Are Structured Data Structured Identically?

Summary

Objective: OpenSDE is an application that supports structured recording of narrative patient data to enable use of the data in both clinical practice and clinical research. Reliability and accuracy of collected data are essential for subsequent data use. In this study we analyze the uniformity of data entered with OpenSDE. Our objective is to obtain insight into the consensus and differences of recorded data.

Methods: Three pediatricians transcribed 20 paper patient records using OpenSDE. The transcribed records were compared and all recorded findings were classified into one of six categories of difference.

Results: Of all findings 22% were recorded identically; 17% of the findings were recorded differently (predominantly as free text); 61% was omitted, inferred, or in conflict with the paper record.

Conclusion: The results of this study show that recording patient data using structured data entry does not necessarily lead to uniformly structured data.

Keywords

Structured data entry - information storage and retrieval - medical records

• References

• 1 Dick RS, Steen EB, Detmer DE. (eds.) The Computer- Based Patient Record: An Essential Technology for Health Care. Revised Edition ed. Washington: National Academy Press; 1997
• 2 van Ginneken AM. The Computerized Patient Record: Balancing Effort and Benefit. Int J Med Inf 2002; 65 (02) 97-119.
• 3 Powsner SM, Wyatt JC, Wright P. Opportunities for and Challenges of Computerisation. Lancet 1998; 352 9140 1617-22.
• 4 Brown PJ, Sönksen P. Evaluation of the Quality of Information Retrieval of Clinical Findings from a Computerized Patient Database Using a Semantic Terminological Model. J Am Med Inform Assoc 2000; 7 (04) 392-403.
• 5 Moorman PW, van Ginneken AM, van der Lei J, van Bemmel JH. A Model for Structured Data Entry Based on Explicit Descriptional Knowledge. Methods Inf Med 1994; 33 (05) 454-63.
• 6 Tange H. How to Approach the Structuring of the Medical Record? Towards a Model for Flexible Access to Free Text Medical Data. Int J Biomed Comput 1996; 42 1-2 27-34.
• 7 Walsh SH. The Clinician's Perspective on Electronic Health Records and How They Can Affect Patient Care. Bmj 2004; 328 7449 1184-7.
• 8 Klar R. Selected Impressions on the Beginning of the Electronic Medical Record and Patient Information. Methods Inf Med 2004; 43 (05) 537-42.
• 9 Tange HJ, Hasman A, de Vries Robbe PF, Schouten HC. Medical Narratives in Electronic Medical Records. Int J Med Inf 1997; 46 (01) 7-29.
• 10 Los RK, van Ginneken AM, de Wilde M, van der Lei J. Opensde: Row Modeling Applied to Generic Structured Data Entry. J Am Med Inform Assoc 2004; 11 (02) 162-65.
• 11 Open SDE. Opensde (Oss) http://sourceforge.net/projects/opensde Last accessed: March 31, 2005
• 12 Beard CM, Yunginger JW, Reed CE, OConnell EJ, Silverstein MD. Interobserver Variability in Medical Record Review: An Epidemiological Study of Asthma. J Clin Epidemiol 1992; 45 (09) 1013-20.
• 13 Williams JG. Measuring the Completeness and Currency of Codified Clinical Information. Methods Inf Med 2003; 42 (04) 482-8.
• 14 Mikkelsen G, Aasly J. Consequences of Impaired Data Quality on Information Retrieval in Electronic Patient Records. Int J Med Inform 2005; 74 (05) 387-94.
• 15 Ammenwerth E, Shaw NT. Bad Health Informatics Can Kill--Is Evaluation the Answer?. Methods Inf Med 2005; 44 (01) 1-3.
• 16 Wyatt J. Same Information, Different Decisions: Format Counts. Bmj 1999; 318: 1501-2.
• 17 van Ginneken AM, Verkoijen MJ. A Multi-Disciplinary Approach to a User Interface for Structured Data Entry. Medinfo 2001; 10 (Pt 1) 693-7.
• 18 Los RK, van Ginneken AM, van der Lei J. Opensde: A Strategy for Expressive and Flexible Structured Data Entry. Int J Med Inform 2005; 74 (06) 481-90.
• 19 Roukema J, van Ginneken AM, Moll HA. The Use of Structured Data Entry in the Outpatient’s Clinic for Paediatrics. Health Information Developments in the Netherlands 2003; 6: 27-30.
• 20 Kahn CE, Huynh Jr. PN. Knowledge Representation for Platform-Independent Structured Reporting. Proc AMIA Annu Fall Symp 1996: 478-82.
• 21 Stoop AP, Berg M. Integrating Quantitative and Qualitative Methods in Patient Care Information System Evaluation: Guidance for the Organizational Decision Maker. Methods Inf Med 2003; 42 (04) 458-62.
• 22 Rubenfeld GD. Using Computerized Medical Databases to Measure and to Improve the Quality of Intensive Care. J Crit Care 2004; 19 (04) 248-56.
• 23 Winthereik BR. “We Fill in Our Working Understanding”: On Codes, Classifications and the Production of Accurate Data. Methods Inf Med 2003; 42 (04) 489-96.
• 24 Thiru K, Hassey A, Sullivan F. Systematic Review of Scope and Quality of Electronic Patient Record Data in Primary Care. Bmj 2003; 326 7398 1070
• 25 Pringle M, Ward P, Chilvers C. Assessment of the Completeness and Accuracy of Computer Medical Records in Four Practices Committed to Recording Data on Computer. Br J Gen Pract 1995; 45 (399) 537-41.
• 26 Peat G, Wood L, Wilkie R, Thomas E. How Reliable Is Structured Clinical History-Taking in Older Adults with Knee Problems? Inter- and Intraobserver Variability of the Kne-Sci. J Clin Epidemiol 2003; 56 (11) 1030-7.
• 27 McDonald CJ. The Barriers to Electronic Medical Record Systems and How to Overcome Them. J Am Med Inform Assoc 1997; 4 (03) 213-21.
• 28 Wyatt J. Quantitative Evaluation of Clinical Software, Exemplified by Decision Support Systems. Int J Med Inf 1997; 47 (03) 165-73.
• 29 Roukema J, Los RK, Bleeker SE, van Ginneken AM, van der Lei J, Moll HA. Paper Versus Computer: Feasibility of an Electronic Medical Record in General Pediatrics. Pediatrics 2005. accepted for publication
• 30 Burnum JF. The Misinformation Era: The Fall of the Medical Record. Ann Intern Med 1989; 110 (06) 482-4.
• 31 Wyatt JC, Wright P. Design Should Help Use of Patients' Data. Lancet 1998; 352 9137 1375-8.