title: The need for harmonized structured documentation and chances of secondary use - results of a systematic analysis with automated form comparison for prostate and breast cancer.
abstract: BACKGROUND
  Medical documentation is a time-consuming task and there is a growing number of documentation requirements. In order to improve documentation, harmonization and standardization based on existing forms and medical concepts are needed. Systematic analysis of forms can contribute to standardization building upon new methods for automated comparison of forms. Objectives of this research are quantification and comparison of data elements for breast and prostate cancer to discover similarities, differences and reuse potential between documentation sets. In addition, common data elements for each entity should be identified by automated comparison of forms.
  
  
  METHODS
  A collection of 57 forms regarding prostate and breast cancer from quality management, registries, clinical documentation of two university hospitals (Erlangen, Münster), research datasets, certification requirements and trial documentation were transformed into the Operational Data Model (ODM). These ODM-files were semantically enriched with concept codes and analyzed with the compareODM algorithm. Comparison results were aggregated and lists of common concepts were generated. Grid images, dendrograms and spider charts were used for illustration.
  
  
  RESULTS
  Overall, 1008 data elements for prostate cancer and 1232 data elements for breast cancer were analyzed. Average routine documentation consists of 390 data elements per disease entity and site. Comparisons of forms identified up to 20 comparable data elements in cancer conference forms from both hospitals. Urology forms contain up to 53 comparable data elements with quality management and up to 21 with registry forms. Urology documentation of both hospitals contains up to 34 comparable items with international common data elements. Clinical documentation sets share up to 24 comparable data elements with trial documentation. Within clinical documentation administrative items are most common comparable items. Selected common medical concepts are contained in up to 16 forms.
  
  
  CONCLUSIONS
  The amount of documentation for cancer patients is enormous. There is an urgent need for standardized structured single source documentation. Semantic annotation is time-consuming, but enables automated comparison between different form types, hospital sites and even languages. This approach can help to identify common data elements in medical documentation. Standardization of forms and building up forms on the basis of coding systems is desirable. Several comparable data elements within the analyzed forms demonstrate the harmonization potential, which would enable better data reuse.
  
  
  CONCLUSIONS
  Identifying common data elements in medical forms from different settings with systematic and automated form comparison is feasible.
authors.affiliation: Institute of Medical Informatics, University of Münster, Albert-Schweitzer-Campus 1, A11, D-48149 Münster, Germany. Electronic address: Rainer.Krumm@uni-muenster.de.
authors.forename: Rainer
authors.initials: R
authors.lastname: Krumm
authors.affiliation: University Hospital Münster, Department of Urology - Prostate Center, Albert-Schweitzer-Campus 1, A1, D-48149 Münster, Germany. Electronic address: Axel.Semjonow@ukmuenster.de.
authors.forename: Axel
authors.initials: A
authors.lastname: Semjonow
authors.affiliation: University Hospital Münster, Department of Obstetrics and Gynecology, Albert-Schweitzer-Campus 1, A1, D-48149 Münster, Germany. Electronic address: Joke.Tio@ukmuenster.de.
authors.forename: Joke
authors.initials: J
authors.lastname: Tio
authors.affiliation: University Hospital Münster, Comprehensive Cancer Center Münster, Waldeyerstr. 1, D-48149 Münster, Germany. Electronic address: Heike.Duhme@ukmuenster.de.
authors.forename: Heike
authors.initials: H
authors.lastname: Duhme
authors.affiliation: University Erlangen-Nürnberg, Chair of Medical Informatics, Krankenhausstraße 12, D-91054 Erlangen, Germany. Electronic address: Thomas.Buerkle@imi.med.uni-erlangen.de.
authors.forename: Thomas
authors.initials: T
authors.lastname: Bürkle
authors.affiliation: University Hospital Münster, Comprehensive Cancer Center Münster, Waldeyerstr. 1, D-48149 Münster, Germany. Electronic address: Joerg.Haier@ukmuenster.de.
authors.forename: Jörg
authors.initials: J
authors.lastname: Haier
authors.affiliation: Institute of Medical Informatics, University of Münster, Albert-Schweitzer-Campus 1, A11, D-48149 Münster, Germany. Electronic address: Dugas@uni-muenster.de.
authors.forename: Martin
authors.initials: M
authors.lastname: Dugas
authors.affiliation: Institute of Medical Informatics, University of Münster, Albert-Schweitzer-Campus 1, A11, D-48149 Münster, Germany. Electronic address: Bernhard.Breil@uni-muenster.de.
authors.forename: Bernhard
authors.initials: B
authors.lastname: Breil
mesh_terms: D001943:Breast Neoplasms / Q000145:classification*; D066289:Data Curation / Q000379:methods; D057225:Data Mining / Q000379:methods; D057286:Electronic Health Records / Q000145:classification*; D005260:Female; D005568:Forms and Records Control / Q000379:methods*; D005858:Germany; D006801:Humans; D008297:Male; D008498:Medical Record Linkage / Q000379:methods*; D009323:Natural Language Processing; D010363:Pattern Recognition, Automated / Q000379:methods*; D011471:Prostatic Neoplasms / Q000145:classification*; D011996:Records; D012660:Semantics
keywords: Automated form comparison; Clinical documentation; Common data elements; Secondary use; Semantic interoperability; Standardization