title: Longitudinal comparative study on the influence of computers on reporting of clinical data.
abstract: The impact of the clinical database system SISCOPE on medical services was evaluated and objective data compiled on the quality of information recording and reporting using a fully structured data entry system compared to traditional free text reporting. 1565 upper endoscopy reports produced with SISCOPE over a period of 12 months were assessed for completeness and compared to 152 and 208 free text reports done 4 months before and 1 month after the study period, respectively. Data on four common gastrointestinal findings (esophageal varices, ulcers, polyps and tumors) were evaluated. Physicians' compliance with the new system was good, as reflected by a constant level of quality of reporting over time, although a very slight decline in the ratio of computer generated reports to the total number of examinations was noted. Structured reports had an 18% missing data rate and contained 60% more relevant information than free text reports, which had a 48% missing data rate. No educational effect of the system was seen as missing data rates returned to pre-computerization levels just one month after the end of the study. It is concluded that menu-driven structured data entry systems result in production of far superior reports as compared to free text systems, probably due to their reminder effect.
authors.affiliation: Department of Biomathematics, Faculty of Medicine, University of Lisbon, Portugal.
authors.forename: A
authors.initials: A
authors.lastname: Gouveia-Oliveira
authors.forename: V D
authors.initials: VD
authors.lastname: Raposo
authors.forename: N C
authors.initials: NC
authors.lastname: Salgado
authors.forename: I
authors.initials: I
authors.lastname: Almeida
authors.forename: C
authors.initials: C
authors.lastname: Nobre-Leitão
authors.forename: F G
authors.initials: FG
authors.lastname: de Melo
mesh_terms: D016145:Endoscopy, Digestive System; D006801:Humans; D008137:Longitudinal Studies; D008331:Management Information Systems / Q000706:statistics & numerical data