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clinical deterioration, home healthcare, natural language processing, nursing informatics, Omaha System, risk assessment



  1. Song, Jiyoun
  2. Ojo, Marietta
  3. Bowles, Kathryn H.
  4. McDonald, Margaret V.
  5. Cato, Kenrick
  6. Rossetti, Sarah Collins
  7. Adams, Victoria
  8. Chae, Sena
  9. Hobensack, Mollie
  10. Kennedy, Erin
  11. Tark, Aluem
  12. Kang, Min-Jeoung
  13. Woo, Kyungmi
  14. Barron, Yolanda
  15. Sridharan, Sridevi
  16. Topaz, Maxim


Background: About one in five patients receiving home healthcare (HHC) services are hospitalized or visit an emergency department (ED) during a home care episode. Early identification of at-risk patients can prevent these negative outcomes. However, risk indicators, including language in clinical notes that indicate a concern about a patient, are often hidden in narrative documentation throughout their HHC episode.


Objective: The aim of the study was to develop an automated natural language processing (NLP) algorithm to identify concerning language indicative of HHC patients' risk of hospitalizations or ED visits.


Methods: This study used the Omaha System-a standardized nursing terminology that describes problems/signs/symptoms that can occur in the community setting. First, five HHC experts iteratively reviewed the Omaha System and identified concerning concepts indicative of HHC patients' risk of hospitalizations or ED visits. Next, we developed and tested an NLP algorithm to identify these concerning concepts in HHC clinical notes automatically. The resulting NLP algorithm was applied on a large subset of narrative notes (2.3 million notes) documented for 66,317 unique patients (n = 87,966 HHC episodes) admitted to one large HHC agency in the Northeast United States between 2015 and 2017.


Results: A total of 160 Omaha System signs/symptoms were identified as concerning concepts for hospitalizations or ED visits in HHC. These signs/symptoms belong to 31 of the 42 available Omaha System problems. Overall, the NLP algorithm showed good performance in identifying concerning concepts in clinical notes. More than 18% of clinical notes were detected as having at least one concerning concept, and more than 90% of HHC episodes included at least one Omaha System problem. The most frequently documented concerning concepts were pain, followed by issues related to neuromusculoskeletal function, circulation, mental health, and communicable/infectious conditions.


Conclusion: Our findings suggest that concerning problems or symptoms that could increase the risk of hospitalization or ED visit were frequently documented in narrative clinical notes. NLP can automatically extract information from narrative clinical notes to improve our understanding of care needs in HHC. Next steps are to evaluate which concerning concepts identified in clinical notes predict hospitalization or ED visit.