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Essential Data Elements for Electronic Cardiovascular Medical Record Systems in Iran

Abbas Sheikhtaheri, Farid Khorami, Hedyeh Mohammadzadeh
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Abstract

Introduction: Electronic medical records play an important role in the management of patients. In order to develop cardiovascular electronic medical record systems, determining minimum data set is necessary. This study aimed to determine the essential data elements for electronic cardiovascular medical record systems.

Methods: Medical records of patients with cardiovascular diseases and also the literature were reviewed to develop a questionnaire regarding the data elements.  87 cardiovascular specialists and residents as well as 50 nurses working in cardiovascular departments of hospitals affiliated with Iran University of Medical Sciences participated in the study. The data elements with at least 75% of agreement were considered essential for electronic medical records. Data were analyzed using descriptive statistics in SPSS software.

Results: The essential  data elements were classified in 29 classes including admission, death, patients’ main complaints, clinical signs, observations, medications, cardiac surgery, risk factors, laboratory and pathology results, consultation, resuscitation, anesthetic, electrocardiography, blood transfusion or blood products, rehabilitation measures, angiography/venography, exercise testing, endoscopy/colonoscopy, medical imaging, echocardiography, nursing interventions, allergies and side effects, therapeutic implantations, cardiac examinations, physical examinations, angina, referrals, social backgrounds and history., Totally, out of 276 data elements, 245 elements were identified as the essential data elements for electronic cardiovascular medical record systems.

Conclusion: In this study, essential data elements were defined for electronic cardiovascular medical records. Identifying cardiovascular minimum data set will be an effective step towards integrating and improving the management of these patients' information.


References

Salem M, Alali A, Bashwar Z. Improving documentation of cardio-vascular disease risk in medical records of diabetic patients attending non communicable disease clinics at West Bay health center in Qatar. BMJ Qual Improv Rep. 2015; 4(1): u207778.w3190. PMID: 26734364 DOI: 10.1136/bmjquality.u207778.w3190

World Health Organization. Cardiovascular diseases (CVDs) [Internet]. 2017 [cited: 25 Nov 2020]. Available from: https://www.who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)

Virani Salim S, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics-2020 update: A report from the American Heart Association. Circulation. 2020; 141(9): e139-e596. PMID: 31992061 DOI: 10.1161/CIR.0000000000000757

Gamissi J, Hosseinian A. Spatial statistics application in comparative study of Ardabil province counties status in the basis of hospitalization rate due to coronary disease. Journal of Health and Care. 2017; 19(3): 168-81.

Safdari R. Electronic health record system. Tehran: Jafari Publication; 2011.

Carpeggiani C, Dalmiani S, Taddei A, Franchi D, Michelassi C, Chelozzi L, et al. Use of an electronic medical record in a department of cardiology. Computers in Cardiology. Cambridge: IEEE; 2000.

Ghazi Saeidi M, Moghimi Araghi S, Babadi S. Determining the required minimum data set and data elements to create a web-based electronic record for glaucoma patients. Journal of Payavard Salamat. 2018; 11(6): 675-84.

Gholami Parizad E, Sharifian R. Designing the minimum data set for Iranian children’ health records. Journal of Ilam University of Medical Sciences. 2016; 24(1): 114-25.

Zahmatkeshan M, Farjam M, Mohammadzadeh N, Noori T, Karbasi Z, Safdari R, et al. Design of infertility monitoring system: Minimum data set approach. J Med Life. 2019; 12(1): 56-64. PMID: 31123526 DOI: 10.25122/jml-2018-0071

Karen L. Use of the SGNA minimum data set in the clinical area. Gastroenterol Nurs. 2005; 28(1): 59-60. PMID: 15738737 DOI: 10.1097/00001610-200501000-00015

Mohammadi A, Ahmadi M, Bashiri A, Nazemi Z. Designing the minimum data set for orthopedic injuries. Journal of Clinical Research in Paramedical Sciences. 2014; 3(2): 75-83.

Hashemi N, Sheikhtaheri A, Hashemi NS, Rawassizadeh R. Electronic medical records for mental disorders: What data elements should these systems contain? Stud Health Technol Inform. 2019; 260: 25-32. PMID: 31118315

Boris JR, Béland MJ, Bergensen LJ, Colan SD, Dangel J, Daniels CJ, et al. 2017 AHA/ACC key data elements and definitions for ambulatory electronic health records in pediatric and congenital cardiology: A report of the american college of cardiology/american heart association task force on clinical data standards. J Am Coll Cardiol. 2017; 70(8): 1029-95. PMID: 28716477 DOI: 10.1016/j.jacc.2017.06.027

Weintraub WS, sKarlsberg RP, Tcheng JE, Boris JR, Buxton AE, Dove JT, et al. ACCF/AHA 2011 key data elements and definitions of a base cardiovascular vocabulary for electronic health records: a report of the American College of Cardiology Foundation/American Heart Association task force on clinical data standards. J Am Coll Cardiol. 2011; 58(2): 202-22. PMID: 21652161 DOI: 10.1016/j.jacc.2011.05.001

Douglas PS, Carabello BA, Lang RM, Lopez L, Pellikka PA, Picard MH, et al. 2019 ACC/AHA/ASE Key data elements and definitions for transthoracic echocardiography: a report of the American College of Cardiology/American Heart Association task force on clinical data standards and the American Society of Echocardiography. Circ Cardiovasc Imaging. 2019; 12(7): e000027. PMID: 31233331 DOI: 10.1161/HCI.0000000000000027

Asselbergs FW, Visseren FL, Bots ML, de Borst GJ, Buijsrogge MP, Dieleman JM, et al. Uniform data collection in routine clinical practice in cardiovascular patients for optimal care, quality control and research: The Utrecht cardiovascular cohort. Eur J Prev Cardiol. 2017; 24(8): 840-47. PMID: 28128643 DOI: 10.1177/2047487317690284

Langarizadeh M, Gholinezhad M. A minimum data set of laboratory reporting system for exchanging with electronic health record system in Iran. Journal of Health Administration. 2017; 19(66): 61-70.

Fallahnejad E, Niknam F, Nikandish Nobar R, Zand F, Sharifian R. Development of minimum data set for electronic documentation of progress note in the general intensive care unit. Frontiers in Health Informatics. 2020; 9: 37.

HL7. Domain analysis model: Cardiology [Internet]. 2013 [cited: 25 Nov 2020]. Available from: https://www.hl7.org/Special/committees/cardiology/index.cfm




DOI: http://dx.doi.org/10.30699/fhi.v10i1.252

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