JMIR Publications

ABSTRACT

Background:

Standardization in clinical documentation can increase efficiency, save time and resources.

Objective:

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 Unified Medical Language System (UMLS).

Methods:

86 sources from registries, studies, risk scores, quality assurance, official guidelines and routine documentation of four hospitals in Germany were semantically annotated. This allowed for automatic comparison of concept frequencies and generation of a list of most common concepts. 3.710 forms items were semantically annotated using 842 unique UMLS concepts.

Results:

Half of all medical concept occurrences are covered by 60 unique concepts, which suggests the existence of a core data set of relevant concepts. Overlap percentages between forms are relatively low, hinting at inconsistent documentation structures and lack of standardization.

Conclusions:

This analysis shows a lack of standardized and semantically enriched documentation for patients with ACS. Efforts made by official institutions like the ESC have not yet been fully implemented. Utilizing a standardized and annotated core data set of the most important data concepts could make export and automatic re-use of data easier. The generated list of common data elements is an exemplary implementation suggestion of the concepts to use in a standardized approach.