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首页> 外文期刊>JMIR Medical Informatics >Common Data Elements for Acute Coronary Syndrome: Analysis Based on the Unified Medical Language System
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Common Data Elements for Acute Coronary Syndrome: Analysis Based on the Unified Medical Language System

机译：急性冠状动脉综合征的常见数据元素：基于统一医学语言系统的分析

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Background Standardization in clinical documentation can increase efficiency and can save time and resources. Objective The objectives of this work are to compare documentation forms for acute coronary syndrome (ACS), check for standardization, and generate a list of the most common data elements using semantic form annotation with the Unified Medical Language System (UMLS). Methods Forms from registries, studies, risk scores, quality assurance, official guidelines, and routine documentation from four hospitals in Germany were semantically annotated using UMLS. This allowed for automatic comparison of concept frequencies and the generation of a list of the most common concepts. Results A total of 3710 forms items from 86 sources were semantically annotated using 842 unique UMLS concepts. Half of all medical concept occurrences were covered by 60 unique concepts, which suggests the existence of a core dataset of relevant concepts. Overlap percentages between forms were relatively low, hinting at inconsistent documentation structures and lack of standardization. Conclusions This analysis shows a lack of standardized and semantically enriched documentation for patients with ACS. Efforts made by official institutions like the European Society for Cardiology have not yet been fully implemented. Utilizing a standardized and annotated core dataset of the most important data concepts could make export and automatic reuse of data easier. The generated list of common data elements is an exemplary implementation suggestion of the concepts to use in a standardized approach.
机译：临床文档中的背景标准化可以提高效率，可以节省时间和资源。目的这项工作的目标是比较急性冠状动脉综合征（ACS）的文件表单，检查标准化，并使用统一医疗语言系统（UMLS）使用语义形式注释生成最常见的数据元素列表。方法从注册机构，研究，风险评分，质量保证，德国四家医院的官方指南和常规文件中的形式进行了语义，使用UML进行语义注释。这允许自动比较概念频率和生成最常见的概念的列表。结果使用842个独特的UMLS概念，用86个来源共注出3710个表格。所有医学概念出现的一半被60个独特的概念涵盖，这表明存在相关概念的核心数据集。形式之间的重叠百分比相对较低，暗示在不一致的文档结构和缺乏标准化。结论该分析显示ACS患者缺乏标准化和语义富集的文档。官方机构等欧洲心脏病学会所作的努力尚未完全实施。利用最重要的数据概念的标准化和注释的核心数据集可以使输出和自动再利用数据更容易。所生成的常见数据元素列表是以标准化方法使用的概念的示例性实现建议。

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