Abstract
BackgroundStandardization in clinical documentation can increase efficiency and can save time and resources.ObjectiveThe 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).MethodsForms 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.ResultsA 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.ConclusionsThis 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.
Highlights
Acute coronary syndrome (ACS), with its three subforms—ST elevated myocardial infarction (STEMI), non-ST elevated myocardial infarction (NSTEMI), and unstable angina pectoris (UAP)—is among the leading causes of mortality around the world [1,2]
Efforts made by official institutions like the European Society for Cardiology have not yet been fully implemented
Based on a workflow already successfully used for acute myeloid leukemia [26], a set of five documentation contexts in which information is collected for ACS patients was defined: routine documentation, research, quality measurements, official recommendations, and clinical risk scores
Summary
Acute coronary syndrome (ACS), with its three subforms—ST elevated myocardial infarction (STEMI), non-ST elevated myocardial infarction (NSTEMI), and unstable angina pectoris (UAP)—is among the leading causes of mortality around the world [1,2]. Studies estimate that more than 3 million people worldwide each year get diagnosed with STEMI and more than 4 million with NSTEMI [3]. Documentation is an important and required part of patient care. For patients with ACS, data collection often starts in the emergency department and can continue beyond the discharge date, when documentation for quality assurance or research purposes is needed. Documentation has been found to be lacking important information [8], with potentially dangerous effects for patients [9]. Parallel and redundant documentation for uses other than routine patient care, such as quality measurements or research and patient registries, make this process even more time-consuming and can result in documentation inconsistencies or errors. Over the past several years, spending for data management in research studies has increased. Standardization in clinical documentation can increase efficiency and can save time and resources
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