BMC Med Inform Decis Mak - Evaluation of data completeness in the electronic health record for the purpose of patient recruitment into clinical trials: a retrospective analysis of element presence.

Tópicos

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Resumo

CKGROUND: Computerized clinical trial recruitment support is one promising field for the application of routine care data for clinical research. The primary task here is to compare the eligibility criteria defined in trial protocols with patient data contained in the electronic health record (EHR). To avoid the implementation of different patient definitions in multi-site trials, all participating research sites should use similar patient data from the EHR. Knowledge of the EHR data elements which are commonly available from most EHRs is required to be able to define a common set of criteria. The objective of this research is to determine for five tertiary care providers the extent of available data compared with the eligibility criteria of randomly selected clinical trials.METHODS: Each participating study site selected three clinical trials at random. All eligibility criteria sentences were broken up into independent patient characteristics, which were then assigned to one of the 27 semantic categories for eligibility criteria developed by Luo et al. We report on the fraction of patient characteristics with corresponding structured data elements in the EHR and on the fraction of patients with available data for these elements. The completeness of EHR data for the purpose of patient recruitment is calculated for each semantic group.RESULTS: 351 eligibility criteria from 15 clinical trials contained 706 patient characteristics. In average, 55% of these characteristics could be documented in the EHR. Clinical data was available for 64% of all patients, if corresponding data elements were available. The total completeness of EHR data for recruitment purposes is 35%. The best performing semantic groups were 'age' (89%), 'gender' (89%), 'addictive behaviour' (74%), 'disease, symptom and sign' (64%) and 'organ or tissue status' (61%). No data was available for 6 semantic groups.CONCLUSIONS: There exists a significant gap in structure and content between data documented during patient care and data required for patient eligibility assessment. Nevertheless, EHR data on age and gender of the patient, as well as selected information on his disease can be complete enough to allow for an effective support of the manual screening process with an intelligent preselection of patients and patient data.

Resumo Limpo

ckground computer clinic trial recruit support one promis field applic routin care data clinic research primari task compar elig criteria defin trial protocol patient data contain electron health record ehr avoid implement differ patient definit multisit trial particip research site use similar patient data ehr knowledg ehr data element common avail ehr requir abl defin common set criteria object research determin five tertiari care provid extent avail data compar elig criteria random select clinic trialsmethod particip studi site select three clinic trial random elig criteria sentenc broken independ patient characterist assign one semant categori elig criteria develop luo et al report fraction patient characterist correspond structur data element ehr fraction patient avail data element complet ehr data purpos patient recruit calcul semant groupresult elig criteria clinic trial contain patient characterist averag characterist document ehr clinic data avail patient correspond data element avail total complet ehr data recruit purpos best perform semant group age gender addict behaviour diseas symptom sign organ tissu status data avail semant groupsconclus exist signific gap structur content data document patient care data requir patient elig assess nevertheless ehr data age gender patient well select inform diseas can complet enough allow effect support manual screen process intellig preselect patient patient data

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