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Meaningful Use of Clinical Documents: Benefits and Challenges of Analyzing Big Data from a Modern EMR

Zhiyi Zhou, PhD, Simon Lin, MD, Joe Ellefson, MA, Min He, PhD, Aaron Miller , PhD, Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield Clinic, Marshfield, WI, USA

Contact
Zhiyi Zhou, PhD. Biomedical Informatics Research Center 1000 North Oak Avenue Marshfield, WI 54449 1-715-221-8871 zhou.zhiyi@mcrf.mfldclin.edu http://www.marshfieldclinic.org/birc

Background
As clinical documents migrate from paper to electronic format, a large portion of healthcare data captured during clinical practice has become easily accessible to researchers. This study shows the benefits and challenges of analyzing the text data contained in the electronic medical record (EMR) system.

Research Data Flow

Results
The number of clinical notes stored in the MC EMR dramatically increased during the past 20 years, although the number of MC patients remained relatively constant, reflecting increased utilization of the EMR in healthcare. Data currently stored in electronic clinic documents will be used to facilitate research cohort selection for clinical trials; elucidation of uncoded symptoms and adverse events; and syndromic surveillance for public health research. Analysis of text documents may also reveal previously unidentified disease-disease, drug-drug, and drugdisease interactions through data mining and advanced statistical approaches. BLOOD PRESSURE: 152/72 mm Hg thigh cuff PULSE: 102 bpm, repeat 86 WEIGHT: 150.1 kg (335.00 lb) HEIGHT: 158.12 cm (62.25 in) BODY MASS INDEX: 60.1 kg/m^2 HISTORY OF PRESENT ILLNESS: Patient presents to the Clinic today for an annual review of her multiple medical problems. She did get her menses today, therefore, her urinalysis and urine for microalbumin needed to be cancelled. She states her breathing is back to baseline. ... Review of her diabetic book reveals blood sugars in the 90s to 130s in the morning, 130s to mid-200s in the afternoon and evening. CURRENT MEDICATIONS: Glyburide 5 mg two tablets b.i.d. Metformin 500 mg two tablets b.i.d. .PAST MEDICAL HISTORY: 1. Diabetes mellitus Type II. 2. Morbid obesity. 3. Menometorrhagia. ALLERGIES: Penicillin SOCIAL HISTORY: She has a significant other. Currently not smoking. Patient has not smoked in greater than nine months. She is not employed outside the home. FAMILY HISTORY: Negative for early coronary artery disease and diabetes mellitus. HEALTH MAINTENANCE: Tetanus: Updated in 2001. Flu Vaccination: None. Pneumovax: None. Colon Study: None. Mammogram: None. Pelvic Exam: Completed in 12/02 in Gynecology Department. REVIEW OF SYSTEMS: GENERAL: Patient feels like she is fully recovered from her upper respiratory tract infection. No wheezing or bronchospasm. HEENT: Denies headaches, recent trauma, fainting or dizziness. . LYMPHATIC/HEME: Denies lymph node enlargement. No history of bleeding disorders. She has known cardiolipin antibody positive on chronic anticoagulation. ... GENERAL: Patient is a 35year-old female who appears her stated age and in no acute distress. INTEGUMENT: Skin is warm and dry. ... CHEST: Normal AP diameter. Lungs clear to auscultation and percussion. HEART: Regular rate and rhythm. No S3, S4, murmurs, gallops or rubs auscultated. Radial, femoral, dorsal pedal and posterior tibial pulses are palpable and symmetrical. ABDOMEN: Obese and soft. Surgical incisions are intact. No hepatosplenomegaly. Exam is limited by body habitus. PELVIC: Deferred - completed in Gynecology Department. RECTAL: Deferred completed in December. . LABORATORY STUDIES: Cholesterol 141, HDL 33, LDL 81, triglycerides 162, glucose 153, sodium 136, potassium 4.0, BUN 13, creatinine 0.6, GFR 100.9. Urine creatinine is 57, . IMPRESSION: 1. Diabetes mellitus Type II, poor control. 2. Morbid obesity. 3. Hypertension. 4. Diabetic nephropathy. . PLAN: She will increase her insulin to 105 units in the morning and 110 units at bedtime. She will continue on her Glyburide, Metformin, birth control pills, Enalapril, Lipitor, Combivent and Flovent. Scripts were given. Follow-up is in three months. We will also refer her to Neurology for a Neurology consult and sleep study.

Methods
We evaluated the number and types of clinical documents currently stored in the EMR at Marshfield Clinic (MC). Between 1992 and 2011, 79 million documents in more than 60 distinct document types have been captured for greater than 7 million MC patient-years. Stored documents are electronically searchable and contain data that are captured nowhere else in the EMR.

Discussion
The information stored in electronic clinical documents provides a rich resource for biomedical research, yet the nature of unstructured text poses challenges for data analysis. The difficulty in using text notes frequently lies in developing algorithms to accurately and reliably identify clinicallyrelevant data from the notes themselves; this represents an ongoing challenge to the biomedical informatics researcher.
Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield Clinic

Acknowledgements
The above work was supported by the Clinical and Translational Science Award (CTSA) program and Marshfield Clinic Research Foundation.

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