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Populating Physician Biographical Pages Based on EMR Data.

The physicians’ biographical pages are essential in providing information about physicians’ specialties. However, physicians may not have biographical pages or the current pages are not comprehensive. We hypothesize that physicians’ specialty information can be mined from Electronic Medical Records (EMRs) of their patients. We proposed an automated physician specialty populating (PSP) system that analyzes physician-ascertained diagnoses in EMRs, aggregates them to an appropriate granularity based on the current biographical pages, and populates the biographical pages accordingly. In this study, we applied the system using EMR data from Mayo Clinic and evaluated the system using the current biographical pages regarding various ranking strategies. Preliminary results demonstrated that using EMR data is a scalable and systematic way to populate physicians’ biographical pages.


Introduction
With the wide usage of information technology in healthcare, physicians' biographical pages have become the most commonly accessed institutionally oriented web pages. An internal study conducted by the Mayo Clinic User Experience (UX) team indicated that biographical information facilitates decision-making of key audiences, including current and prospective patients, referring physicians, research collaborators, students, job seekers, and grant-funding agencies. The study also identified the specific types of biographical information needed to support decision-making by different audiences.
Enriching physicians' biographical pages is critical in healthcare delivery as it can align "people, processes, data and technologies to optimize information, collaboration, expertise, and experience" according to Healthcare Information & Management Systems Society (HIMSS) 1 . Especially in the era of Electronic Medical Records (EMRs) and big data, data-driven decision making has been widely adopted in the healthcare domain. Lobach et al., have conducted experiments to show strong evidences of using both clinical decision support systems (CDSSs) and knowledge management systems (KMSs) to facilitate the process of healthcare management 2 . Facing a large amount of underutilized data stored in hospital systems, Chawla and Davis proposed a patient individualized framework to improve personalized healthcare 3 . Similarly, Dixon et al., developed a cloud based distributed framework for knowledge management and clinical decision support 4 . Furthermore, by utilizing the combination of local mining and global learning approach, Nie et al., is able to bridge the vocabulary gap between health consumers and healthcare knowledge 5 . In addition, some other researches incorporate with semantic web technology to support decision making, play as an active role in managing healthcare knowledge 6-8 . There are some expert recommendation systems to impetus healthcare delivery. For example, Jiang and Xu proposed a doctor recommendation model which includes a quality analysis component 9 . Fang and Zhai targeted on the problem of expert finding by adopting probabilistic models with the focus on building ranking oriented match making between candidate profiles and topic groups 10 . Balog et al., applied a language modeling framework to achieve expert finding 11 . These studies focus on intelligent interfaces for consumers at the point of care seeking not about how to populate the content of biographical pages.
Hence, there is an urgent need to have physicians' biographical pages populated with useful content at the point of needs for diverse information seekers. However, biographical pages are usually filled up manually and displayed in various types of design, standards, content, and functionality. Furthermore, take Mayo Clinic as an example, although there are 88.7% staff physicians and scientists having biographical pages across three campuses (Arizona, Florida and Minnesota), only 72.7% of them have their interests field populated with their interests and specialties. Many healthcare organizations do not maintain a comprehensive list of specialties of their physicians. One major reason is the lack of time for physicians to create and update their biographical pages. Additionally, biographical pages are not well-integrated with other contents from other resources, indicating a missing opportunity in facilitating decision making.
In this paper, we proposed an automated physician specialty populating (PSP) system. Our hypothesis is that the diagnosis information in EMRs represents the specialties of the corresponding physicians and it can be utilized to populate physicians' biographical pages. The paper is organized as follows: we first introduce methodology and workflow of our system. Then we describe experiments and present the results. Finally, current issues and possible ways to make improvement as future directions are discussed.

Methods
Our PSP system is composed of multiple components as shown in Figure 1. The system starts with the component of EMRs parsing and normalization, which performs as a preprocessing step on unstructured EMRs so that only keep diagnosis sections for physicians. The significant diagnoses detection component takes outputs from the previous step to filter out non-significant diagnoses and keep those with high frequencies for each specific physician. The semantic granularity checking component reviews high-ranked diagnoses for each physician and maps them to SNOMED-CT. Meanwhile, this component also takes the existing biographical pages as gold standard and annotates them with SNOMED-CT in order to check whether EMR diagnoses could be mapped to gold standard terms from a semantic hierarchical perspective to finalize the granularity. In the rest of this section, we provide detailed strategies, methods and algorithms for each component.

EMR Parsing and Normalization
This component retrieves clinical notes and only uses physician-ascertained diagnoses under the diagnosis section. Along with diagnoses, we also prepare specific patient ID, practice setting, provider ID and provider type. For the purpose of normalization, we tokenize sentences of diagnoses and process them through MetaMap 12 to get relevant UMLS concepts, preferred names and concept unique identifiers (CUIs) 13 . To better improve the accuracy of specialty populating, we put a restriction on selecting CUIs by checking their semantic types. As shown in Table 1, we only focus on CUIs with semantic type patf, dsyn, mobd, neop, comd, emod, hlca, lbpr, diap, and topp, which are specific to diseases and procedures.
In addition, to represent diagnoses in ontology, we conduct a further annotation about converting CUIs to SNOMED-CT codes 14, 15 by using UMLS Metathesaurus file in Rich Release Format (RRF) 13,16 . Particularly, to address the mismatching issue between CUIs and SNOMED-CT codes, we not only find mapping codes directly in Metathesaurus RRF file, but also check the concepts/preferred names and make an algorithm to optimize the decision-making in a heuristic way. Basically, we first conduct a mapping between CUIs and SNOMED-CT codes. If there is only one matching, we directly use the outcome. But if there are more than one matched codes, it means there exists a possibility of mismatch. To make this step accurately done, we check Metathesaurus RRF file with concept/preferred names to retrieve SNOMED-CT codes directly from there. As a result, outputs generated from this preprocessing component are a list of physicians with several SNOMED-CT codes along with patients' information, practice settings and providers' details.

Significant Diagnoses Detection
This component is responsible for selecting top diagnoses for each physician. To achieve this goal, we respectively apply three algorithms on SNOMED-CT codes for all physicians: 1) term frequency (TF); 2) term frequency-inverse document frequency (TF-IDF) 17 ; 3) a hybrid algorithm using TF and TF-IDF. TF based algorithm simply picks the top K frequent SNOMED-CT codes and considers them as the most significant representatives. The TF-IDF aims to weight how important a term is to a document within a number of documents. In this study, we treat each physician as a document, and consider all SNOMED-CT codes as terms. Therefore, by using TF-IDF, we are able to find more important SNOMED-CT codes related to each physician and consider them as significant ones. The process of TF-IDF can be summarized as: where ( , ) is weighted term frequency for each SNOMED-CT code c in each physician p, , stands for the number of occurrences of the considered code c for physician p, ( , ) represents inverse document frequency for code c in the whole physician collection P, and ( , , ) is calculated by the product of ( , ) and ( , ). Based on the weight measured by TF-IDF, we choose the top K SNOMED-CT codes for each physician and rank them in a descending order as the output of this component.
We also combine TF and TF-IDF approaches and select the top A terms based on TF and the top B terms based on TF-IDF. In our implementation, we choose A and B equally.

Semantic Granularity Checking
Diagnoses in clinical notes are always described in a specific way. However, patients may have limited medical knowledge where specific terms may not have the right granularity for patients. In this step, we identify the appropriate granularity based on the current biographical pages.
Specifically, as the current biographical pages are manually written by physicians about their high level specialties and general interests, it can be served as a gold standard to determine the appropriate granularity and evaluate the ranking algorithms. Here, we map unstructured terms contained in biographical pages to SNOMED-CT codes with the annotation approach described in the EMR Parsing and Normalization component.
Then we use information content 18 to check hierarchical granularity of each concept in ontology. Information content in ontology illustrates how informative one node is based on its annotation frequencies and how many descendants it holds. Specifically for SNOMED-CT, we only consider two nodes as ancestors and descendants relationship if they are connected with "is-a" relationship. The measurement of SNOMED-CT annotation starts with a probability measure of each SNOMED-CT term t. Let be the collection of SNOMED-CT terms that are either t or its descendants and u be the element in . Let O (t, c) be the occurrence of t annotations given a collection c. The information probability of t in c, denoted as p (t, c), is defined as Equation 4 shown 19 .
( , ) = ( , ) ∑ ( , ) ∈ ( 4) Figure 2 gives an example to illustrate how information content is calculated. In this graph, as bottom level nodes, concept 7200100 occurs 126 times, concept 9813009 occurs 4 times and concept 37119500 occurs 33 times. Based on "is-a" link, frequencies appear on bottom level can be propagated to their direct parent nodes, which makes frequency of concept 281244004 become 126, and frequency of concept 281243005 become 33 + 4 = 37. Similarly, as the top level in this example, concept 281242000 holds a total frequency as 126 + 37 = 163. It is obvious that the frequency and probability of each concept increases as we move up the graph to the root, and the probability of root concept will be 1. Therefore, we can quantify the hierarchical relationship based on information probability, and granularity is able to be determined according to the probability threshold we set. Otherwise, we compare information probability of the specific node with a granularity threshold . If information content meets the criteria, even though there is no match in gold standard, we still consider such node as a concept with high granularity.

Experimental Results
This proposed system was implemented with Eclipse Standard/SDK version Luna 4.4.0 20 . The interfaces to access MetaMap, UMLS and SNOMED-CT were coded in Java programming language. To facilitate the processing speed on large amount of clinical notes, we also deployed the PSP system on the Open Grid Scheduler (OGS) 21 framework running on 64 bit Linux CentOS 6.8 servers hosted by Mayo Clinic, which is a scheduler to run distributed tasks on clusters.
The clinical notes we processed were collected during the year of 2010 to 2015 provided by Mayo Clinic Minnesota campus. Table 2 gives detailed statistics of the data. To accurately find specialties for each physician, we processed a subset of clinical notes to keep problems of all patients which first diagnosed by each physician, which ends up with the same amount of patients but lower number of providers and clinical notes. Among these clinical notes, we parsed all problem lists contained in diagnosis section and stored them along with patients' and providers' information. One point needs to be noticed is that, although there are 8,078 providers showed up on EMRs from Mayo Clinic Minnesota campus, since Mayo Clinic only set up biographical pages for doctors who serve as primary or secondary appointment, therefore, not all of those providers have clinical biographies. As shown in Table 3 For those 658 physicians, we extracted the top 100 significant SNOMED-CT codes based on the three algorithms. We also used EMRs, claim data, and the combination of EMRs and claim data to evaluate the performance. Then we applied the granularity checking algorithm to map each SNOMED code to an appropriate level. Specifically, we set parameter as 6, and threshold as the average of the information probability of annotated SNOMED-CT codes. In general, nine different experimental groups are formed as: 1) TF-IDF with EMRs; 2) TF-IDF with claim data; 3) TF-IDF with EMRs and claim data; 4) TF with EMRs; 5) TF with claim data; 6) TF with EMRs and claim data; 7) Hybrid with EMRs; 8) Hybrid with claim data; 9) Hybrid with EMRs and claim data.  The total number of unique SNOMED-CT codes is 999, 1,038, 1,244, 355, 330, 319, 1,564, 1,216, and 1,245 for experimental group 1 to group 9, respectively. In addition, we grouped physicians by their practice settings and counted the number of SNOMED-CT codes for each category with different experimental groups. As shown in Figure 3, one physician may have one or more practice settings, and we listed the top 10 practice settings with the descending order of population of physicians in x axis with the number of physicians in parentheses. Cardiology had more physicians, and Nephrology had more SNOMED-CT codes than other settings. The combination of EMRs and claim data always produced the most number of SNOMED-CT codes while running on claim data always led to the least number of codes.
In Figure 4, we elaborated the precision (rounded to two decimal places) of SNOMED-CT codes that covered by the gold standard for these 10 practice settings for nine different experimental groups. The claim data yields low precision. However, the selection of different approaches to acquire high precision varies across different practice settings. Additionally, the current biographic pages do not seem to represent the practice of the physicians as codes mined from EMR are mostly missed from their current pages. For example, a physician has Cardiac transplantation and Mechanical circulatory support listed in their biographic page. However, we found more practical procedures including Aortic valve stenosis and Mitral stenosis in his clinical notes. This may reflect the gap between what physicians think their specialties/research and what they are actually doing in routine practice. The PSP system is able to quantify such gap for physicians and enrich their biographical pages with their clinical specialties. We conducted a comparison among 9 experimental groups in terms of their performance. As shown in Table 4, overall precision/recall/F-measure results for 658 physicians were given. We found that the use of TF-IDF algorithm with EMRs produced the highest precision as 0.49, the use of TF-IDF algorithm with EMRs and claim data contributed to the highest recall as 0.67, and the use of hybrid algorithm with EMRs yielded highest F-measure as 0.51. It showed that EMRs is able to provide more significant specialties than claim data with either TF-IDF or hybrid algorithm, while using frequency algorithm was not good enough to generate as informative contents as the others. However, for claim data, no matter what kind of algorithms we applied, it always performed with low precision/recall/F-measure, it indicated that claim data did not cover a fine granularity of specialties and cannot reflect physicians' practices very well. Moreover, the combination of EMRs and claim data did not have a better performance than using EMRs. It is because EMRs contain more useful information than what claim data holds, and when we mixed them together, the ranking of terms was changed, and less informative term may have a higher frequency, which makes important terms become invisible.
Although we got the highest F-measure by using hybrid algorithm with EMRs, 0.51 is not satisfactory score. The reason is that gold standard we referred to did not have a comprehensive description of practices while most diagnose sections EMRs provide are about clinical practices and procedures. In other words, F-measure score with 0.51 actually quantified such gap between clinical practices and real specialties. Ideally, with more practices involved in biographical pages, higher F-measure score will be achieved.

Discussion
Our proposed physician specialty populating (PSP) system is able to automatically populate potential specialty candidates for physicians from EMRs. The motivation of making this system is based on observations that most physicians fill their biographical pages manually with no standardization, which makes it difficult to deliver healthcare knowledge to consumers and providers. In addition, physicians' biographical pages may not be up to date. The proposed PSP system has the potential to enrich the current biographical pages and keep it up to date by leveraging EMR.
Normalizations for both EMRs and existing biographical pages are initial processes of the proposed system. Note that here, we took existing biographical pages as gold standard, the coverage of 60.4% may make the granularity checking suboptimal.
There is a debate of whether using TF or TF-IDF to find significant SNOMED-CT codes for physicians from EMRs. Usually, frequency of SNOMED-CT codes tells us which specialties are commonly applied by each physician and TF-IDF can indicate which specialties are especially unique for each physician. From patients' point of view, frequency is an essential key since it tells them which specialties physicians are frequently performing. TF-IDF also provides specialties information with not only relative high frequency but also uniqueness for each physician. Such ranking scheme will rank more specific specialties to a specific physician higher. However, using TF-IDF might miss some common practices that with high frequencies but most physicians can do. In this study, we gave the same weight to each approach aiming to get benefit from both approaches. Although the hybrid approach yielded the best F-measure, there is still some room for improvement. In the future, we will use a heuristic approach to find the optimal balance point in combining the two approaches. Meanwhile, we will also send outputs to physicians at Mayo Clinic to get their feedback to adjust the weight. By doing so, we aim to make better balance between consumers' needs and physicians' requirements.
One challenge we faced is how to decide the right granularity. We always wanted to give coarse granularities with more general terms for the convenience of search. However, terms with fine granularities may also be useful to provide specific division of specialties. Therefore, in this study, we picked the granularity based on the average of the information content as the threshold to balance the granularity. Note that, the PSP system tends to populate what physicians do in the practice. From the experiments, we found that claim data cannot reflect physicians' specialties very well which may be due to the institutional and financial constraints. Hence, it provides evidences to the current situation of health systems that there exists a divergence between structured claim data and unstructured EMRs. How to use both datasets to understand the status and activities of healthcare is another interesting topic to investigate on.

Conclusion
We have investigated on the use of EMR data to populate physicians' biographical pages. The proposed PSP system provides a scalable way to automatically populate physicians' biographical pages. We plan to collaborate with physicians and refine system settings. In addition to populating physicians' clinical specialties, the same approach will be utilized to discover their research expertise by analyzing keywords appeared in their research articles and grant proposals.