BACKGROUND
Artificial intelligence (AI), more specifically large language models (LLMs), holds significant potential in revolutionizing emergency care delivery by optimizing clinical workflows and enhancing the quality of decision-making. Although enthusiasm for integrating LLMs into emergency medicine (EM) is growing, the existing literature is characterized by a disparate collection of individual studies, conceptual analyses, and preliminary implementations. Given these complexities and gaps in understanding, a cohesive framework is needed to comprehend the existing body of knowledge on the application of LLMs in EM.


OBJECTIVE
Given the absence of a comprehensive framework for exploring the roles of LLMs in EM, this scoping review aims to systematically map the existing literature on LLMs' potential applications within EM and identify directions for future research. Addressing this gap will allow for informed advancements in the field.


METHODS
Using PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) criteria, we searched Ovid MEDLINE, Embase, Web of Science, and Google Scholar for papers published between January 2018 and August 2023 that discussed LLMs' use in EM. We excluded other forms of AI. A total of 1994 unique titles and abstracts were screened, and each full-text paper was independently reviewed by 2 authors. Data were abstracted independently, and 5 authors performed a collaborative quantitative and qualitative synthesis of the data.


RESULTS
A total of 43 papers were included. Studies were predominantly from 2022 to 2023 and conducted in the United States and China. We uncovered four major themes: (1) clinical decision-making and support was highlighted as a pivotal area, with LLMs playing a substantial role in enhancing patient care, notably through their application in real-time triage, allowing early recognition of patient urgency; (2) efficiency, workflow, and information management demonstrated the capacity of LLMs to significantly boost operational efficiency, particularly through the automation of patient record synthesis, which could reduce administrative burden and enhance patient-centric care; (3) risks, ethics, and transparency were identified as areas of concern, especially regarding the reliability of LLMs' outputs, and specific studies highlighted the challenges of ensuring unbiased decision-making amidst potentially flawed training data sets, stressing the importance of thorough validation and ethical oversight; and (4) education and communication possibilities included LLMs' capacity to enrich medical training, such as through using simulated patient interactions that enhance communication skills.


CONCLUSIONS
LLMs have the potential to fundamentally transform EM, enhancing clinical decision-making, optimizing workflows, and improving patient outcomes. This review sets the stage for future advancements by identifying key research areas: prospective validation of LLM applications, establishing standards for responsible use, understanding provider and patient perceptions, and improving physicians' AI literacy. Effective integration of LLMs into EM will require collaborative efforts and thorough evaluation to ensure these technologies can be safely and effectively applied.

From Triage to Treatment: Scoping the Role of Large Language Models in Transforming Emergency Medicine (Preprint)

Electronic health records (EHRs) are a valuable resource for data-driven medical research. However, the presence of protected health information (PHI) makes EHRs unsuitable to be shared for research purposes. De-identification, i.e. the process of removing PHI is a critical step in making EHR data accessible. Natural language processing has repeatedly demonstrated its feasibility in automating the de-identification process. Our study aims to provide systematic evidence on how the de-identification of clinical free text written in English has evolved in the last thirteen years, and to report on the performances and limitations of the current state-of-the-art systems for the English language. In addition, we aim to identify challenges and potential research opportunities in this field. A systematic search in PubMed, Web of Science, and the DBLP was conducted for studies published between January 2010 and February 2023. Titles and abstracts were examined to identify the relevant studies. Selected studies were then analysed in-depth, and information was collected on de-identification methodologies, data sources, and measured performance. A total of 2125 publications were identified for the title and abstract screening. 69 studies were found to be relevant. Machine learning (37 studies) and hybrid (26 studies) approaches are predominant, while six studies relied only on rules. The majority of the approaches were trained and evaluated on public corpora. The 2014 i2b2/UTHealth corpus is the most frequently used (36 studies), followed by the 2006 i2b2 (18 studies) and 2016 CEGS N-GRID (10 studies) corpora. Earlier de-identification approaches aimed at English were mainly rule and machine learning hybrids with extensive feature engineering and post-processing, while more recent performance improvements are due to feature-inferring recurrent neural networks. Current leading performance is achieved using attention-based neural models. Recent studies report state-of-the-art F1-scores (over 98 %) when evaluated in the manner usually adopted by the clinical natural language processing community. However, their performance needs to be more thoroughly assessed with different measures to judge their reliability to safely de-identify data in a real-world setting. Without additional manually labeled training data, state-of-the-art systems fail to generalise well across a wide range of clinical sub-domains. 

De-identification of clinical free text using natural language processing: A systematic review of current approaches


 
 Public health surveillance relies on the collection of data, often in near-real time. Recent advances in natural language processing make it possible to envisage an automated system for extracting information from electronic health records.
 
 
 
 To study the feasibility of setting up a national trauma observatory in France, we compared the performance of several automatic language processing methods in a multiclass classification task of unstructured clinical notes.
 
 
 
 A total of 69,110 free-text clinical notes related to visits to the emergency departments of the University Hospital of Bordeaux, France, between 2012 and 2019 were manually annotated. Among these clinical notes, 32.5% (22,481/69,110) were traumas. We trained 4 transformer models (deep learning models that encompass attention mechanism) and compared them with the term frequency–inverse document frequency associated with the support vector machine method.
 
 
 
 The transformer models consistently performed better than the term frequency–inverse document frequency and a support vector machine. Among the transformers, the GPTanam model pretrained with a French corpus with an additional autosupervised learning step on 306,368 unlabeled clinical notes showed the best performance with a micro F1-score of 0.969.
 
 
 
 The transformers proved efficient at the multiclass classification of narrative and medical data. Further steps for improvement should focus on the expansion of abbreviations and multioutput multiclass classification.


pdf/deep-learning-transformer-models-for-building-a-6p3ttrfs.pdf

Deep Learning Transformer Models for Building a Comprehensive and Real-time Trauma Observatory: Development and Validation Study

The objective of this study is to address the critical issue of de-identification of clinical reports in order to allow access to data for research purposes, while ensuring patient privacy. The study highlights the difficulties faced in sharing tools and resources in this domain and presents the experience of the Greater Paris University Hospitals (AP-HP) in implementing a systematic pseudonymization of text documents from its Clinical Data Warehouse. We annotated a corpus of clinical documents according to 12 types of identifying entities, and built a hybrid system, merging the results of a deep learning model as well as manual rules. Our results show an overall performance of 0.99 of F1-score. We discuss implementation choices and present experiments to better understand the effort involved in such a task, including dataset size, document types, language models, or rule addition. We share guidelines and code under a 3-Clause BSD license.

pdf/development-and-validation-of-a-natural-language-processing-c4n0gqrm.pdf

Development and validation of a natural language processing algorithm to pseudonymize documents in the context of a clinical data warehouse

Unstructured textual data are at the heart of health systems: liaison letters between doctors, operating reports, coding of procedures according to the ICD10 standard, etc. The details included in these documents make it possible to get to know the patient better, to better manage him or her, to better study the pathologies, to accurately remunerate the associated medical acts. . . All this seems to be (at least partially) within reach of today by artiﬁcial intelligence techniques. However, for obvious reasons of privacy protection, the designers of these AIs do not have the legal right to access these documents as long as they contain identifying data. De-identifying these documents, i.e. detecting and deleting all identifying information present in them, is a legally necessary step for sharing this data between two complementary worlds. Over the last decade, several proposals have been made to de-identify documents, mainly in English. While the detection scores are often high, the substitution methods are often not very robust to attack. In French, very few methods are based on arbitrary detection and/or substitution rules. In this paper, we propose a new comprehensive de-identiﬁcation method dedicated to French-language medical documents. Both the approach for the detection of identifying elements (based on deep learning) and their substitution (based on diﬀerential privacy) are based on the most proven existing approaches. The result is an approach the The approach a the

pdf/de-identification-of-french-unstructured-clinical-notes-for-2lug74k2.pdf

De-Identification of French Unstructured Clinical Notes for Machine Learning Tasks

In France, structured data from emergency room (ER) visits are aggregated at the national level to build a syndromic surveillance system for several health events. For visits motivated by a traumatic event, information on the causes are stored in free-text clinical notes. To exploit these data, an automated de-identification system guaranteeing protection of privacy is required.In this study we review available de-identification tools to de-identify free-text clinical documents in French. A key point is how to overcome the resource barrier that hampers NLP applications in languages other than English. We compare rule-based, named entity recognition, new Transformer-based deep learning and hybrid systems using, when required, a fine-tuning set of 30,000 unlabeled clinical notes. The evaluation is performed on a test set of 3,000 manually annotated notes.Hybrid systems, combining capabilities in complementary tasks, show the best performance. This work is a first step in the foundation of a national surveillance system based on the exhaustive collection of ER visits reports for automated trauma monitoring.

/pdf/de-identification-of-emergency-medical-records-in-french-18optkqcaw.pdf

De-identification of Emergency Medical Records in French: Survey and Comparison of State-of-the-Art Automated Systems

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De-identification of Emergency Medical Records in French: Survey and Comparison of State-of-the-Art Automated Systems

Deep Learning Transformer Models for Building a Comprehensive and Real-time Trauma Observatory: Development and Validation Study