English

Fast, Structured Clinical Documentation via Contextual Autocomplete

Machine Learning 2020-07-31 v1 Computation and Language Information Retrieval Machine Learning

Abstract

We present a system that uses a learned autocompletion mechanism to facilitate rapid creation of semi-structured clinical documentation. We dynamically suggest relevant clinical concepts as a doctor drafts a note by leveraging features from both unstructured and structured medical data. By constraining our architecture to shallow neural networks, we are able to make these suggestions in real time. Furthermore, as our algorithm is used to write a note, we can automatically annotate the documentation with clean labels of clinical concepts drawn from medical vocabularies, making notes more structured and readable for physicians, patients, and future algorithms. To our knowledge, this system is the only machine learning-based documentation utility for clinical notes deployed in a live hospital setting, and it reduces keystroke burden of clinical concepts by 67% in real environments.

Keywords

Cite

@article{arxiv.2007.15153,
  title  = {Fast, Structured Clinical Documentation via Contextual Autocomplete},
  author = {Divya Gopinath and Monica Agrawal and Luke Murray and Steven Horng and David Karger and David Sontag},
  journal= {arXiv preprint arXiv:2007.15153},
  year   = {2020}
}

Comments

Published in Machine Learning for Healthcare 2020 conference

R2 v1 2026-06-23T17:30:35.475Z