Single-Source Tumor Documentation - Reusing Oncology Data for Different Purposes

Abstract

SummaryWe present a path towards single-source tumor documentation established at the Comprehensive Cancer Center Erlangen-Nürnberg (CCC-EN). Our goal was to derive data for cancer quality assurance and certification, cancer registry documentation and cancer research directly from routine care documentation. Therefore, clinical documentation activities were analyzed and a cancer data superset, containing these required elements, was developed. This superset was then split into appropriate clinical documentation packages, and the existing information technology infrastructure was analyzed and adapted to accommodate those documentation packages. A clinical documentation package is the amount of cancer-relevant data that can be captured within a clinical encounter. This grouping of data enables integration into existing clinical documentation workflows. We present examples in which single-source tumor documentation has been successfully established at the CCC-EN. The resulting cancer documentation reference model is described and its transferability to other institutions discussed.

Oncology Information System: A Qualitative Study of Users’ Requirements

“…The results are in line with the findings of other similar studies which showed that various data, such as disease history, tests results, final diagnosis and cancer stage, long-term adverse effects and outcomes should be recorded for cancer patients (Yu et al, 2010). In a study conducted by Ries et al (2012), the needed data were extracted from different clinical information systems and were integrated to report the patient's health status.…”

“…For example, the results of Scicotte et al,'s study (2016) showed that the use of electronic medical records in outpatient cancer centers could help to improve the flow of information and reduced the average waiting time. In another study, the interest of clinicians in using oncology electronic medical records has been highlighted (Ries et al, 2012) or an oncology information system has been developed to record cancer data electronically (Yu et al, 2010). It seems that collecting cancer care data electronically has a number of benefits for patients, clinicians and policy makers and can be regarded as an important tool for improving quality of care, making informed decisions, saving costs and reducing time for patient care.…”

Registries in Clinical Epidemiology: the European Surveillance System on Contact Allergies (ESSCA)

“…A more comprehensive approach would be to implement a "single source" documentation strategy, in which all data elements required both for routine care as well as associated research projects are entered in the EHR, and research data is consecutively extracted [10,11]. As such, the "single source" strategy would mostly be a "replacement" (of a previous, less comprehensive and flexible EHR) strategy, while trying to minimise documentation efforts by providing a single "all-purpose" EHR, without, however, restricting the scope of data a priori as a "minimal add-on" strategy necessarily would.…”

Electronic Support for Retrospective Analysis in the Field of Radiation Oncology: Proof of Principle Using an Example of Fractionated Stereotactic Radiotherapy of 251 Meningioma Patients

“…Although most university hospitals already implemented commercial hospital information systems and started to develop comprehensive EHRs, there is still a gap between clinical care and using this data for medical research that needs to be filled (10, 11). Recent studies have focused on providing routine clinical data for research purposes, e.g., by using a single-source tumor documentation or supporting systems for patient recruitment into clinical trials in the field of radiation oncology (12) and intensive care (13). …”