BACKGROUND: Mild cognitive impairment and early-stage dementia significantly impact healthcare utilization and costs, yet more than half of affected patients remain underdiagnosed. This study leverages audio-recorded patient-nurse verbal communication in home healthcare settings to develop an artificial intelligence-based screening tool for early detection of cognitive decline. OBJECTIVE: To develop a speech processing algorithm using routine patient-nurse verbal communication and evaluate its performance when combined with electronic health record (EHR) data in detecting early signs of cognitive decline. METHOD: We analyzed 125 audio-recorded patient-nurse verbal communication for 47 patients from a major home healthcare agency in New York City. Out of 47 patients, 19 experienced symptoms associated with the onset of cognitive decline. A natural language processing algorithm was developed to extract domain-specific linguistic and interaction features from these recordings. The algorithm's performance was compared against EHR-based screening methods. Both standalone and combined data approaches were assessed using F1-score and area under the curve (AUC) metrics. RESULTS: The initial model using only patient-nurse verbal communication achieved an F1-score of 85 and an AUC of 86.47. The model based on EHR data achieved an F1-score of 75.56 and an AUC of 79. Combining patient-nurse verbal communication with EHR data yielded the highest performance, with an F1-score of 88.89 and an AUC of 90.23. Key linguistic indicators of cognitive decline included reduced linguistic diversity, grammatical challenges, repetition, and altered speech patterns. Incorporating audio data significantly enhanced the risk prediction models for hospitalization and emergency department visits. DISCUSSION: Routine verbal communication between patients and nurses contains critical linguistic and interactional indicators for identifying cognitive impairment. Integrating audio-recorded patient-nurse communication with EHR data provides a more comprehensive and accurate method for early detection of cognitive decline, potentially improving patient outcomes through timely interventions. This combined approach could revolutionize cognitive impairment screening in home healthcare settings.

OBJECTIVES: To explore home healthcare (HHC) clinicians' needs for Clinical Decision Support Systems (CDSS) information delivery for early risk warning within HHC workflows. METHODS: Guided by the CDS "Five-Rights" framework, we conducted semi-structured interviews with multidisciplinary HHC clinicians from April 2023 to August 2023. We used deductive and inductive content analysis to investigate informants' responses regarding CDSS information delivery. RESULTS: Interviews with thirteen HHC clinicians yielded 16 codes mapping to the CDS "Five-Rights" framework (right information, right person, right format, right channel, right time) and 11 codes for unintended consequences and training needs. Clinicians favored risk levels displayed in color-coded horizontal bars, concrete risk indicators in bullet points, and actionable instructions in the existing EHR system. They preferred non-intrusive risk alerts requiring mandatory confirmation. Clinicians anticipated risk information updates aligned with patient's condition severity and their visit pace. Additionally, they requested training to understand the CDSS's underlying logic, and raised concerns about information accuracy and data privacy. DISCUSSION: While recognizing CDSS's value in enhancing early risk warning, clinicians highlighted concerns about increased workload, alert fatigue, and CDSS misuse. The top risk factors identified by machine learning algorithms, especially text features, can be ambiguous due to a lack of context. Future research should ensure that CDSS outputs align with clinical evidence and are explainable. CONCLUSION: This study identified HHC clinicians' expectations, preferences, adaptations, and unintended uses of CDSS for early risk warning. Our findings endorse operationalizing the CDS "Five-Rights" framework to optimize CDSS information delivery and integration into HHC workflows.

BACKGROUND: In the United States, over 12 000 home healthcare agencies annually serve 6+ million patients, mostly aged 65+ years with chronic conditions. One in three of these patients end up visiting emergency department (ED) or being hospitalized. Existing risk identification models based on electronic health record (EHR) data have suboptimal performance in detecting these high-risk patients. OBJECTIVES: To measure the added value of integrating audio-recorded home healthcare patient-nurse verbal communication into a risk identification model built on home healthcare EHR data and clinical notes. METHODS: This pilot study was conducted at one of the largest not-for-profit home healthcare agencies in the United States. We audio-recorded 126 patient-nurse encounters for 47 patients, out of which 8 patients experienced ED visits and hospitalization. The risk model was developed and tested iteratively using: (1) structured data from the Outcome and Assessment Information Set, (2) clinical notes, and (3) verbal communication features. We used various natural language processing methods to model the communication between patients and nurses. RESULTS: Using a Support Vector Machine classifier, trained on the most informative features from OASIS, clinical notes, and verbal communication, we achieved an AUC-ROC = 99.68 and an F1-score = 94.12. By integrating verbal communication into the risk models, the F-1 score improved by 26%. The analysis revealed patients at high risk tended to interact more with risk-associated cues, exhibit more "sadness" and "anxiety," and have extended periods of silence during conversation. CONCLUSION: This innovative study underscores the immense value of incorporating patient-nurse verbal communication in enhancing risk prediction models for hospitalizations and ED visits, suggesting the need for an evolved clinical workflow that integrates routine patient-nurse verbal communication recording into the medical record.

OBJECTIVES: Little is known about proactive risk assessment concerning emergency department (ED) visits and hospitalizations in patients with heart failure (HF) who receive home healthcare (HHC) services. This study developed a time series risk model for predicting ED visits and hospitalizations in patients with HF using longitudinal electronic health record data. We also explored which data sources yield the best-performing models over various time windows. MATERIALS AND METHODS: We used data collected from 9362 patients from a large HHC agency. We iteratively developed risk models using both structured (eg, standard assessment tools, vital signs, visit characteristics) and unstructured data (eg, clinical notes). Seven specific sets of variables included: (1) the Outcome and Assessment Information Set, (2) vital signs, (3) visit characteristics, (4) rule-based natural language processing-derived variables, (5) term frequency-inverse document frequency variables, (6) Bio-Clinical Bidirectional Encoder Representations from Transformers variables, and (7) topic modeling. Risk models were developed for 18 time windows (1-15, 30, 45, and 60 days) before an ED visit or hospitalization. Risk prediction performances were compared using recall, precision, accuracy, F1, and area under the receiver operating curve (AUC). RESULTS: The best-performing model was built using a combination of all 7 sets of variables and the time window of 4 days before an ED visit or hospitalization (AUC = 0.89 and F1 = 0.69). DISCUSSION AND CONCLUSION: This prediction model suggests that HHC clinicians can identify patients with HF at risk for visiting the ED or hospitalization within 4 days before the event, allowing for earlier targeted interventions.

OBJECTIVE: This study aimed to identify temporal risk factor patterns documented in home health care (HHC) clinical notes and examine their association with hospitalizations or emergency department (ED) visits. MATERIALS AND METHODS: Data for 73 350 episodes of care from one large HHC organization were analyzed using dynamic time warping and hierarchical clustering analysis to identify the temporal patterns of risk factors documented in clinical notes. The Omaha System nursing terminology represented risk factors. First, clinical characteristics were compared between clusters. Next, multivariate logistic regression was used to examine the association between clusters and risk for hospitalizations or ED visits. Omaha System domains corresponding to risk factors were analyzed and described in each cluster. RESULTS: Six temporal clusters emerged, showing different patterns in how risk factors were documented over time. Patients with a steep increase in documented risk factors over time had a 3 times higher likelihood of hospitalization or ED visit than patients with no documented risk factors. Most risk factors belonged to the physiological domain, and only a few were in the environmental domain. DISCUSSION: An analysis of risk factor trajectories reflects a patient's evolving health status during a HHC episode. Using standardized nursing terminology, this study provided new insights into the complex temporal dynamics of HHC, which may lead to improved patient outcomes through better treatment and management plans. CONCLUSION: Incorporating temporal patterns in documented risk factors and their clusters into early warning systems may activate interventions to prevent hospitalizations or ED visits in HHC.

OBJECTIVES: Patient-clinician communication provides valuable explicit and implicit information that may indicate adverse medical conditions and outcomes. However, practical and analytical approaches for audio-recording and analyzing this data stream remain underexplored. This study aimed to 1) analyze patients' and nurses' speech in audio-recorded verbal communication, and 2) develop machine learning (ML) classifiers to effectively differentiate between patient and nurse language. MATERIALS AND METHODS: Pilot studies were conducted at VNS Health, the largest not-for-profit home healthcare agency in the United States, to optimize audio-recording patient-nurse interactions. We recorded and transcribed 46 interactions, resulting in 3494 "utterances" that were annotated to identify the speaker. We employed natural language processing techniques to generate linguistic features and built various ML classifiers to distinguish between patient and nurse language at both individual and encounter levels. RESULTS: A support vector machine classifier trained on selected linguistic features from term frequency-inverse document frequency, Linguistic Inquiry and Word Count, Word2Vec, and Medical Concepts in the Unified Medical Language System achieved the highest performance with an AUC-ROC = 99.01 ± 1.97 and an F1-score = 96.82 ± 4.1. The analysis revealed patients' tendency to use informal language and keywords related to "religion," "home," and "money," while nurses utilized more complex sentences focusing on health-related matters and medical issues and were more likely to ask questions. CONCLUSION: The methods and analytical approach we developed to differentiate patient and nurse language is an important precursor for downstream tasks that aim to analyze patient speech to identify patients at risk of disease and negative health outcomes.

OBJECTIVE: To identify the risk factors home healthcare (HHC) clinicians associate with patient deterioration and understand how clinicians respond to and document these risk factors. METHODS: We interviewed multidisciplinary HHC clinicians from January to March of 2021. Risk factors were mapped to standardized terminologies (eg, Omaha System). We used directed content analysis to identify risk factors for deterioration. We used inductive thematic analysis to understand HHC clinicians' response to risk factors and documentation of risk factors. RESULTS: Fifteen HHC clinicians identified a total of 79 risk factors that were mapped to standardized terminologies. HHC clinicians most frequently responded to risk factors by communicating with the prescribing provider (86.7% of clinicians) or following up with patients and caregivers (86.7%). HHC clinicians stated that a majority of risk factors can be found in clinical notes (ie, care coordination (53.3%) or visit (46.7%)). DISCUSSION: Clinicians acknowledged that social factors play a role in deterioration risk; but these factors are infrequently studied in HHC. While a majority of risk factors were represented in the Omaha System, additional terminologies are needed to comprehensively capture risk. Since most risk factors are documented in clinical notes, methods such as natural language processing are needed to extract them. CONCLUSION: This study engaged clinicians to understand risk for deterioration during HHC. The results of our study support the development of an early warning system by providing a comprehensive list of risk factors grounded in clinician expertize and mapped to standardized terminologies.

OBJECTIVE: This article reports a systematic review of studies containing development and validation of models predicting postacute care destination after adult inpatient hospitalization, summarizes clinical populations and variables, evaluates model performance, assesses risk of bias and applicability, and makes recommendations to reduce bias in future models. MATERIALS AND METHODS: A systematic literature review was conducted following PRISMA guidelines and the Cochrane Prognosis Methods Group criteria. Online databases were searched in June 2020 to identify all published studies in this area. Data were extracted based on the CHARMS checklist, and studies were evaluated based on predictor variables, validation, performance in validation, risk of bias, and applicability using the Prediction Model Risk of Bias Assessment Tool (PROBAST) tool. RESULTS: The final sample contained 28 articles with 35 models for evaluation. Models focused on surgical (22), medical (5), or both (8) populations. Eighteen models were internally validated, 10 were externally validated, and 7 models underwent both types. Model performance varied within and across populations. Most models used retrospective data, the median number of predictors was 8.5, and most models demonstrated risk of bias. DISCUSSION AND CONCLUSION: Prediction modeling studies for postacute care destinations are becoming more prolific in the literature, but model development and validation strategies are inconsistent, and performance is variable. Most models are developed using regression, but machine learning methods are increasing in frequency. Future studies should ensure the rigorous variable selection and follow TRIPOD guidelines. Only 14% of the models have been tested or implemented beyond original studies, so translation into practice requires further investigation.

OBJECTIVE: Patient transitions into home health care (HHC) often occur without the transfer of information needed for critical clinical decisions and the plan of care. Owing to a lack of universally implemented standards, there is wide variation in information transfer. We sought to characterize missing information at HHC admission. MATERIALS AND METHODS: We conducted a mixed methods study with 3 diverse HHC agencies. Focus groups with nurses at each agency identified what information supports patient care decisions at admission. Thirty-six in-home admissions with associated documentation review determined the available information. To inform information standards development for the HHC admission process, we compared the types of information desired and available to an international standard for transitions in care information, the Continuity of Care Document (CCD) enhanced with Office of the National Coordinator for Healthcare Information Technology summary terms (CCD/S). RESULTS: Three-quarters of the items from the focus groups mapped to the CCD/S. Regarding available information at admission, no observation included all CCD/S data items. While medication information was needed and often available for 4 important decisions, concepts related to patient medication self-management appeared in neither the CCD/S nor the admission documentation. DISCUSSION: The CCD/S mostly met HHC nurses' information needs and is recommended to begin to fill the current information gap. Electronic health record recommendations include use of a data standard: the CCD or the proposed, more parsimonious U.S. Core Data for Interoperability. CONCLUSIONS: Referral source and HHC agency adoption of data standards is recommended to support structured, consistent data and information sharing.

BACKGROUND: Natural language processing (NLP) of health-related data is still an expertise demanding, and resource expensive process. We created a novel, open source rapid clinical text mining system called NimbleMiner. NimbleMiner combines several machine learning techniques (word embedding models and positive only labels learning) to facilitate the process in which a human rapidly performs text mining of clinical narratives, while being aided by the machine learning components. OBJECTIVE: This manuscript describes the general system architecture and user Interface and presents results of a case study aimed at classifying fall-related information (including fall history, fall prevention interventions, and fall risk) in homecare visit notes. METHODS: We extracted a corpus of homecare visit notes (n = 1,149,586) for 89,459 patients from a large US-based homecare agency. We used a gold standard testing dataset of 750 notes annotated by two human reviewers to compare the NimbleMiner's ability to classify documents regarding whether they contain fall-related information with a previously developed rule-based NLP system. RESULTS: NimbleMiner outperformed the rule-based system in almost all domains. The overall F- score was 85.8% compared to 81% by the rule based-system with the best performance for identifying general fall history (F = 89% vs. F = 85.1% rule-based), followed by fall risk (F = 87% vs. F = 78.7% rule-based), fall prevention interventions (F = 88.1% vs. F = 78.2% rule-based) and fall within 2 days of the note date (F = 83.1% vs. F = 80.6% rule-based). The rule-based system achieved slightly better performance for fall within 2 weeks of the note date (F = 81.9% vs. F = 84% rule-based). DISCUSSION & CONCLUSIONS: NimbleMiner outperformed other systems aimed at fall information classification, including our previously developed rule-based approach. These promising results indicate that clinical text mining can be implemented without the need for large labeled datasets necessary for other types of machine learning. This is critical for domains with little NLP developments, like nursing or allied health professions.

BACKGROUND: The Omaha System (OS) is one of the oldest of the American Nurses Association recognized standardized terminologies describing and measuring the impact of healthcare services. This systematic review presents the state of science on the use of the OS in practice, research, and education. AIMS: (1) To identify, describe and evaluate the publications on the OS between 2004 and 2011, (2) to identify major trends in the use of the OS in research, practice, and education, and (3) to suggest areas for future research. METHODS: Systematic search in the largest online healthcare databases (PUBMED, CINAHL, Scopus, PsycINFO, Ovid) from 2004 to 2011. Methodological quality of the reviewed research studies was evaluated. RESULTS: 56 publications on the OS were identified and analyzed. The methodological quality of the reviewed research studies was relatively high. Over time, publications' focus shifted from describing clients' problems toward outcomes research. There was an increasing application of advanced statistical methods and a significant portion of authors focused on classification and interoperability research. There was an increasing body of international literature on the OS. Little research focused on the theoretical aspects of the OS, the effective use of the OS in education, or cultural adaptations of the OS outside the USA. CONCLUSIONS: The OS has a high potential to provide meaningful and high quality information about complex healthcare services. Further research on the OS should focus on its applicability in healthcare education, theoretical underpinnings and international validity. Researchers analyzing the OS data should address how they attempted to mitigate the effects of missing data in analyzing their results and clearly present the limitations of their studies.