Classification of Diseases codes are widely used to describe diagnosis information, but manual coding relies heavily on human interpretation, which can be expensive, time consuming, and prone to errors. With the transition from the International Classification of Diseases, Ninth Revision, to the International Classification of Diseases, Tenth Revision (ICD-10), the coding process has become more complex, highlighting the need for automated approaches to enhance coding efficiency and accuracy. Inaccurate coding can result in substantial financial losses for hospitals, and a precise assessment of outcomes generated by a natural language processing (NLP)-driven autocoding system thus assumes a critical role in safeguarding the accuracy of the Taiwan diagnosis related groups (Tw-DRGs)., Objective: This study aims to evaluate the feasibility of applying an International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), autocoding system that can automatically determine diagnoses and codes based on free-text discharge summaries to facilitate the assessment of Tw-DRGs, specifically principal diagnosis and major diagnostic categories (MDCs)., Methods: By using the patient discharge summaries from Kaohsiung Medical University Chung-Ho Memorial Hospital (KMUCHH) from April 2019 to December 2020 as a reference data set we developed artificial intelligence (AI)-assisted ICD-10-CM coding systems based on deep learning models. We constructed a web-based user interface for the AI-assisted coding system and deployed the system to the workflow of the certified coding specialists (CCSs) of KMUCHH. The data used for the assessment of Tw-DRGs were manually curated by a CCS with the principal diagnosis and MDC was determined from discharge summaries collected at KMUCHH from February 2023 to April 2023., Results: Both the reference data set and real hospital data were used to assess performance in determining ICD-10-CM coding, principal diagnosis, and MDC for Tw-DRGs. Among all methods, the GPT-2 (OpenAI)-based model achieved the highest F 1 -score, 0.667 (F 1 -score 0.851 for the top 50 codes), on the KMUCHH test set and a slightly lower F 1 -score, 0.621, in real hospital data. Cohen κ evaluation for the agreement of MDC between the models and the CCS revealed that the overall average κ value for GPT-2 (κ=0.714) was approximately 12.2 percentage points higher than that of the hierarchy attention network (κ=0.592). GPT-2 demonstrated superior agreement with the CCS across 6 categories of MDC, with an average κ value of approximately 0.869 (SD 0.033), underscoring the effectiveness of the developed AI-assisted coding system in supporting the work of CCSs., Conclusions: An NLP-driven AI-assisted coding system can assist CCSs in ICD-10-CM coding by offering coding references via a user interface, demonstrating the potential to reduce the manual workload and expedite Tw-DRG assessment. Consistency in performance affirmed the effectiveness of the system in supporting CCSs in ICD-10-CM coding and the judgment of Tw-DRGs., (©Hong-Jie Dai, Chen-Kai Wang, Chien-Chang Chen, Chong-Sin Liou, An-Tai Lu, Chia-Hsin Lai, Bo-Tsz Shain, Cheng-Rong Ke, William Yu Chung Wang, Tatheer Hussain Mir, Mutiara Simanjuntak, Hao-Yun Kao, Ming-Ju Tsai, Vincent S Tseng. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 20.09.2024.)

Electronic health records (EHRs) at medical institutions provide valuable sources for research in both clinical and biomedical domains. However, before such records can be used for research purposes, protected health information (PHI) mentioned in the unstructured text must be removed. In Taiwan's EHR systems the unstructured EHR texts are usually represented in the mixing of English and Chinese languages, which brings challenges for de-identification. This paper presented the first study, to the best of our knowledge, of the construction of a code-mixed EHR de-identification corpus and the evaluation of different mature entity recognition methods applied for the code-mixed PHI recognition task.

Background: Many studies have used Taiwan's National Health Insurance Research database (NHIRD) to conduct psychiatric research. However, the accuracy of the diagnostic codes for psychiatric disorders in NHIRD is not validated, and the symptom profiles are not available either. This study aimed to evaluate the accuracy of diagnostic codes and use text mining to extract symptom profile and functional impairment from electronic health records (EHRs) to overcome the above research limitations., Methods: A total of 500 discharge notes were randomly selected from a medical center's database. Three annotators reviewed the notes to establish gold standards. The accuracy of diagnostic codes for major psychiatric illness was evaluated. Text mining approaches were applied to extract depressive symptoms and function profiles and to identify patients with major depressive disorder., Results: The accuracy of the diagnostic code for major depressive disorder, schizophrenia, and dementia was acceptable but that of bipolar disorder and minor depression was less satisfactory. The performance of text mining approach to recognize depressive symptoms is satisfactory; however, the recall for functional impairment is lower resulting in lower F-scores of 0.774-0.753. Using the text mining approach to identify major depressive disorder, the recall was 0.85 but precision was only 0.69., Conclusions: The accuracy of the diagnostic code for major depressive disorder in discharge notes was generally acceptable. This finding supports the utilization of psychiatric diagnoses in claims databases. The application of text mining to EHRs might help in overcoming current limitations in research using claims databases., (Copyright © 2019. Published by Elsevier B.V.)

Electronic medical records (EMRs) for diabetic patients contain information about heart disease risk factors such as high blood pressure, cholesterol levels, and smoking status. Discovering the described risk factors and tracking their progression over time may support medical personnel in making clinical decisions, as well as facilitate data modeling and biomedical research. Such highly patient-specific knowledge is essential to driving the advancement of evidence-based practice, and can also help improve personalized medicine and care. One general approach for tracking the progression of diseases and their risk factors described in EMRs is to first recognize all temporal expressions, and then assign each of them to the nearest target medical concept. However, this method may not always provide the correct associations. In light of this, this work introduces a context-aware approach to assign the time attributes of the recognized risk factors by reconstructing contexts that contain more reliable temporal expressions. The evaluation results on the i2b2 test set demonstrate the efficacy of the proposed approach, which achieved an F-score of 0.897. To boost the approach's ability to process unstructured clinical text and to allow for the reproduction of the demonstrated results, a set of developed .NET libraries used to develop the system is available at https://sites.google.com/site/hongjiedai/projects/nttmuclinicalnet., (Copyright © 2015 Elsevier Inc. All rights reserved.)