Supporting Uniform Representation of Data: Structuring Medical Narratives for Care and Research

Electronic patient data are associated with many potential benefits, e.g. data sharing, quality assessment, research, and management of patient care. The degree to which patient data are currently available electronically varies. To harvest the potential benefits of electronic data, the data must also be available in a structured format to enable processing by computer applications. Narrative data are typically recorded as free text. As a result, researchers still have to perform the labor-intensive task of reading and interpreting free text in individual electronic medical records. Structuring the medical narrative poses a significant challenge: content and level of detail are often unpredictable and vary per domain (and even per clinician). In an attempt to support structured recording of medical narratives we have developed OpenSDE (SDE: structured data entry). OpenSDE is intended for use in both care and research. Therefore, OpenSDE is designed to accommodate the structured recording of data in settings where content and order of data entry can often not be predicted. The aim of this research project is to investigate the feasibility of using data recorded with OpenSDE, for research purposes. Consistency and accuracy of collected data are pivotal for research, and are especially challenging if data will be collected over long periods of time and by different users. This Ph.D. project, therefore, focuses on pitfalls for data extraction for research purposes, and aims to formulate strategies to improve uniformity in data entry to enhance the reliability of data retrieval. In this research project we studied: • The possibility of extracting data recorded with OpenSDE and representing the extracted data in a manner suitable for research purposes. • The uniformity of recorded data when OpenSDE is used to transcribe data from the same source. • The origin of differences in representation of semantically identical information. • Strategies that can improve uniformity in data entry

Why are structured data different? Relating differences in data representation to the rationale of OpenSDE

OpenSDE is an application that supports clinicians with structured recording of narrative patient data to enable use of data in both clinical practice and research. OpenSDE is based on a rationale and requirements for structured data entry. In this study, we analyse the impact of the rationale and the requirements on data representation using OpenSDE. Three paediatricians transcribed 20 paper patient records using OpenSDE. The transcribed records were compared; the findings that were the same in content but differed in representation (e.g. recorded as free text instead of in a structured manner) were categorized in one of three categories of difference in representation. The transcribed records contained 1764 findings in total. The medical content of 302 of these findings was represented differently by at least one clinician and was thus included in this study. In OpenSDE, clinicians are free to determine the degree of detail at which patient data are described. This flexibility accounts for 87% of the differences in data representation. Thirteen per cent of the differences are due to clinicians interpreting and translating phrases from the source text and transcribing these to (different) concepts in OpenSDE. The differences in data representation largely result from initial design decisions for OpenSDE

Paper versus computer: Feasibility of an electronic medical record in general pediatrics

BACKGROUND. Implementation of electronic medical record systems promises significant advances in patient care, because such systems enhance readability, availability, and data quality. Structured data entry (SDE) applications can prompt for completeness, provide greater accuracy and better ordering for searching and retrieval, and permit validity checks for data quality monitoring, research, and especially decision support. A generic SDE application (OpenSDE) to support documentation of patient history and physical examination findings was developed and tailored for the domain of general pediatrics. OBJECTIVE. To evaluate OpenSDE for its completeness, uniformity of reporting, and usability in general pediatrics. METHODS. Four (trainee) pediatricians documented data for 8 first-visit patients in the traditional, paper-based, medical record and immediately thereafter in OpenSDE (electronic record). The 32 paper records obtained served as the common data source for data entry in OpenSDE by the other 3 physicians (transcribed record). Data entered by 2 experienced users, with all patient information present in the paper record, served as the control record. Data entry times were recorded, and a questionnaire was used to assess users' experiences with OpenSDE. RESULTS. Clinicians documented 44% of all available patient information identically in the paper and electronic records. Twenty-five percent of all patient information was documented only in the paper record, and 31% was present only in the electronic record. Differences were found in patient history and physical examination documentation in the electronic record; more information was missing for patient history (38%) than for physical examination (15%). Furthermore, physical examination contained more additional information (39%) than did patient history (21%). The interobserver agreement of documentation of patient information from the same data source was fair to moderate, with κ values of 0.39 for patient history and 0.40 for physical examination. Data entry times in OpenSDE decreased from 25 minutes to <15 minutes, indicating a learning effect. The questionnaire revealed a positive attitude toward the use of OpenSDE in daily practice. CONCLUSION. OpenSDE seems to be a promising application for the support of physician data entry in general pediatrics. Copyrigh