Are Structured Data Structured Identically?

R. K. Los; J. Roukema; A. M. van Ginneken; M. de Wilde; J. van der Lei

doi:10.1055/s-0038-1634019

Methods of Information in Medicine, Inhaltsverzeichnis

Methods Inf Med 2005; 44(05): 631-638
DOI: 10.1055/s-0038-1634019

Original Article

Schattauer GmbH

Are Structured Data Structured Identically?

Investigating the Uniformity of Pediatric Patient Data Recorded Using OpenSDE

Autoren

R. K. Los

¹Department of Medical Informatics, Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands
J. Roukema

²Department of Pediatrics, Sophia Children’s Hospital, Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands
A. M. van Ginneken

¹Department of Medical Informatics, Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands
M. de Wilde

¹Department of Medical Informatics, Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands
J. van der Lei

¹Department of Medical Informatics, Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands

Abstract

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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

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Referenzen

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