Background: Accurate, coded problem lists are valuable for data reuse, including clinical decision support and research. However, healthcare providers frequently modify coded diagnoses by including or removing common contextual properties in free-text diagnosis descriptions: uncertainty (suspected glaucoma), laterality (left glaucoma) and temporality (glaucoma 2002). These contextual properties could cause a difference in meaning between underlying diagnosis codes and modified descriptions, inhibiting data reuse. We therefore aimed to develop and evaluate an algorithm to identify these contextual properties. Methods: A rule-based algorithm called UnLaTem (Uncertainty, Laterality, Temporality) was developed using a single-center dataset, including 288,935 diagnosis descriptions, of which 73,280 (25.4%) were modified by healthcare providers. Internal validation of the algorithm was conducted with an independent sample of 980 unique records. A second validation of the algorithm was conducted with 996 records from a Dutch multicenter dataset including 175,210 modified descriptions of five hospitals. Two researchers independently annotated the two validation samples. Performance of the algorithm was determined using means of the recall and precision of the validation samples. The algorithm was applied to the multicenter dataset to determine the actual prevalence of the contextual properties within the modified descriptions per specialty. Results: For the single-center dataset recall (and precision) for removal of uncertainty, uncertainty, laterality and temporality respectively were 100 (60.0), 99.1 (89.9), 100 (97.3) and 97.6 (97.6). For the multicenter dataset for removal of uncertainty, uncertainty, laterality and temporality it was 57.1 (88.9), 86.3 (88.9), 99.7 (93.5) and 96.8 (90.1). Within the modified descriptions of the multicenter dataset, 1.3% contained removal of uncertainty, 9.9% uncertainty, 31.4% laterality and 9.8% temporality. Conclusions: We successfully developed a rule-based algorithm named UnLaTem to identify contextual properties in Dutch modified diagnosis descriptions. UnLaTem could be extended with more trigger terms, new rules and the recognition of term order to increase the performance even further. The algorithm’s rules are available as additional file 2. Implementing UnLaTem in Dutch hospital systems can improve precision of information retrieval and extraction from diagnosis descriptions, which can be used for data reuse purposes such as decision support and research.
- Electronic health record
- Problem list
- Problem-oriented medical record
- Reuse of clinical data
- Rule-based algorithm development
- Single-center and multicenter validation