(P021) Improving Clinical Documentation and Prospectively Populating a Research Database Through an Electronic Data Capture System for Routine Clinical Care

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OncologyOncology Vol 29 No 4_Suppl_1
Volume 29
Issue 4_Suppl_1

We implemented an EDC system for routine clinical use in our breast RT service that resulted in significant time savings for clinical documentation and a prospective population of a database for future outcomes research. Additional follow-up is needed to determine how easily this system can be generalized to other RT disease sites and practices.

Hubert Y. Pan, MD, Timothy J. Edwards, BS, David P. Giragosian, PsyD, Emma B. Holliday, MD, Cameron W. Swanick, MD, Geoffrey V. Martin, MD, Karen E. Hoffman, MD, Simona F. Shaitelman, MD, Wendy A. Woodward, MD, PhD, Benjamin D. Smith, MD; UT MD Anderson Cancer Center

INTRODUCTION: With the current emphasis on value-based health care, there is increased importance of quantifying value and reducing cost. Electronic health records (EHRs) are being adopted at an increasing rate but often capture information as unstructured text, requiring time-consuming retrospective reviews to extract outcomes data. Electronic data capture (EDC) using case report forms is commonly used to collect structured data for clinical trials. We implemented a web-based EDC system for routine clinical care and describe our experience piloting the system for our breast radiation therapy (RT) service.

METHODS: Our institution uses dictation and transcription for clinical documentation stored in an in-house–developed EHR. A separate RT-specific system contains RT prescriptions, schedules, and treatment records. The implemented EDC serves as an intermediary between these two systems. Providers specify patient, tumor, and treatment characteristics through the EDC using structured data fields. These fields are merged with relevant data extracted from the RT system to generate template-based notes in the EHR for simulation, treatment planning, quality assurance (QA), weekly on-treatment visits (OTVs), and treatment summaries. Dictation and EDC times are reported as means and compared using t-tests.

RESULTS: The EDC had been used by 21 providers and generated 850 notes for 127 patients during the most recent month. A consult form collecting tumor and treatment details was completed in the EDC as an initial additional step, requiring 2.5 minutes. This form generated a patient identifier used in all subsequent notes. Simulation notes, treatment planning notes, and treatment summaries were all completed more quickly using the EDC as compared with dictation (P < .001). QA notes recording the results of weekly treatment plan reviews were completed in real time during the conference (2.1 min with dictation). OTV notes were often completed during the patient encounter using a tablet (1.8 min with dictation). The total documentation time for a typical course of breast RT was 5.4 minutes with EDC and 22.1 minutes with dictation.

CONCLUSION: We implemented an EDC system for routine clinical use in our breast RT service that resulted in significant time savings for clinical documentation and a prospective population of a database for future outcomes research. Additional follow-up is needed to determine how easily this system can be generalized to other RT disease sites and practices.

Proceedings of the 97th Annual Meeting of the American Radium Society - americanradiumsociety.org

Articles in this issue

(P005) Ultrasensitive PSA Identifies Patients With Organ-Confined Prostate Cancer Requiring Postop Radiotherapy
(P001) Disparities in the Local Management of Breast Cancer in the United States According to Health Insurance Status
(P002) Predictors of CNS Disease in Metastatic Melanoma: Desmoplastic Subtype Associated With Higher Risk
(P003) Identification of Somatic Mutations Using Fine Needle Aspiration: Correlation With Clinical Outcomes in Patients With Locally Advanced Pancreatic Cancer
(P004) A Retrospective Study to Assess Disparities in the Utilization of Intensity-Modulated Radiotherapy (IMRT) and Proton Therapy (PT) in the Treatment of Prostate Cancer (PCa)
(S001) Tumor Control and Toxicity Outcomes for Head and Neck Cancer Patients Re-Treated With Intensity-Modulated Radiation Therapy (IMRT)-A Fifteen-Year Experience
(S003) Weekly IGRT Volumetric Response Analysis as a Predictive Tool for Locoregional Control in Head and Neck Cancer Radiotherapy 
(S004) Combination of Radiotherapy and Cetuximab for Aggressive, High-Risk Cutaneous Squamous Cell Cancer of the Head and Neck: A Propensity Score Analysis
(S005) Radiotherapy for Carcinoma of the Hypopharynx Over Five Decades: Experience at a Single Institution
(S002) Prognostic Value of Intraradiation Treatment FDG-PET Parameters in Locally Advanced Oropharyngeal Cancer
(P006) The Role of Sequential Imaging in Cervical Cancer Management
(P008) Pretreatment FDG Uptake of Nontarget Lung Tissue Correlates With Symptomatic Pneumonitis Following Stereotactic Ablative Radiotherapy (SABR)
(P009) Monte Carlo Dosimetry Evaluation of Lung Stereotactic Body Radiosurgery
(P010) Stereotactic Body Radiotherapy for Treatment of Adrenal Gland Metastasis: Toxicity, Outcomes, and Patterns of Failure
(P011) Stereotactic Radiosurgery and BRAF Inhibitor Therapy for Melanoma Brain Metastases Is Associated With Increased Risk for Radiation Necrosis
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