JMIR Publications

Background:

Standardization in clinical documentation can increase efficiency and can 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 the Unified Medical Language System (UMLS).

Methods:

Forms 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.

Results:

A 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.

Conclusions:

This 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.