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

Rainer Krumm; Axel Semjonow; Joke Tio; Heike Duhme; Thomas Bürkle; Jörg Haier; Martin Dugas; Bernhard Breil

doi:10.1016/j.jbi.2014.04.008

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

Standard

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. / Krumm, Rainer; Semjonow, Axel; Tio, Joke; Duhme, Heike; Bürkle, Thomas; Haier, Jörg; Dugas, Martin; Breil, Bernhard.

In: J BIOMED INFORM, Vol. 51, 10.2014, p. 86-99.

Research output: SCORING: Contribution to journal › SCORING: Journal article › Research › peer-review

Harvard

Krumm, R, Semjonow, A, Tio, J, Duhme, H, Bürkle, T, Haier, J, Dugas, M & Breil, B 2014, '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', J BIOMED INFORM, vol. 51, pp. 86-99. https://doi.org/10.1016/j.jbi.2014.04.008

APA

Krumm, R., Semjonow, A., Tio, J., Duhme, H., Bürkle, T., Haier, J., Dugas, M., & Breil, B. (2014). 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. J BIOMED INFORM, 51, 86-99. https://doi.org/10.1016/j.jbi.2014.04.008

Vancouver

Krumm R, Semjonow A, Tio J, Duhme H, Bürkle T, Haier J et al. 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. J BIOMED INFORM. 2014 Oct;51:86-99. https://doi.org/10.1016/j.jbi.2014.04.008

Bibtex

@article{655a9fe10b3e47febdd5d5be510d3e8e,

title = "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",

abstract = "INTRODUCTION: 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{\"u}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.",

keywords = "Breast Neoplasms, Data Curation, Data Mining, Electronic Health Records, Female, Forms and Records Control, Germany, Humans, Male, Medical Record Linkage, Natural Language Processing, Pattern Recognition, Automated, Prostatic Neoplasms, Records as Topic, Semantics",

author = "Rainer Krumm and Axel Semjonow and Joke Tio and Heike Duhme and Thomas B{\"u}rkle and J{\"o}rg Haier and Martin Dugas and Bernhard Breil",

year = "2014",

month = oct,

doi = "10.1016/j.jbi.2014.04.008",

language = "English",

volume = "51",

pages = "86--99",

journal = "J BIOMED INFORM",

issn = "1532-0464",

publisher = "Academic Press Inc.",

}

RIS

TY - JOUR

T1 - 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

AU - Krumm, Rainer

AU - Semjonow, Axel

AU - Tio, Joke

AU - Duhme, Heike

AU - Bürkle, Thomas

AU - Haier, Jörg

AU - Dugas, Martin

AU - Breil, Bernhard

PY - 2014/10

Y1 - 2014/10

N2 - INTRODUCTION: 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, Münster), 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.

AB - INTRODUCTION: 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, Münster), 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.

KW - Breast Neoplasms

KW - Data Curation

KW - Data Mining

KW - Electronic Health Records

KW - Female

KW - Forms and Records Control

KW - Germany

KW - Humans

KW - Male

KW - Medical Record Linkage

KW - Natural Language Processing

KW - Pattern Recognition, Automated

KW - Prostatic Neoplasms

KW - Records as Topic

KW - Semantics

U2 - 10.1016/j.jbi.2014.04.008

DO - 10.1016/j.jbi.2014.04.008

M3 - SCORING: Journal article

C2 - 24747879

VL - 51

SP - 86

EP - 99

JO - J BIOMED INFORM

JF - J BIOMED INFORM

SN - 1532-0464

ER -