Van Batavia Jason P, Weiss Dana A, Long Christopher J, Madison Julian, McCarthy Gus, Plachter Natalie, Zderic Stephen A
Division of Urology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
The Division of Pediatric Urology and Information Services, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
J Pediatr Rehabil Med. 2018;11(4):303-309. doi: 10.3233/PRM-170525.
The era of the electronic health record (EHR) 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.
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 weekly export of data to clinicians in spreadsheet form.
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.
Designing and implementing a SDES based on a flowsheet that can allow data to be placed seamlessly 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.
电子健康记录（EHR）时代使得系统收集和记录诸如视频尿动力学研究（VUDS）等复杂程序的无数数据成为可能。我们开发了一种结构化数据录入系统（SDES），作为一种更好地规范VUDS以实现质量改进和研究能力的方法。
一个工作组召开会议，以流程图格式设计我院EHR中VUDS的SDES表单，以便将信息轻松整合到临床病程记录中，并每周以电子表格形式向临床医生导出数据。
对每周VUDS数据的分析显示，在所有已完成的SDES表单中，3%的单元格存在数据缺失。Excel电子表格中的数据可用性便于进行操作、计算临床变量，并通过图表进行简化分析以识别风险最高的患者。
基于流程图设计和实施SDES，使数据能够无缝地置于临床记录中，并整合到可搜索数据库中以实现质量改进和研究目的，能够充分发挥EHR的真正潜力。
