Prompt engineering paradigms for medical applications: scoping review and recommendations for better practices

Prompt engineering is crucial for harnessing the potential of large language models (LLMs), especially in the medical domain where specialized terminology and phrasing is used. However, the efficacy of prompt engineering in the medical domain remains to be explored. In this work, 114 recent studies (2022-2024) applying prompt engineering in medicine, covering prompt learning (PL), prompt tuning (PT), and prompt design (PD) are reviewed. PD is the most prevalent (78 articles). In 12 papers, PD, PL, and PT terms were used interchangeably. ChatGPT is the most commonly used LLM, with seven papers using it for processing sensitive clinical data. Chain-of-Thought emerges as the most common prompt engineering technique. While PL and PT articles typically provide a baseline for evaluating prompt-based approaches, 64% of PD studies lack non-prompt-related baselines. We provide tables and figures summarizing existing work, and reporting recommendations to guide future research contributions.

A Benchmark Evaluation of Clinical Named Entity Recognition in French

Background: Transformer-based language models have shown strong performance on many Natural LanguageProcessing (NLP) tasks. Masked Language Models (MLMs) attract sustained interest because they can be adaptedto different languages and sub-domains through training or fine-tuning on specific corpora while remaining lighterthan modern Large Language Models (LLMs). Recently, several MLMs have been released for the biomedicaldomain in French, and experiments suggest that they outperform standard French counterparts. However, nosystematic evaluation comparing all models on the same corpora is available. Objective: This paper presentsan evaluation of masked language models for biomedical French on the task of clinical named entity recognition.Material and methods: We evaluate biomedical models CamemBERT-bio and DrBERT and compare them tostandard French models CamemBERT, FlauBERT and FrALBERT as well as multilingual mBERT using three publicallyavailable corpora for clinical named entity recognition in French. The evaluation set-up relies on gold-standardcorpora as released by the corpus developers. Results: Results suggest that CamemBERT-bio outperformsDrBERT consistently while FlauBERT offers competitive performance and FrAlBERT achieves the lowest carbonfootprint. Conclusion: This is the first benchmark evaluation of biomedical masked language models for Frenchclinical entity recognition that compares model performance consistently on nested entity recognition using metricscovering performance and environmental impact.

Few shot clinical entity recognition in three languages: Masked language models outperform LLM prompting

Large Language Models are becoming the go-to solution for many natural language processing tasks, including in specialized domains where their few-shot capacities are expected to yield high performance in low-resource settings. Herein, we aim to assess the performance of Large Language Models for few shot clinical entity recognition in multiple languages. We evaluate named entity recognition in English, French and Spanish using 8 in-domain (clinical) and 6 out-domain gold standard corpora. We assess the performance of 10 auto-regressive language models using prompting and 16 masked language models used for text encoding in a biLSTM-CRF supervised tagger. We create a few-shot set-up by limiting the amount of annotated data available to 100 sentences. Our experiments show that although larger prompt-based models tend to achieve competitive F-measure for named entity recognition outside the clinical domain, this level of performance does not carry over to the clinical domain where lighter supervised taggers relying on masked language models perform better, even with the performance drop incurred from the few-shot set-up. In all experiments, the CO2 impact of masked language models is inferior to that of auto-regressive models. Results are consistent over the three languages and suggest that few-shot learning using Large language models is not production ready for named entity recognition in the clinical domain. Instead, models could be used for speeding-up the production of gold standard annotated data.

Impact of translation on biomedical information extraction from real-life clinical notes

The objective of our study is to determine whether using English tools to extract and normalize French medical concepts on translations provides comparable performance to French models trained on a set of annotated French clinical notes. We compare two methods: a method involving French language models and a method involving English language models. For the native French method, the Named Entity Recognition (NER) and normalization steps are performed separately. For the translated English method, after the first translation step, we compare a two-step method and a terminology-oriented method that performs extraction and normalization at the same time. We used French, English and bilingual annotated datasets to evaluate all steps (NER, normalization and translation) of our algorithms. Concerning the results, the native French method performs better than the translated English one with a global f1 score of 0.51 [0.47;0.55] against 0.39 [0.34;0.44] and 0.38 [0.36;0.40] for the two English methods tested. In conclusion, despite the recent improvement of the translation models, there is a significant performance difference between the two approaches in favor of the native French method which is more efficient on French medical texts, even with few annotated documents.

Detecting automatically the layout of clinical documents to enhance the performances of downstream natural language processing

Objective:Develop and validate an algorithm for analyzing the layout of PDF clinical documents to improve the performance of downstream natural language processing tasks. Materials and Methods: We designed an algorithm to process clinical PDF documents and extract only clinically relevant text. The algorithm consists of several steps: initial text extraction using a PDF parser, followed by classification into categories such as body text, left notes, and footers using a Transformer deep neural network architecture, and finally an aggregation step to compile the lines of a given label in the text. We evaluated the technical performance of the body text extraction algorithm by applying it to a random sample of documents that were annotated. Medical performance was evaluated by examining the extraction of medical concepts of interest from the text in their respective sections. Finally, we tested an end-to-end system on a medical use case of automatic detection of acute infection described in the hospital report. Results:Our algorithm achieved per-line precision, recall, and F1 score of 98.4, 97.0, and 97.7, respectively, for body line extraction. The precision, recall, and F1 score per document for the acute infection detection algorithm were 82.54 (95CI 72.86-91.60), 85.24 (95CI 76.61-93.70), 83.87 (95CI 76, 92-90.08) with exploitation of the results of the advanced body extraction algorithm, respectively. Conclusion:We have developed and validated a system for extracting body text from clinical documents in PDF format by identifying their layout. We were able to demonstrate that this preprocessing allowed us to obtain better performances for a common downstream task, i.e., the extraction of medical concepts in their respective sections, thus proving the interest of this method on a clinical use case.

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

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.

Learning structures of the French clinical language:development and validation of word embedding models using 21 million clinical reports from electronic health records

Background Clinical studies using real-world data may benefit from exploiting clinical reports, a particularly rich albeit unstructured medium. To that end, natural language processing can extract relevant information. Methods based on transfer learning using pre-trained language models have achieved state-of-the-art results in most NLP applications; however, publicly available models lack exposure to speciality-languages, especially in the medical field. Objective We aimed to evaluate the impact of adapting a language model to French clinical reports on downstream medical NLP tasks. Methods We leveraged a corpus of 21M clinical reports collected from August 2017 to July 2021 at the Greater Paris University Hospitals (APHP) to produce two CamemBERT architectures on speciality language: one retrained from scratch and the other using CamemBERT as its initialisation. We used two French annotated medical datasets to compare our language models to the original CamemBERT network, evaluating the statistical significance of improvement with the Wilcoxon test. Results Our models pretrained on clinical reports increased the average F1-score on APMed (an APHP-specific task) by 3 percentage points to 91%, a statistically significant improvement. They also achieved performance comparable to the original CamemBERT on QUAERO. These results hold true for the fine-tuned and from-scratch versions alike, starting from very few pre-training samples. Conclusions We confirm previous literature showing that adapting generalist pre-train language models such as CamenBERT on speciality corpora improves their performance for downstream clinical NLP tasks. Our results suggest that retraining from scratch does not induce a statistically significant performance gain compared to fine-tuning.

Identifying causal associations in tweets using deep learning: Use case on diabetes-related tweets from 2017-2021

Objective: Leveraging machine learning methods, we aim to extract both explicit and implicit cause-effect associations in patient-reported, diabetes-related tweets and provide a tool to better understand opinion, feelings and observations shared within the diabetes online community from a causality perspective. Materials and Methods: More than 30 million diabetes-related tweets in English were collected between April 2017 and January 2021. Deep learning and natural language processing methods were applied to focus on tweets with personal and emotional content. A cause-effect-tweet dataset was manually labeled and used to train 1) a fine-tuned Bertweet model to detect causal sentences containing a causal association 2) a CRF model with BERT based features to extract possible cause-effect associations. Causes and effects were clustered in a semi-supervised approach and visualised in an interactive cause-effect-network. Results: Causal sentences were detected with a recall of 68% in an imbalanced dataset. A CRF model with BERT based features outperformed a fine-tuned BERT model for cause-effect detection with a macro recall of 68%. This led to 96,676 sentences with cause-effect associations. "Diabetes" was identified as the central cluster followed by "Death" and "Insulin". Insulin pricing related causes were frequently associated with "Death". Conclusions: A novel methodology was developed to detect causal sentences and identify both explicit and implicit, single and multi-word cause and corresponding effect as expressed in diabetes-related tweets leveraging BERT-based architectures and visualised as cause-effect-network. Extracting causal associations on real-life, patient reported outcomes in social media data provides a useful complementary source of information in diabetes research.

Effect of depth order on iterative nested named entity recognition models

This paper studies the effect of the order of depth of mention on nested named entity recognition (NER) models. NER is an essential task in the extraction of biomedical information, and nested entities are common since medical concepts can assemble to form larger entities. Conventional NER systems only predict disjointed entities. Thus, iterative models for nested NER use multiple predictions to enumerate all entities, imposing a predefined order from largest to smallest or smallest to largest. We design an order-agnostic iterative model and a procedure to choose a custom order during training and prediction. To accommodate for this task, we propose a modification of the Transformer architecture to take into account the entities predicted in the previous steps. We provide a set of experiments to study the model's capabilities and the effects of the order on performance. Finally, we show that the smallest to largest order gives the best results.

Terminologies augmented recurrent neural network model for clinical named entity recognition

We aimed to enhance the performance of a supervised model for clinical named-entity recognition (NER) using medical terminologies. In order to evaluate our system in French, we built a corpus for 5 types of clinical entities. We used a terminology-based system as baseline, built upon UMLS and SNOMED. Then, we evaluated a biGRU-CRF, and an hybrid system using the prediction of the terminology-based system as feature for the biGRU-CRF. In English, we evaluated the NER systems on the i2b2-2009 Medication Challenge for Drug name recognition, which contained 8,573 entities for 268 documents. In French, we built APcNER, a corpus of 147 documents annotated for 5 entities (drug name, sign or symptom, disease or disorder, diagnostic procedure or lab test and therapeutic procedure). We evaluated each NER systems using exact and partial match definition of F-measure for NER. The APcNER contains 4,837 entities which took 28 hours to annotate, the inter-annotator agreement was acceptable for Drug name in exact match (85%) and acceptable for other entity types in non-exact match (>70%). For drug name recognition on both i2b2-2009 and APcNER, the biGRU-CRF performed better that the terminology-based system, with an exact-match F-measure of 91.1% versus 73% and 81.9% versus 75% respectively. Moreover, the hybrid system outperformed the biGRU-CRF, with an exact-match F-measure of 92.2% versus 91.1% (i2b2-2009) and 88.4% versus 81.9% (APcNER). On APcNER corpus, the micro-average F-measure of the hybrid system on the 5 entities was 69.5% in exact match, and 84.1% in non-exact match. APcNER is a French corpus for clinical-NER of five type of entities which covers a large variety of document types. Extending supervised model with terminology allowed for an easy performance gain, especially in low regimes of entities, and established near state of the art results on the i2b2-2009 corpus.