J Biomed Inform - The need for harmonized structured documentation and chances of secondary use - results of a systematic analysis with automated form comparison for prostate and breast cancer.

Tópicos

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Resumo

TRODUCTION: Medical documentation is a time-consuming task and there is a growing number of documentation requirements. In order to improve documentation, harmonization and standardization based on existing forms and medical concepts are needed. Systematic analysis of forms can contribute to standardization building upon new methods for automated comparison of forms. Objectives of this research are quantification and comparison of data elements for breast and prostate cancer to discover similarities, differences and reuse potential between documentation sets. In addition, common data elements for each entity should be identified by automated comparison of forms.MATERIALS AND METHODS: A collection of 57 forms regarding prostate and breast cancer from quality management, registries, clinical documentation of two university hospitals (Erlangen, M?nster), research datasets, certification requirements and trial documentation were transformed into the Operational Data Model (ODM). These ODM-files were semantically enriched with concept codes and analyzed with the compareODM algorithm. Comparison results were aggregated and lists of common concepts were generated. Grid images, dendrograms and spider charts were used for illustration.RESULTS: Overall, 1008 data elements for prostate cancer and 1232 data elements for breast cancer were analyzed. Average routine documentation consists of 390 data elements per disease entity and site. Comparisons of forms identified up to 20 comparable data elements in cancer conference forms from both hospitals. Urology forms contain up to 53 comparable data elements with quality management and up to 21 with registry forms. Urology documentation of both hospitals contains up to 34 comparable items with international common data elements. Clinical documentation sets share up to 24 comparable data elements with trial documentation. Within clinical documentation administrative items are most common comparable items. Selected common medical concepts are contained in up to 16 forms.DISCUSSION: The amount of documentation for cancer patients is enormous. There is an urgent need for standardized structured single source documentation. Semantic annotation is time-consuming, but enables automated comparison between different form types, hospital sites and even languages. This approach can help to identify common data elements in medical documentation. Standardization of forms and building up forms on the basis of coding systems is desirable. Several comparable data elements within the analyzed forms demonstrate the harmonization potential, which would enable better data reuse.CONCLUSION: Identifying common data elements in medical forms from different settings with systematic and automated form comparison is feasible.

Resumo Limpo

troduct medic document timeconsum task grow number document requir order improv document harmon standard base exist form medic concept need systemat analysi form can contribut standard build upon new method autom comparison form object research quantif comparison data element breast prostat cancer discov similar differ reus potenti document set addit common data element entiti identifi autom comparison formsmateri method collect form regard prostat breast cancer qualiti manag registri clinic document two univers hospit erlangen mnster research dataset certif requir trial document transform oper data model odm odmfil semant enrich concept code analyz compareodm algorithm comparison result aggreg list common concept generat grid imag dendrogram spider chart use illustrationresult overal data element prostat cancer data element breast cancer analyz averag routin document consist data element per diseas entiti site comparison form identifi compar data element cancer confer form hospit urolog form contain compar data element qualiti manag registri form urolog document hospit contain compar item intern common data element clinic document set share compar data element trial document within clinic document administr item common compar item select common medic concept contain formsdiscuss amount document cancer patient enorm urgent need standard structur singl sourc document semant annot timeconsum enabl autom comparison differ form type hospit site even languag approach can help identifi common data element medic document standard form build form basi code system desir sever compar data element within analyz form demonstr harmon potenti enabl better data reuseconclus identifi common data element medic form differ set systemat autom form comparison feasibl

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