Leveraging Existing Tools in Electronic Health Record Systems to Automate Clinical Registry Compilation

Development of an Electronic Health Record Registry to Facilitate Collection of Commission on Cancer Metrics for Patients Undergoing Surgery for Breast Cancer

PURPOSE

Accurate and efficient data collection is a challenge for quality improvement initiatives and clinical research. We describe the development of a custom electronic health record (EHR)–based registry to automatically extract structured Commission on Cancer axillary surgery-specific metrics from a custom synoptic note template included in the operative reports for patients with breast cancer undergoing surgery.

METHODS

The smart functionality of our enterprise-based EHR system was leveraged to create a custom smart phrase to capture axillary surgery-specific variables. A multidisciplinary team developed structured data elements correlating to each axillary surgery-specific variable. These data elements were then included in a note template for the operative report. Each variable could be aggregated and converted into a single flat database through the EHR's reporting workbench and serve as a live, prospective registry for all users within the EHR.

RESULTS

The final axillary surgery-specific note template in a synoptic format allowed for efficient and easy entry and automatic collection of breast cancer–specific metrics. From initial adoption in February 2021-December 2021, there were 1,254 patients who underwent breast surgery with axillary surgery. The operative notes allowed for automatic capture of metrics from 60.5% (n = 759) of patients. Data capture improved from 37.6% in the initial adoption period of 6 months to 86.2% in the last 5 months.

CONCLUSION

We were able to demonstrate successful implementation of provider-driven structured data entry into EHR systems that permits automatic data capture. The end result is a custom synoptic note template and a real-time, prospective registry of breast cancer–specific Commission on Cancer metrics that are robust enough to use for quality improvement initiatives and clinical research.

Improving Communication by Standardizing Pediatric Rapid Response Team Documentation

BACKGROUND

Rapid response teams (RRTs) have been used by multiple hospital systems to enhance patient care and safety. However, processes to document rapid response events (RRE) are often varied among providers and teams, which can lead to suboptimal communication of recommendations to both the primary medical team and family.

METHODS

A preintervention chart review was conducted from January-March 2018 and revealed suboptimal baseline documentation following RREs. A literature review and survey of RRT team members led to the creation of a standardized document with an Epic SmartPhrase which included six key elements of RRE documentation: physical examination, intervention performed, response to intervention, plan of care, communication with care team, and communication with family. A postintervention chart review was completed from April-June 2019 to assess improvements in documentation with the use of this SmartPhrase.

RESULTS

There were 23 RRE activations in the postintervention period, of which 60.8% were due to respiratory distress. The documentation of the six key elements improved (p < .05) after SmartPhrase creation and serial educational interventions.

CONCLUSIONS

Standardized RRE documentation of six key elements significantly improved with the implementation of an Epic SmartPhrase. Improved quality of documentation enhances communication between team members and can contribute to safer patient care.

Design and development of a web-based registry for Coronavirus (COVID-19) disease

Background: The 2019 coronavirus (COVID-19) is a highly contagious disease associated with a high morbidity and mortality worldwide. The accumulation of data through a prospective clinical registry enables public health authorities to make informed decisions based on real evidence obtained from surveillance of COVID-19. This registry is also fundamental to providing robust infrastructure for future research surveys. The purpose of this study was to design a registry and its minimum data set (MDS), as a valid and reliable data source for reporting and benchmarking COVID-19. Methods: This cross sectional and descriptive study provides a template for the required MDS to be included in COVID-19 registry. This was done by an extensive literature review and 2 round Delphi survey to validate the content, which resulted in a web-based registry created by Visual Studio 2019 and a database designed by Structured Query Language (SQL). Results: The MDS of COVID-19 registry was categorized into the administrative part with 3 sections, including 30 data elements, and the clinical part with 4 sections, including 26 data elements. Furthermore, a web-based registry with modular and layered architecture was designed based on final data classes and elements. Conclusion: To the best of our knowledge, COVID-19 registry is the first designed instrument from information management perspectives in Iran and can become a homogenous and reliable infrastructure for collecting data on COVID-19. We hope this approach will facilitate epidemiological surveys and support policymakers to better plan for monitoring patients with COVID-19.