Purpose: To standardize disease site-specific templates with discrete data elements in the Computerized Patient Record System (CPRS). To enable practice assessment, enterprise wide outcome analysis, and improvement of clinical work flow using structured data.
Background: There is no consensus in radiation oncology clinics on essential data elements used in clinical encounters for any disease site. Additionally, the radiation oncology specific treatment, planning and delivery management systems do not connect with the hospital-based CPRS electronic medical record where clinical encounters are recorded. This often results in redundant data entry in multiple systems, which is error prone. Standardization of templates provides the framework for structured data recording in clinical encounters. Linking templated data elements from previous clinical encounters and repopulating in subsequent notes adds new laborsaving functionality, which may reduce errors as well.
Methods: A team of radiation oncologists and physicists from the Hunter Holmes McGuire VAMC in Richmond, Virginia, created consensus templates for prostate cancer. These included initial consultation, treatment directive, on treatment, end-of-treatment and follow-up notes. Templates were designed to repopulate subsequent notes seamlessly. Separately, we are developing a mechanism whereby treatment delivery-related information is automatically sent to CPRS from the treatment management system. Together these methods produce relational, or smart, templates.
Results: We were able to successfully implement and perform beta testing validation of these templates. Standardized templates provided framework to physicians for consistent data entry and required minimal training. Data from the consult notes are abstracted and stored in the CPRS/VistA database and can be used to perform individual and aggregate level searches. Implementation of consultation note and automated information flow to the subsequent treatment directive note has been successfully demonstrated. Redundant data entry was avoided, and missing data elements were flagged in the disease site-specific templates in CPRS.