Natural Language Processing–Enabled and Conventional Data Capture Methods for Input to Electronic Health Records: A Comparative Usability Study

Jun 24, 2019 | Jonathan Maisel

Published in JMIR Medical Informatics, 28.10.16 in Vol 4, No 4 (2016): Oct-Dec.

Available on PubMedCentral:

Kaufman, D. R., Sheehan, B., Stetson, P., Bhatt, A. R., Field, A. I., Patel, C., & Maisel, J. M. (2016). Natural Language Processing–Enabled and Conventional Data Capture Methods for Input to Electronic Health Records: A Comparative Usability Study. JMIR Medical Informatics, 4(4), e35. PMCID: PMC5106560

Authors: David Kaufman; Barbara Sheehan; Peter Stetson; Ashish Bhatt; Adele Field; Chirag Patel; James M. Maisel

Copyright Notice: (c) 2016 David Kaufman, Barbara Sheehan, Peter Stetson, Ashish Bhatt, Adele Field, Chirag Patel, James M. Maisel.


Background: The process of documentation in electronic health records (EHRs) is known to be time consuming, inefficient, and cumbersome. The use of dictation coupled with manual transcription has become an increasingly common practice. In recent years, natural language processing (NLP)–enabled data capture has become a viable alternative for data entry. It enables the clinician to maintain control of the process and potentially reduce the documentation burden. The question remains how this NLP-enabled workflow will impact EHR usability and whether it can meet the structured data and other EHR requirements while enhancing the user’s experience.

Objective: To evaluate the comparative effectiveness of an NLP-enabled data capture method using dictation and data extraction from transcribed documents (NLP Entry) in terms of documentation time, documentation quality, and usability versus standard EHR keyboard-and-mouse data entry.

Methods: This formative study investigated the results of using 4 combinations of NLP Entry and Standard Entry methods (“protocols”) of EHR data capture. We compared a novel dictation-based protocol using MediSapien NLP (NLP-NLP) for structured data capture against a standard structured data capture protocol (Standard-Standard) as well as 2 novel hybrid protocols (NLP-Standard and Standard-NLP). The 31 participants included neurologists, cardiologists, and nephrologists. Participants generated 4 consultation or admission notes using 4 documentation protocols. We recorded the time on task, documentation quality (using the Physician Documentation Quality Instrument, PDQI-9), and usability of the documentation processes.

Results: A total of 118 notes were documented across the 3 subject areas. The NLP-NLP protocol required a median of 5.2 minutes per cardiology note, 7.3 minutes per nephrology note, and 8.5 minutes per neurology note compared with 16.9, 20.7, and 21.2 minutes, respectively, using the Standard-Standard protocol and 13.8, 21.3, and 18.7 minutes using the Standard-NLP protocol (1 of 2 hybrid methods). Using 8 out of 9 characteristics measured by the PDQI-9 instrument, the NLP-NLP protocol received a median quality score sum of 24.5; the Standard-Standard protocol received a median sum of 29; and the Standard-NLP protocol received a median sum of 29.5. The mean total score of the usability measure was 36.7 when the participants used the NLP-NLP protocol compared with 30.3 when they used the Standard-Standard protocol.

Conclusions: In this study, the feasibility of an approach to EHR data capture involving the application of NLP to transcribed dictation was demonstrated. This novel dictation-based approach has the potential to reduce the time required for documentation and improve usability while maintaining documentation quality. Future research will evaluate the NLP-based EHR data capture approach in a clinical setting. It is reasonable to assert that EHRs will increasingly use NLP-enabled data entry tools such as MediSapien NLP because they hold promise for enhancing the documentation process and end-user experience.

ZyDoc acknowledges the partial financial support for development work on this product conducted at Columbia University and provided by the Center for Advanced Information Management, a New York State Center for Advanced Technology funded by Empire State Development’s Division of Science, Technology and Innovation (NYSTAR).

Research reported in this publication was supported by the National Library of Medicine of the National Institutes of Health under Award Number R43LM011165. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

For more information about MediSapien:

MediSapien Structured Data

MediSapien Analytics

For more information about the Study:

Contact James M. Maisel, MD, 800.546.5633 or submit the form below.

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