Background and Study Aims: The text report is the primary tool for documenting endoscopic findings but there is no consensus on the content and structure of these reports. Therefore, at four Norwegian hospitals, the content of endoscopy reports concerning ulcerative colitis was assessed. Quality indices for the medical history of active ulcerative colitis and endoscopic signs of inflammation were determined, as well as technical items in the report. The effect of structured compared with free-text reporting was evaluated.
Materials and Methods: Endoscopy reports in 445 cases of ulcerative colitis were retrieved. Two of the hospitals used a semi-structured computerized documentation system, and two hospitals used transcription-based free-text reports.
Results: A substantial amount of information was missing in the majority of the reports. Individual endoscopic signs of inflammation were defined in 27 % - 77 % of the reports. Various clinical symptoms of active ulcerative colitis were defined in 1 % - 44 % of the reports. We observed a reminder effect of structured systems in that they prompted more informative reports. There was a tendency towards better free-text documentation in the transcription-based systems than in the free text of the semi-structured ones.
Conclusions: There is a potential for improving the content, completeness and standardization of endoscopy reports. Standardization efforts may be a part of the solution.
References
-
1
Moorman P W, van Ginneken A M, van der Lei J. et al .
A model for structured data entry based on explicit descriptional knowledge.
Meth Inform Med.
1994;
33
454-463
-
2
Waye J D, Aabakken L, Alvarez S. et al .
Endoscopy reports, databases, and computers in 2001.
Gastrointest Endosc.
2001;
53
838-839
-
3
Korman L Y, Delvaux M, Crespi M.
The minimal standard terminology in digestive endoscopy: perspective on a standard endoscopic vocabulary.
Gastrointest Endosc.
2001;
53
392-396
-
4
Maratka Z.
The role of terminology in medical education and training.
Scand J Gastroenterol.
1991;
189 Suppl
30-31
-
5
Joint Committee for Minimal Standard Terminology of ESGE, ASGE, OMED.
Minimal Standard Terminology in Digestive Endoscopy.
Endoscopy.
2000;
32
162-188
-
6
Crespi M, Delvaux M, Schapiro M. et al .
Minimal standards for a computerized endoscopic database. Ad Hoc Task Force of the Committee for Minimal Standards of Digestive Endoscopy of the European Society of Gastrointestinal Endoscopy (ESGE).
Am J Gastroenterol.
1994;
89 (8 Suppl)
S144-S153
-
7
Crespi M, Delvaux M, Schapiro M. et al .
Working Party Report by the Committee for Minimal Standards of Terminology and Documentation in Digestive Endoscopy of the European Society of Gastrointestinal Endoscopy. Minimal standard terminology for a computerized endoscopic database. Ad Hoc Task Force of the Committee.
Am J Gastroenterol.
1996;
91
191-216
-
8
Delvaux M, Crespi M, Armengol-Miro JR, et al.
Minimal standard terminology for digestive endoscopy: results of prospective testing and validation in the GASTER Project.
Endoscopy.
2000;
32
345-355
-
9
Delvaux M, Korman L Y, Armengol-Miro J R. et al .
The minimal standard terminology for digestive endoscopy: introduction to structured reporting.
Int J Med Informatics.
1998;
48
217-225
-
10
Delvaux M M, Crespi M, Armengol-Miro J R. et al .
The GASTER Project: building a computer network in digestive endoscopy: the experience of the European Society for Gastrointestinal Endoscopy. Gastrointestinal endoscopy application for standards in telecommunication, education and research.
J Clin Gastroenterol.
1999;
29
118-126
-
11
Korman L Y.
Standardization in endoscopic reporting: implications for clinical practice and research.
J Clin Gastroenterol.
1999;
28
217-223
-
12
Marteau P.
Inflammatory bowel disease.
Endoscopy.
2002;
34
63-68
-
13
Walmsley R S, Ayres R C, Pounder R E, Allan R N.
A simple clinical colitis activity index.
Gut.
1998;
43
29-32
-
14
Baron J H, Connell A M, Lennard-Jones J E.
Variation between observers in describing mucosal appearances in proctocolitis.
Br Med J.
1964;
1
89-92
-
15
Roseth A G, Aadland E, Jahnsen J, Raknerud N.
Assessment of disease activity in ulcerative colitis by faecal calprotectin, a novel granulocyte marker protein.
Digestion.
1997;
58
176-180
-
16 Altman D G. Practical statistics for medical research. London; Chapman and Hall 1991
-
17 Kleinbaum D G. Applied regression analysis and other multivariable methods. Boston; PWS-Kent Pub. Co. 1988
-
18 Agresti A. Categorical data analysis. New York; Wiley 1990
-
19
Kuhn K, Gaus W, Wechsler J G. et al .
Structured reporting of medical findings: evaluation of a system in gastroenterology.
Meth Inform Med.
1992;
31
268-274
-
20
Kuhn K, Swobodnik W, Johannes R S. et al .
The quality of gastroenterological reports based on free text dictation: an evaluation in endoscopy and ultrasonography.
Endoscopy.
1991;
23
262-264
-
21
Moorman P W, van Ginneken A M, van der Lei J. et al .
The contents of free-text endoscopy reports: an inventory and evaluation by peers.
Endoscopy.
1994;
26
531-538
-
22
Gouveia-Oliveira A, Raposo V D, Salgado N C. et al .
Longitudinal comparative study on the influence of computers on reporting of clinical data.
Endoscopy.
1991;
23
334-337
-
23
Moorman P W, van Ginneken A M, Siersema P D. et al .
Evaluation of reporting based on descriptional knowledge.
J Am Med Inform Assoc.
1995;
2
365-373
-
24
Logan J R, Klopfer K C.
The use of a standardized terminology for comparison of free text and structured data entry.
Proc AMIA Symp. From the symposium „Converging Information, Technology, and Health Care” in Los Angeles, CA. .
2000;
512-516
-
25
Rey J F, Lambert R.
ESGE recommendations for quality control in gastrointestinal endoscopy: guidelines for image documentation in upper and lower GI endoscopy.
Endoscopy.
2001;
33 (10)
901-903
T. de Lange, M. D.
Department of Gastroenterology, Ullevaal University Hospital
Kirkeveien 166 · 0407 Oslo · Norway
Fax: + 47-22-119942
eMail: t.d.lange@ioks.uio.no
