Data acquisition in emergency medicine: electronic communication using free text.

Area of Science:

• Medical Informatics
• Patient-Reported Outcomes
• Clinical Data Entry

Background:

• Electronic health records (EHRs) are increasingly used in healthcare.
• Patient input via free text offers a valuable data source.
• Understanding the nature and utility of parent-generated free text is crucial for optimizing EHR systems.

Purpose of the Study:

• To characterize the content of medical data parents enter as free text during computer interviews.
• To determine if parental demographics or computer experience influence free text generation.
• To compare parent-entered free text chief complaints with physician-generated electronic medical records (EMRs).

Main Methods:

• Prospective trial analyzing parent free text entries from a computer interview system.
• Content analysis of free text for word count and information type.
• Statistical analysis of demographic and computer experience variables against text production.
• Independent reviewer assessment of agreement between parent and physician chief complaint entries.

Main Results:

• Of 100 parents, 30 used free text for chief complaints, with a median of 8 words.
• Entries were categorized as descriptive, problem-focused, or including past medical history.
• Parental demographics and computer experience did not significantly affect free text quantity or type.
• Agreement between parent and physician chief complaints was high (73-80%), with 23% of parent entries containing unique data.

Conclusions:

• Parents predominantly use brief, descriptive phrases for chief complaints in electronic interviews.
• Parental free text entry demonstrates substantial agreement with physician EMR documentation.
• Free text provides supplementary information not always captured in standard EMR formats.