Using structured data entry systems in the electronic medical record to collect clinical data for quality and research: Can we efficiently serve multiple needs for complex patients with spina bifida?

Issue title: Spina Bifida Care Among a Global Community

Guest editors: Jonathan Castillo

Article type: Research Article

Authors: Van Batavia, Jason P.^{a; *} | Weiss, Dana A.^a | Long, Christopher J.^a | Madison, Julian^b | McCarthy, Gus^b | Plachter, Natalie^a | Zderic, Stephen A.^a

Affiliations: [a] Division of Urology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA | [b] The Division of Pediatric Urology and Information Services, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA

Correspondence: [*] Corresponding author: Jason P. Van Batavia, Pediatric Urology, The Children’s Hospital of Philadelphia, Division of Urology, 3rd Floor, Wood Building, 34th and Civic Center Blvd, Philadelphia, PA 19104, USA. Tel.: +1 267 608 5467; Fax: +1 215 590 3895; E-mail: [email protected].

Abstract: PURPOSE: The era of the electronic health record (EHR) generates the ability to systematically collect and record innumerable data for complex procedures such as videourodynamic studies (VUDS). We developed a Structured Data Entry System (SDES) that would serve as a way to better standardize VUDS for both quality improvement and research capabilities. METHODS: A working group convened to design a SDES form for VUDS in a flow sheet format in our hospital’s EHR, allowing for easy integration of the information into the clinical encounter note and for weekly export of data to clinicians in spreadsheet form. RESULTS: Analysis of weekly VUDS data revealed that entries were missing in 3% of cells in all SDES forms completed. The availability of the data in an Excel spreadsheet allows for easy manipulation, calculation of clinical variables, and streamlined analysis in figures or graphs to identify patients at the highest risk. CONCLUSION: Designing and implementing a SDES based on a flowsheet that can allow data to be placed seamlessly in the clinical record and to be integrated into a searchable database for quality improvement and research purposes allows one to harness the true potential of the EHR.

Keywords: Electronic medical records, standardized data entry system, urodynamics, pediatric urology, health information technology

DOI: 10.3233/PRM-170525

Journal: Journal of Pediatric Rehabilitation Medicine, vol. 11, no. 4, pp. 303-309, 2018