Structured data entry for narrative data in a broad specialty: patient history and physical examination in pediatrics

Abstract

Background: Whereas an electronic medical record (EMR) system can partly address the limitations, of paper-based documentation, such as fragmentation of patient data, physical paper records missing and poor legibility, structured data entry (SDE, i.e. data entry based on selection of predefined medical concepts) is essential for uniformity of data, easier reporting, decision support, quality assessment, and patient-oriented clinical research. The aim of this project was to explore whether a previously developed generic (i.e. content independent) SDE application to support the structured documentation of narrative data (called OpenSDE) can be used to model data obtained at history taking and physical examination of a broad specialty.

Methods: OpenSDE was customized for the broad domain of general pediatrics: medical concepts and its descriptors from history taking and physical examination were modeled into a tree structure.

Results: An EMR system allowing structured recording (OpenSDE) of pediatric narrative data was developed. Patient history is described by 20 main concepts and physical examination by 11. In total, the thesaurus consists of about 1800 items, used in 8648 nodes in the tree with a maximum depth of 9 levels. Patient history contained 6312 nodes, and physical examination 2336. User-defined entry forms can be composed according to individual needs, without affecting the underlying data representation. The content of the tree can be adjusted easily and sharing records among different disciplines is possible. Data that are relevant in more than one context can be accessed from multiple branches of the tree without duplication or ambiguity of data entry via "shortcuts".

Conclusion: An expandable EMR system with structured data entry (OpenSDE) for pediatrics was developed, allowing structured documentation of patient history and physical examination. For further evaluation in other environments, the tree structure for general pediatrics is available at the Erasmus MC Web site (in Dutch, translation into English in progress) 1. The generic OpenSDE application is available at the OpenSDE Web site 2.

Figure 1

Editor for creating the tree structure. The right side of the screen shows the properties associated with the selected node 'body height'. 'Minimum' and 'Maximum' indicate the plausible range for body height. A condition is added to accommodate rare, but potentially valid values. The 'Codes' field can be used to assign identifiers from one or more standard terminologies. Each node is displayed with its associated term from the thesaurus. Unique numeric identifiers are meaningless and hidden. These can be shown on demand.

Figure 2

EMR system with structured data entry for pediatric patient history and physical examination data with a view on the standard entry form on the right side.

Figure 3

Continuous data validation: a warning appears entering an implausible value.

Figure 4

EMR system with structured data entry for pediatric patient history and physical examination data with a custom entry form on the right side.