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?

Abstract

Purpose: The era of the electronic health record (ERH) 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 a 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 seamlessly be placed 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.

The Value of Auditing Surgical Records in a Tertiary Hospital Setting

“…Looking at the individual sections of the tool, it is clear that improvement is present in every domain except for anesthesia recordings that show a clear plateau at a score of 98; this might be because that even before the start of this audit, anesthesia records were standardized into a form required to undergo any elective surgery, and is consistent with the finding of Mafrachi et al who noticed the same plateau while studying anesthesia STAR scores in JUH [13]. This suggests that standardizing a form for record entry is useful especially with EMRs, which is consistent with previously reported results [26,27].…”

Development of an Innovative Digital Data Collection System for Routine Mental Health Care Delivery in Rural Haiti

“…Based on best practices in HMIS and feedback from the PIH medical informatics team, structured data entry was used wherever possible to record the data elements, in the form of dropdowns or auto-complete fields to ensure ease of use for users and reduce skipped fields. 21 , 23 …”

“…Based on best practices in HMIS and feedback from the PIH medical informatics team, structured data entry was used wherever possible to record the data elements, in the form of dropdowns or autocomplete fields to ensure ease of use for users and reduce skipped fields. 21,23 Since the system was intended to facilitate programmatic and clinical decision making, key design inputs were made from providers and clinical supervisors. Initially, the intention was to include only high-level diagnoses (e.g., depression, anxiety, or psychotic disorders) to ease diagnosis among task-shared providers who had less experience with diagnosis.…”

To assess the impact of problem lists' accuracy in electronic health records on clinical decision-making: protocol for a randomized controlled trial

“…Clinicians are therefore often reluctant to the extra burden of structured data registration, unless they receive signi cant returns for their effort [12,13]. It is therefore necessary to reduce healthcare providers' resistance by developing a structured data entry system that is user-friendly without adding to the work load and time burden [2].…”

“…The Electronic Health Record (EHR) system comprises of extensively documented patient data. These data could allow healthcare providers to track patient health information and make better decisions [1], but these data could also be used for secondary purposes, such as quality improvement and research [2,3]. That requires data to be captured in a structured and coded format as much as possible, instead of being captured as narrative free text [4].…”