Introduction: Documentation as well as IT-based management of medical data is of ever-increasing relevance in modern medicine. As radiation oncology is a rather technical, data-driven discipline, standardization, and data exchange are in principle possible. We examined electronic healthcare documents to extract structured information. Planning CT order entry documents were chosen for the analysis, as this covers a common and structured step in radiation oncology, for which standardized documentation may be achieved. The aim was to examine the extent to which relevant information may be exchanged among different institutions. Materials and Methods: We contacted representatives of nine radiation oncology departments. Departments using standardized electronic documentation for planning CT were asked to provide templates of their records, which were analyzed in terms of form and content. Structured information was extracted by identifying definite common data elements, containing explicit information. Relevant common data elements were identified and classified. A quantitative analysis was performed to evaluate the possibility of data exchange. Results: We received data of seven documents that were heterogeneous regarding form and content. 181 definite common data elements considered relevant for the planning CT were identified and assorted into five semantic groups. 139 data elements (76.8%) were present in only one document. The other 42 data elements were present in two to six documents, while none was shared among all seven documents. Conclusion: Structured and interoperable documentation of medical information can be achieved using common data elements. Our analysis showed that a lot of information recorded with healthcare documents can be presented with this approach. Yet, in the analyzed cohort of planning CT order entries, only a few common data elements were shared among the majority of documents. A common vocabulary and consensus upon relevant information is required to promote interoperability and standardization.

Journal Section:
Oncology and Informatics
Keywords:
Interoperability, Standardization, Common data element, Electronic healthcare records, Planning CT
1.
Lehne M, Luijten S, Vom Felde Genannt Imbusch P, Thun S. The use of FHIR in digital health: a review of the scientific literature. Stud Health Technol Inform. 2019 Sep 3;267:52–8.
2.
Integrating Healthcare Enterprise. Available from: https://www.ihe.net/.
3.
Bernstam EV, Warner JL, Krauss JC, Ambinder E, Rubinstein WS, Komatsoulis G, et al. Quantitating and assessing interoperability between electronic health records. J Am Med Inform Assoc. 2022 Apr 13;29(5):753–60.
4.
Gold M, McLAUGHLIN C. Assessing HITECH implementation and lessons: 5 years later. Milbank Q. 2016 Sep;94(3):654–87.
5.
Turbow S, Hollberg JR, Ali MK. Electronic health record interoperability: how did we get here and how do we move forward?JAMA Health Forum. 2021 Mar 1;2(3):e210253.
6.
Carter AB, de Baca ME, Luu HS, Campbell WS, Stram MN. Use of LOINC for interoperability between organisations poses a risk to safety. Lancet Digit Health. 2020 Nov;2(11):e569.
7.
Ward MC, Tendulkar RD, Videtic GMM, editors Essentials of clinical radiation oncology. [Enhanced Credo edition]. New York, NY, Boston; Massachusetts: Demos Medical, Credo Reference; 2019.
8.
Luh JY, Albuquerque KV, Cheng C, Ermoian RP, Nabavizadeh N, Parsai H, et al. ACR-ASTRO practice parameter for image-guided radiation therapy (IGRT). Am J Clin Oncol. 2020 Jul;43(7):459–68.
9.
Beets-Tan RGH, Oyen WJG, Valentini V, editors. Imaging and interventional radiology for radiation oncology. Cham: Springer International Publishing; 2020. [cited 2023 Jun 19]. [Medical Radiology]. Available from: https://link.springer.com/10.1007/978-3-030-38261-2.
10.
Silva JS, Ball MJ, Douglas JV. The Cancer Informatics Infrastructure (CII): an architecture for translating clinical research into patient care. Stud Health Technol Inform. 2001;84(Pt 1):114–7.
11.
Winget MD, Baron JA, Spitz MR, Brenner DE, Warzel D, Kincaid H, et al. Development of common data elements: the experience of and recommendations from the early detection research network. Int J Med Inform. 2003 Apr;70(1):41–8.
12.
Goel AK, Campbell WS, Moldwin R. Structured data capture for oncology. JCO Clin Cancer Inform. 2021 Feb;5:194–201.
13.
Pronovost PJ, National Academy of Medicine (U.S), editor. Procuring interoperability: achieving high-quality, connected, and person-centered care. Washington, DC: NAM.EDU; 2018. p. 1. [Learning health system series].
14.
Wood DL, Brennan MD, Chaudhry R, Chihak AA, Feyereisn WL, Woychick NL, et al. Standardized care processes to improve quality and safety of patient care in a large academic practice: the plummer project of the department of medicine, mayo clinic. Health Serv Manage Res. 2008 Nov;21(4):276–80.
15.
Dennstädt F, Treffers T, Iseli T, Panje C, Putora PM. Creation of clinical algorithms for decision-making in oncology: an example with dose prescription in radiation oncology. BMC Med Inform Decis Mak. 2021 Dec;21(1):212.
16.
Sinsky CA, Beasley JW, Simmons GE, Baron RJ. Electronic health records: design, implementation, and policy for higher-value primary care. Ann Intern Med. 2014 May 20;160(10):727–8.
17.
McLachlan S, Kyrimi E, Dube K, Hitman G, Simmonds J, Fenton N. Towards standardisation of evidence-based clinical care process specifications. Health Inform J. 2020 Dec;26(4):2512–37.
18.
De Mello BH, Rigo SJ, Da Costa CA, Da Rosa Righi R, Donida B, Bez MR, et al. Semantic interoperability in health records standards: a systematic literature review. Health Technol. 2022 Mar;12(2):255–72.
19.
Hayman JA, Dekker A, Feng M, Keole SR, McNutt TR, Machtay M, et al. Minimum data elements for radiation oncology: an American society for radiation oncology consensus paper. Pract Radiat Oncol. 2019 Nov;9(6):395–401.
20.
International Society for Radiation Oncology Informatics (ISROI) Landing page [Internet]. Available from: https://isroi.org/.
21.
SSRMP - Bulletin No. 103; Report from 4th radiation oncology informatics meetings [Internet]. Available from: https://ssrpm.ch/wp-content/uploads/2022/08/Bullettin-103.pdf.
22.
Sheehan J, Hirschfeld S, Foster E, Ghitza U, Goetz K, Karpinski J, et al. Improving the value of clinical research through the use of common data elements. Clin Trials. 2016 Dec;13(6):671–6.
23.
Common Data Element “Cancer Extent” as provided by the NIH [Internet]. Available from: https://cde.nlm.nih.gov/deView?tinyId=8xhJ3GJQZ2.
24.
Schulz S, Stegwee R, Chronaki C. Standards in healthcare data. In: Kubben P, Dumontier M, Dekker A, editors. Fundamentals of clinical data science. Cham (CH): Springer; 2019 [cited 2023 Jun 19]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK543525/.
25.
Rubin DL, Kahn CE. Common data elements in radiology. Radiology. 2017 Jun;283(3):837–44.
26.
Common Data Elements (CDEs) for Radiology [Internet]. Available from: https://radelement.org/.
27.
Rajamohan AG, Patel V, Sheikh-Bahaei N, Liu C-SJ, Go JL, Kim PE, et al. Common data elements in head and neck radiology reporting. Neuroimaging Clin N Am. 2020 Aug;30(3):379–91.
28.
Cihoric N, Badra EV, Stenger-Weisser A, Aebersold DM, Pavic M. Toward data-driven radiation oncology using standardized terminology as a starting point: cross-sectional study. JMIR Form Res. 2022 Jan 19;6(1):e27550.
29.
Bellary S, Krishnankutty B, Latha MS. Basics of case report form designing in clinical research. Perspect Clin Res. 2014 Oct;5(4):159–66.
30.
Nahm M, Shepherd J, Buzenberg A, Rostami R, Corcoran A, McCall J, et al. Design and implementation of an institutional case report form library. Clin Trials. 2011 Feb;8(1):94–102.
31.
Grégoire V, Mackie TR. State of the art on dose prescription, reporting and recording in intensity-modulated radiation therapy (ICRU report no. 83). Cancer Radiother. 2011 Oct;15(6–7):555–9.
32.
ICRU report 83, prescribing, recording, and reporting intensity-modulated photon-beam therapy (IMRT). Available from: https://www.icru.org/report/prescribing-recording-and-reporting-intensity-modulated-photon-beam-therapy-imrticru-report-83/.
33.
Mayo CS, Moran JM, Bosch W, Xiao Y, McNutt T, Popple R, et al. American association of Physicists in medicine task group 263: standardizing nomenclatures in radiation oncology. Int J Radiat Oncol Biol Phys. 2018 Mar 15;100(4):1057–66.
© 2023 S. Karger AG, Basel
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
2023
You do not currently have access to this content.