PMID: 8581552Nov 1, 1995Paper

Evaluation of reporting based on descriptional knowledge

Journal of the American Medical Informatics Association : JAMIA
P W MoormanJ H van Bemmel

Abstract

In an attempt to enhance the completeness and clarity of clinical narratives, the authors developed a general formalism for the entry of structured data. The objective of this study was to gain insight into the expressive power of the formalism through its use for reporting in endoscopy. Each of ten endoscopists reported twice about eight endoscopy videotapes. They produced free-text reports first, and then structured reports using this formalism. Statements in the resulting reports were compared. In total, 6.8% of the endoscopists' statements could not be expressed in structured options. Most of these statements were not due to limitations of the formalism itself. Topics mentioned in the free-text reports were described more frequently in the structured reports and, in addition, the structured reports included a greater variety of topics. Overall, increases of 83% for topics not related to abnormal findings (366 in free-text reports and 671 in structured reports) and 45% for features of abnormal findings (406 in free-text reports and 586 in structured reports) were observed. Although there was an overall information gain, features of abnormal findings were, on average, described by only half of the endoscopists. The expressive...Continue Reading

References

Jun 21, 1984·The New England Journal of Medicine·G O Barnett
Nov 15, 1993·Annals of Internal Medicine·J van der LeiJ H van Bemmel
Jul 1, 1996·International Journal of Bio-medical Computing·A M van GinnekenP W Moorman

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Citations

Jun 10, 2000·Journal of Digital Imaging·C P Langlotz
Sep 9, 2000·International Journal of Medical Informatics·M J van der MeijdenA Hasman
Jun 8, 2002·International Journal of Medical Informatics·Astrid M van Ginneken
Aug 1, 1997·International Journal of Medical Informatics·H J TangeH C Schouten
Dec 16, 1998·International Journal of Medical Informatics·M BergJ Kwakkernaat
Feb 28, 2002·Pediatric Emergency Care·Stephen C Porter
Feb 21, 2003·Annals of the New York Academy of Sciences·Usha SinhaHooshang Kangarloo
Feb 21, 2003·Annals of the New York Academy of Sciences·Craig A MoriokaHooshang Kangarloo
Nov 18, 2008·Radiology·David L Weiss, Curtis P Langlotz
Jan 27, 2009·Radiographics : a Review Publication of the Radiological Society of North America, Inc·Vijayaraghavan BashyamRicky K Taira
Jan 21, 2000·Journal of the American Medical Informatics Association : JAMIA·J Starren, S B Johnson
Jun 19, 2007·European Journal of Internal Medicine·Jagdiesh K SoekhoeRob J Th Ouwendijk
Jul 1, 1996·International Journal of Bio-medical Computing·D E Detmer, E B Steen
Jul 27, 2005·International Journal of Medical Informatics·Frank MengBernard M Churchill
Apr 28, 2005·Gastrointestinal Endoscopy·Thomas de LangeLars Aabakken
Mar 16, 2004·Journal of Biomedical Informatics·F Martin-SanchezF J Vicente

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