This paper explores whether a previously developed SDE application (called OpenSDE) can accommodate the structured recording of medical narrative data of a broad specialty. An expandable EMR system with OpenSDE for general pediatrics is developed, allowing structured documentation of patient history and physical examination. The resulting thesaurus contains 1800 terms, and the OpenSDE tree contains 8648 nodes (patient history and physical examination contain 6312 and 2336 nodes, respectively).
Developing interface terminologies poses a range of scientific issues that have to be, implicitly or explicitly, addressed [13
]. The ultimate test of our approach will be the use of the system in daily clinical care. During the development of the system, coverage and user friendliness were assessed by physicians entering actual cases; this, however, must be viewed as an initial assessment only.
The content and structure of data in the EMR system may change over time, for example, for expansion of the tree. Previously stored data, however, must remain fully accessible. OpenSDE provides this functionality and thus provides a flexibility that is very important for acceptability of an EMR system among future users.
The main lesson learned from the development of an EMR system with SDE for a broad specialty concerns navigating the tree. To meet this difficulty, the user has the option to use customized entry forms without affecting the underlying data representation. When a medical concept is relevant in more than one context, the user is redirected via "shortcuts" to the one unique node where this concept can be described. Duplicate or inconsistent description of one concept is thus avoided. The "shortcuts" further allow return of the user to his/her last position in the tree structure. Nonetheless, the use of custom forms and "shortcuts" probably will not be conclusive and navigation remains a challenging subject for future developers. This project taught us furthermore that a balance has to be found between research objectives, and demands for patient care. The modeling of free text annotations in the tree structure, enabling the author to describe in his own words a concept or a finding, is an example of a (partial) concession made to the structured entry of data. Thirdly, we experienced that, although pediatric expertise was available during construction of the tree, medical assessments by clinicians who were 'new users', led to adaptations of the tree.
Researchers have developed a number of electronic patient record systems. In the Netherlands, for example, almost all general practitioners use a computer to record patient data [7
]. Typically, these records provide some overall structure and include some coding (e.g., the International Classification for Primary Care, the ICPC). Data dealing with patient history and physical examination, however, are typically recorded as free text. Especially for general and broad specialties, such as pediatrics and internal medicine, in which detailed description of history taking and physical examination is needed, an EMR system with SDE for data from history taking and physical examination has, to our knowledge, never been realized.
In this paper, a pediatric context is used to explore whether the OpenSDE application can be used to model narrative data of such a broad specialty. At present, OpenSDE is also being applied to several other medical domains [28
]. An additional benefit of the developed applications is the possibility that different specialists can share their records, while working with the same recognizable user interface. A common user interface across different specialties enhances familiarity with the system and contributes to the ultimate use of the EMR system in practice.
Before widespread implementation of an EMR, the system should be rigorously evaluated and security and ethical aspects must be addressed [8
]. In a separate study, we evaluated our pediatric EMR system with respect to its completeness, uniformity of reporting, and its usability in clinical practice. The physicians share a positive attitude towards the SDE application and the EMR system appears to be a promising application for the support of physician data entry in general pediatrics [31
Currently, OpenSDE functionality is being implemented in our Hospital Information System, following a pilot in the pediatric emergency department. Among future plans for applications in the pediatric EMR system with SDE are the embedding of age-based normal ranges of measurements for vital signs and other physiological parameters, clinical decision rules and graphic display of growth data and special calculations of growth patterns [32
]. Further prospects are incorporation of reminder systems (e.g. for immunization or differential diagnosis [11
], selection of patient subgroups (e.g. for prevention strategies) and support of adequate drug dosing.