Are structured data structured identically? Investigating the uniformity of pediatric patient data recorded using OpenSDE.
OBJECTIVE
OpenSDE is an application that supports structured recording of narrative patient data to enable use of the data in both clinical practice and clinical research. Reliability and accuracy of collected data are essential for subsequent data use. In this study we analyze the uniformity of data entered with OpenSDE. Our objective is to obtain insight into the consensus and differences of recorded data.


METHODS
Three pediatricians transcribed 20 paper patient records using OpenSDE. The transcribed records were compared and all recorded findings were classified into one of six categories of difference.


RESULTS
Of all findings 22% were recorded identically; 17% of the findings were recorded differently (predominantly as free text); 61% was omitted, inferred, or in conflict with the paper record.


CONCLUSIONS
The results of this study show that recording patient data using structured data entry does not necessarily lead to uniformly structured data.
Los
R K
RK
Department of Medical Informatics, Room Ee2157, Erasmus MC, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands. r.los@erasmusmc.nl
Roukema
J
J
van Ginneken
A M
AM
de Wilde
M
M
van der Lei
J
J
D006801:Humans; D016347:Medical Records Systems, Computerized / Q000592:standards*; D009426:Netherlands; D010372:Pediatrics; D012984:Software