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Natural Language Processing Model for Detecting Inconsistencies between Clinical Notes, Problem Lists, Medication Orders, and Billing Codes in Electronic Health Records
Clinical notes, problem lists, medication orders, and billing codes are core components of the electronic health record. When these components conflict, the record may become less reliable for care delivery, quality measurement, and reimbursement. Current inconsistency detection is largely manual, episodic, and dependent on documentation audits. This approach is difficult to scale across encounters, specialties, and longitudinal records. This article proposes a deep learning NLP model for detecting contradictions among clinical notes, problem lists, medication orders, and billing codes. The goal is to support continuous documentation integrity surveillance. The proposed model uses transformer-based encoders for clinical text and embedding layers for structured coded fields. Cross-attention mechanisms align concepts across EHR modules before classifying consistency relationships. Conceptually, the model could surface discrepancies such as a diagnosis documented in a note but absent from the problem list, or a billing code unsupported by physician documentation. Its output would include an inconsistency category and an interpretable explanation for clinician review. A unified NLP model for cross-module inconsistency detection could improve EHR trustworthiness, documentation quality, and clinical audit workflows. Such a system should be evaluated prospectively before operational deployment.
Journal of Health Informatics and Digital Systems
Original Research | Open access | 25 February 2023 | Article: 74

Sequence Learning Model for Predicting Repeat Diagnostic Imaging Orders Using Prior Imaging History, Symptom Documentation, Specialist Recommendations, Ordering Physician Behavior, and Recent Test Results
Repeat diagnostic imaging is a major driver of healthcare costs, radiation exposure, workflow burden, and downstream follow-up from incidental findings. Its occurrence often follows recognizable patterns shaped by prior imaging, persistent symptoms, specialist advice, recent results, and provider ordering habits. Current utilization management tools often respond after an imaging order has already been placed or rely on static appropriateness rules. They therefore miss opportunities to anticipate repeat ordering risk before the clinician reaches the final order-entry step. This manuscript proposes a sequence learning model that could predict the probability of a repeat diagnostic imaging order within a future clinical window. The model would integrate prior imaging history, symptom documentation, specialist recommendations, ordering physician behavior, and recent test results. The conceptual model would use a recurrent neural network or Transformer encoder to process temporally ordered imaging and clinical events. Structured radiology information system data would be combined with natural language processing features from clinical notes and consult documentation, physician-level ordering context, and recent laboratory or imaging-result signals. Conceptually, the model would forecast whether a repeat CT, MRI, ultrasound, or related diagnostic imaging order is likely to occur. It would also identify major contextual drivers so that the prediction could support pre-emptive review, alternative care suggestions, or guideline-aligned follow-up. A sequence learning model for repeat imaging prediction could function as a safety-and-value layer within radiology workflow. It could reduce unsupported imaging variation while preserving clinically indicated follow-up and surveillance.
Journal of Health Informatics and Digital Systems
Original Research | Open access | 25 February 2025 | Article: 101

Natural Language Processing for Healthcare Administration from 2017 to 2024: A Review of Models for Clinical Documentation, Coding Support, Incident Reporting, Patient Communication, and Workflow Automation
Healthcare administration generates large volumes of textual data, including clinical notes, billing documentation, incident narratives, portal messages, and operational records. These data create administrative burden but also provide opportunities for natural language processing to support documentation, coding, communication, safety review, and workflow automation. This systematic review examined natural language processing models applied to healthcare administration from 2017 to 2024. The review focused on five domains: clinical documentation, coding support, incident reporting, patient communication, and workflow automation. A PRISMA 2020-compliant review was conducted using structured searches of PubMed, Scopus, IEEE Xplore, and Web of Science for studies published between 2017 and 2024. Eligible studies were screened by two reviewers, extracted using a structured template, and synthesized narratively by administrative domain, model type, evaluation approach, and implementation maturity. Transformer-based models were increasingly prominent across the reviewed literature, particularly in documentation support, automated coding, and clinical text classification. Clinical documentation and coding support had the strongest evidence base, while incident reporting, patient communication, and workflow automation remained less mature and less frequently evaluated in real-world settings. Natural language processing for healthcare administration is technically promising, but most applications remain at the retrospective or proof-of-concept stage. Prospective validation, workflow integration, governance, and human oversight are needed before widespread operational adoption.
Journal of Health Informatics and Digital Systems
Review | Open access | 25 February 2025 | Article: 107
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AI-driven Diagnostics Artificial Intelligence in Health Informatics Artificial Intelligence in Healthcare Big Data in Healthcare Clinical Data Mining Clinical Decision Support Systems Clinical Informatics Computer Vision Connected Health Systems Deep Learning Digital Health Digital Healthcare Innovation Digital Transformation in Healthcare Electronic Health Records Ethical AI in Healthcare Explainable AI Health Data Analytics Health Data Privacy Health Informatics Health Information Management Health Information Systems Health System Optimization Health Technology Assessment Healthcare Data Science Healthcare Informatics Healthcare Information Security Healthcare Management Healthcare Management Information Systems Intelligent Medical Systems Internet of Medical Things (IoMT) Interoperability in Healthcare Systems Machine Learning Medical Data Analytics Medical Data Management Medical Imaging Mobile Health (mHealth) Natural Language Processing Precision Medicine Predictive Analytics Remote Patient Monitoring Smart Healthcare Systems Telemedicine Wearable Health Technologies e-Health




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