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Common Data Elements for Meaningful Stroke Documentation in Routine Care and Clinical Research: Retrospective Data
Sarah Berenspöhler1, Jens Minnerup2, Martin Dugas3
1Institute of Medical Informatics, Westfälische Wilhelms-University Münster, Münster, Germany.
JMIR Medical Informatics
|October 12, 2021
Summary
Standardizing stroke patient documentation with a core data set of common medical concepts can improve data exchange and reduce time spent on information management. This approach facilitates interoperable data collection for research and care.
Area of Science:
- Medical Informatics
- Health Data Management
- Clinical Documentation Standards
Background:
- Medical information management for stroke patients is time-consuming.
- Current documentation practices for acute stroke care are not well understood.
- Established guidelines exist, but their reflection in patient records is unclear.
Purpose of the Study:
- To compare various stroke documentation processes.
- To identify common medical concepts in stroke documentation.
- To define a core data set for potential data interfaces and interoperability.
Main Methods:
- Digitized medical source documents from diverse contexts (hospitals, trials, registries).
- Semantically annotated data elements using the Unified Medical Language System.
- Analyzed concept overlaps, identifying common concepts across at least two contexts.
Main Results:
- Identified 1051 unique medical concepts from 3287 data elements.
- The 100 most frequent concepts represent 9.51% of occurrences.
- A common data element list was created in standardized, machine-readable formats.
Conclusions:
- Standardization is crucial for data exchange, transferability, and reuse, saving time and resources.
- Lack of standardization in current stroke information management hinders automated data access.
- A core data set of 50 frequent common elements offers a foundation for standardized, interoperable data collection.
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