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Data acquisition in emergency medicine: electronic communication using free text
1Division of Emergency Medicine, Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02115, USA. porter_s@tch.harvard.edu
Objectives:
1) To describe the content of medical data obtained from parents' use of free text during a computer interview; 2) To assess whether differences in parents' demographics or experience with computers differentiate their production of free text; and 3) To compare parents' entry of free text with the final physician-generated electronic medical record (EMR) regarding the chief complaint.
Methods:
Data entered by parents during a prospective trial of electronic data entry were examined. Content analysis of parents' free text entries examined absolute word count and categorized entries by type of information. Demographic and technology-related variables were analyzed against the type of information and the absolute word count. Two reviewers independently judged agreement between parents' and physicians' data for the chief complaint.
Results:
Of 100 parents enrolled, 30 entered data for the chief complaint using free text. Amount of free text entered ranged from 1 to 142 words with a median of 8 words. Parents' free text was categorized into 4 types of information: simple descriptive (n = 16), problem-focused (n = 7), descriptive plus a question agenda (n = 2), and descriptive with reference to past medical history (n = 5). Parental demographics and computer-related experience did not predict differential production of free text. Agreement between parents' and physicians' entries for the chief complaint was 80% (95% CI 66-94) [reviewer A] and 73% (95% CI 57-89) [reviewer B]. Seven of 30 parental entries (23%) provided data not contained in the EMR.
Conclusions:
When entering a chief complaint during an electronic interview, a majority of parents report descriptive data using short phrases. Good agreement between parents' and physicians' electronic report was demonstrated for the chief complaint.
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