TY - JOUR
T1 - Implementing a Real-Time Electronic Data Capture System to Improve Clinical Documentation in Radiation Oncology
AU - Pan, Hubert Y.
AU - Shaitelman, Simona F.
AU - Perkins, George H.
AU - Schlembach, Pamela J.
AU - Woodward, Wendy A.
AU - Smith, Benjamin D.
N1 - Funding Information:
B.D.S. receives research funding from Varian Medical Systems . The funders had no role in study design, data collection or analysis, decision to publish, or preparation of the article.
Publisher Copyright:
© 2016 American College of Radiology.
Copyright:
Copyright 2017 Elsevier B.V., All rights reserved.
PY - 2016/4/1
Y1 - 2016/4/1
N2 - Purpose Electronic health records (EHRs) often store information as unstructured text, whereas electronic data capture (EDC) using structured fields is common in clinical trials. We implemented a web-based EDC system for routine clinical care, and describe our experience piloting this system for breast cancer patients receiving radiation therapy. Methods Our institution uses dictation for clinical documentation in a centralized EHR; a separate radiation therapy-specific record-and-verify system contains prescriptions, schedules, and treatment documentation. The implemented EDC system collects patient, tumor, and treatment characteristics using structured data fields and merges it with data from the radiation therapy system to generate template-based notes in the EHR. Mean times to create notes using dictation versus EDC were compared. Users were surveyed about their experience. Acute toxicities were captured using the EDC system, and reported. Results The EDC system has been used by 25 providers for 1,296 patients. In the most recent month, 978 clinical notes were generated. The average clinician documentation time over a typical course of radiation was reduced from 22.4 minutes per patient with dictation, to 7.1 minutes with EDC. The user survey response rate was 100%, with 92% of respondents being either satisfied or very satisfied with their experience. The worst acute toxicities were mostly grade 1 (51%) or grade 2 (43%), with rare grade 3 (3%) events. Conclusions We implemented an EDC system for routine clinical use in the breast radiation therapy service that resulted in significant time-savings for clinical documentation and prospective population of a database to facilitate outcomes reporting.
AB - Purpose Electronic health records (EHRs) often store information as unstructured text, whereas electronic data capture (EDC) using structured fields is common in clinical trials. We implemented a web-based EDC system for routine clinical care, and describe our experience piloting this system for breast cancer patients receiving radiation therapy. Methods Our institution uses dictation for clinical documentation in a centralized EHR; a separate radiation therapy-specific record-and-verify system contains prescriptions, schedules, and treatment documentation. The implemented EDC system collects patient, tumor, and treatment characteristics using structured data fields and merges it with data from the radiation therapy system to generate template-based notes in the EHR. Mean times to create notes using dictation versus EDC were compared. Users were surveyed about their experience. Acute toxicities were captured using the EDC system, and reported. Results The EDC system has been used by 25 providers for 1,296 patients. In the most recent month, 978 clinical notes were generated. The average clinician documentation time over a typical course of radiation was reduced from 22.4 minutes per patient with dictation, to 7.1 minutes with EDC. The user survey response rate was 100%, with 92% of respondents being either satisfied or very satisfied with their experience. The worst acute toxicities were mostly grade 1 (51%) or grade 2 (43%), with rare grade 3 (3%) events. Conclusions We implemented an EDC system for routine clinical use in the breast radiation therapy service that resulted in significant time-savings for clinical documentation and prospective population of a database to facilitate outcomes reporting.
KW - Radiation oncology
KW - electronic data capture
KW - electronic health records
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U2 - 10.1016/j.jacr.2015.09.036
DO - 10.1016/j.jacr.2015.09.036
M3 - Article
C2 - 26681164
AN - SCOPUS:84949660657
SN - 1546-1440
VL - 13
SP - 401
EP - 407
JO - Journal of the American College of Radiology
JF - Journal of the American College of Radiology
IS - 4
ER -