Dataset Information

Prevalence of Sensitive Terms in Clinical Notes Using Natural Language Processing Techniques: Observational Study.

ABSTRACT:

Background

With the increased sharing of electronic health information as required by the US 21st Century Cures Act, there is an increased risk of breaching patient, parent, or guardian confidentiality. The prevalence of sensitive terms in clinical notes is not known.

Objective

The aim of this study is to define sensitive terms that represent the documentation of content that may be private and determine the prevalence and characteristics of provider notes that contain sensitive terms.

Methods

Using keyword expansion, we defined a list of 781 sensitive terms. We searched all provider history and physical, progress, consult, and discharge summary notes for patients aged 0-21 years written between January 1, 2019, and December 31, 2019, for a direct string match of sensitive terms. We calculated the prevalence of notes with sensitive terms and characterized clinical encounters and patient characteristics.

Results

Sensitive terms were present in notes from every clinical context in all pediatric ages. Terms related to the mental health category were most used overall (254,975/1,338,297, 19.5%), but terms related to substance abuse and reproductive health were most common in patients aged 0-3 years. History and physical notes (19,854/34,771, 57.1%) and ambulatory progress notes (265,302/563,273, 47.1%) were most likely to include sensitive terms. The highest prevalence of notes with sensitive terms was found in pain management (950/1112, 85.4%) and child abuse (1092/1282, 85.2%) clinics.

Conclusions

Notes containing sensitive terms are not limited to adolescent patients, specific note types, or certain specialties. Recognition of sensitive terms across all ages and clinical settings complicates efforts to protect patient and caregiver privacy in the era of information-blocking regulations.

SUBMITTER: Lee J

PROVIDER: S-EPMC9233261 | biostudies-literature | 2022 Jun

REPOSITORIES: biostudies-literature

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Publications

Prevalence of Sensitive Terms in Clinical Notes Using Natural Language Processing Techniques: Observational Study.

Lee Jennifer J Yang Samuel S Holland-Hall Cynthia C Sezgin Emre E Gill Manjot M Linwood Simon S Huang Yungui Y Hoffman Jeffrey J

JMIR medical informatics 20220610 6

<h4>Background</h4>With the increased sharing of electronic health information as required by the US 21st Century Cures Act, there is an increased risk of breaching patient, parent, or guardian confidentiality. The prevalence of sensitive terms in clinical notes is not known.<h4>Objective</h4>The aim of this study is to define sensitive terms that represent the documentation of content that may be private and determine the prevalence and characteristics of provider notes that contain sensitive t ...[more]

PMID: 35687381

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Dataset Information

Prevalence of Sensitive Terms in Clinical Notes Using Natural Language Processing Techniques: Observational Study.

Background

Objective

Methods

Results

Conclusions

Publications

Prevalence of Sensitive Terms in Clinical Notes Using Natural Language Processing Techniques: Observational Study.

Similar Datasets

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