On educating about medical data management - the other side of the electronic health record

Abstract

Objectives: To summarize background, challenges, objectives, and methods for the usability of patient data, in particular with respect to their multiple use, and to point out how to lecture medical data management.

Methods: Analyzing the literature, providing an example based on Simpson's paradox and summarizing research and education in the field of medical data management, respectively health information management (in German: Medizinische Dokumentation).

Results: For the multiple use of patient data, three main categories of use can be identified: patient-oriented (or casuistic) analysis, patient-group reporting, and analysis for clinical studies. A so-called documentation protocol, related to study plans in clinical trials, supports the multiple use of data from the electronic health record in order to obtain valid, interpretable results. Lectures on medical data management may contain modules on introduction, basic concepts of clinical data management and coding systems, important medical coding systems (e.g. ICD, SNOMED, TNM, UMLS), typical medical documentation systems (e.g. on patient records, clinical and epidemiological registers), utilization of clinical data management systems, planning of medical coding systems and of clinical data management systems, hospital information systems and the electronic patient record, and on data management in clinical studies.

Conclusion: Usability, the ultimate goal of recording and managing patient data, requires, besides technical considerations, in addition appropriate methodology on medical data management, especially if data is intended to be used for multiple purposes, e.g. for patient care and quality management and clinical research. Medical data management should be taught in health and biomedical informatics programs.