Kentgen Markus, Varghese Julian, Samol Alexander, Waltenberger Johannes, Dugas Martin
Institute of Medical Informatics, University of Münster, Münster, Germany.
Medical Faculty, University Hospital of Münster, Münster, Germany.
JMIR Med Inform. 2019 Aug 23;7(3):e14107. doi: 10.2196/14107.
Standardization in clinical documentation can increase efficiency and can save time and resources.
The objectives of this work are to compare documentation forms for acute coronary syndrome (ACS), check for standardization, and generate a list of the most common data elements using semantic form annotation with the Unified Medical Language System (UMLS).
Forms from registries, studies, risk scores, quality assurance, official guidelines, and routine documentation from four hospitals in Germany were semantically annotated using UMLS. This allowed for automatic comparison of concept frequencies and the generation of a list of the most common concepts.
A total of 3710 forms items from 86 sources were semantically annotated using 842 unique UMLS concepts. Half of all medical concept occurrences were covered by 60 unique concepts, which suggests the existence of a core dataset of relevant concepts. Overlap percentages between forms were relatively low, hinting at inconsistent documentation structures and lack of standardization.
This analysis shows a lack of standardized and semantically enriched documentation for patients with ACS. Efforts made by official institutions like the European Society for Cardiology have not yet been fully implemented. Utilizing a standardized and annotated core dataset of the most important data concepts could make export and automatic reuse of data easier. The generated list of common data elements is an exemplary implementation suggestion of the concepts to use in a standardized approach.
临床文档的标准化可提高效率，并节省时间和资源。
本研究旨在比较急性冠状动脉综合征（ACS）的文档形式，检查其标准化程度，并使用统一医学语言系统（UMLS）通过语义表单注释生成最常见数据元素列表。
使用UMLS对来自德国四家医院的注册表、研究、风险评分、质量保证、官方指南和常规文档中的表单进行语义注释。这使得能够自动比较概念频率并生成最常见概念列表。
使用842个独特的UMLS概念对来自86个来源的总共3710个表单项目进行了语义注释。所有医学概念出现次数的一半由60个独特概念涵盖，这表明存在相关概念的核心数据集。表单之间的重叠百分比相对较低，这暗示了文档结构不一致和缺乏标准化。
该分析表明，ACS患者缺乏标准化且语义丰富的文档。欧洲心脏病学会等官方机构所做的努力尚未得到充分实施。利用最重要数据概念的标准化和注释核心数据集可以使数据的导出和自动重用更加容易。生成的常见数据元素列表是在标准化方法中使用的概念的示例性实施建议。
