Data acquisition in emergency medicine: electronic communication using free text.
OBJECTIVE
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.
Porter
Stephen C
SC
Division of Emergency Medicine, Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02115, USA. porter_s@tch.harvard.edu
D003197:Computer Literacy; D004282:Documentation / Q000379:methods*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008487:Medical History Taking / Q000379:methods*; D016347:Medical Records Systems, Computerized; D015588:Observer Variation; D010290:Parents; D010820:Physicians; D011446:Prospective Studies; D012959:Socioeconomic Factors; D018709:Statistics, Nonparametric; D014584:User-Computer Interface