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Common Data Elements for Meaningful Stroke Documentation in Routine Care and Clinical Research: Retrospective Data Analysis.

Sarah BerenspöhlerJens MinnerupMartin DugasJulian Varghese
Published in: JMIR medical informatics (2021)
Standardization of medical documentation is a prerequisite for data exchange as well as the transferability and reuse of data. In the long run, standardization would save time and money and extend the capabilities for which such data could be used. In the context of this work, a lack of standardization was observed regarding current information management. Free-form text fields and intricate questions complicate automated data access and transfer between institutions. This work also revealed the potential of a unified documentation process as a core data set of the 50 most frequent common data elements, accounting for 34% of the documentation in medical information management. Such a data set offers a starting point for standardized and interoperable data collection in routine care, quality management, and clinical research.
Keyphrases
  • electronic health record
  • data analysis
  • big data
  • healthcare
  • clinical practice
  • health information
  • wastewater treatment
  • subarachnoid hemorrhage
  • brain injury
  • cross sectional