Detecting and Identifying Erroneous Medical Abstracting and Coding and Clinical Documentation Omissions

摘要

A method and computer program product for implementing a clinical documentation, code and abstract errors and omissions detector and characterizer (the “code error detector”) are disclosed. Concepts represented in the linguistic surface forms of clinical text data source documents are mapped onto an ontology being indexed as component codes and reference codes where component codes index primitive concepts and reference codes index fully-defined concepts that are produced as linguistic cognitive grammar compositions of the primitive concepts that are indexed by the component codes. Fully-defined concepts indexed by some codes and representing either some standard for required clinical document content or an externally derived mapping of the document content to fully-defined concepts in the ontology are mapped to the ontology as source codes. The fully-defined concepts indexed by the source codes are decomposed, in the ontology, to their primitive concepts. Using measures of compositionality, semantic distance and entailment, the fitness of the concepts indexed by the source codes as proxies for the fully-defined concepts indexed by the reference codes is determined. Further, the distance between the concepts indexed by the source codes and the concepts indexed by the reference codes is characterized in terms of the distances of individual primitive concepts as indexed by component codes. In this manner a measure of fitness is further characterized in terms of particular primitive concepts. The method disclosed may be implemented using a variety of ontology specification and reasoning methods, but it is here described as an implementation using a novel modification to L-space ontology whereby concepts are represented in L-space as data types and the saliences of data types are represented as continuous real values greater than 0 and less than 1 such that the integral or summation of the saliences of all data types in a domain equals 1. Given the mapping of some data type indexed by reference code and the mapping of some data type indexed by source code on the same ontology, the code error detector determines the semantic distance between the reference code data type and any source code data type with respect to component code data types. The distance, as a measure of the fitness of the source code data type as a proxy for the reference code data type with respect to the component code data type(s), is stored and reported.