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Health informatics
Research
Feasibility of real-time capture of routine clinical data in the electronic health record: a hospital-based, observational service-evaluation study
  1. Neil Bodagh1,
  2. R Andrew Archbold1,
  3. Roshan Weerackody1,
  4. Meredith K D Hawking2,
  5. Michael R Barnes3,
  6. Aaron M Lee4,
  7. Surjeet Janjuha1,
  8. Charles Gutteridge1,
  9. John Robson2,
  10. Adam Timmis1,5
  1. 1 Cardiology, Barts Heart Centre, London, UK
  2. 2 Clinical Effectiveness Group, Queen Mary University of London, London, UK
  3. 3 William Harvey Research Institute Queen Mary University of London, London, UK
  4. 4 Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Queen Mary University of London, London, UK
  5. 5 The Farr Institute of Health Informatics Research, University College London, London, UK
  1. Correspondence to Dr Neil Bodagh; neil.bodagh{at}nhs.net

Abstract

Objectives The electronic health record (EHR) is underused in the hospital setting. The aim of this service evaluation study was to respond to National Health Service (NHS) Digital’s ambition for a paperless NHS by capturing routinely collected cardiac outpatient data in the EHR to populate summary patient reports and provide a resource for audit and research.

Design A PowerForm template was developed within the Cerner EHR, for real-time entry of routine clinical data by clinicians attending a cardiac outpatient clinic. Data captured within the PowerForm automatically populated a SmartTemplate to generate a view-only report that was immediately available for the patient and for electronic transmission to the referring general practitioner (GP).

Results During the first 8 months, the PowerForm template was used in 61% (360/594) of consecutive outpatient referrals increasing from 42% to 77% during the course of the study. Structured patient reports were available for immediate sharing with the referring GP using Cerner Health Information Exchange technology while electronic transmission was successfully developed in a substudy of 64 cases, with direct delivery by the NHS Data Transfer Service in 29 cases and NHS mail in the remainder. In feedback, the report’s immediate availability was considered very or extremely important by >80% of the patients and GPs who were surveyed. Both groups reported preference of the patient report to the conventional typed letter. Deidentified template data for all 360 patients were successfully captured within the Trust system, confirming availability of these routinely collected outpatient data for audit and research.

Conclusion Electronic template development tailored to the requirements of a specialist outpatient clinic facilitates capture of routinely collected data within the Cerner EHR. These data can be made available for audit and research. They can also be used to enhance communication by populating structured reports for immediate delivery to patients and GPs.

  • health informatics
  • cardiology
  • information technology

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

https://doi.org/10.1136/bmjopen-2017-019790

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    Footnotes

    • Contributors NB designed data collection tools, monitored data collection for the whole study, wrote the statistical analysis plan, cleaned and analysed the data, and drafted and revised the paper. RAA and RW designed data collection tools (creation of the PowerForm and usage over the period of the study) and cleaned and analysed the data. MKDH designed data collection tools (surveys of feedback) and cleaned and analysed the data. MRB and JR designed data collection tools and cleaned and analysed the data. AML designed data collection tools (download of data from PowerForms) and cleaned and analysed the data. SJ and CG designed data collection tools (creation of PowerForm and SmartTemplate) and cleaned and analysed the data. AT designed data collection tools, monitored data collection for the whole study, cleaned and analysed the data, and drafted and revised the paper. He is a guarantor. All authors provided intellectual input into the draft of the manuscript, and read, edited and approved the final version.

    • Funding This study was funded by The Guttmann Academic Partnership hosted by UCLPartners. MKDH was in part supported by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care North Thames at Bart’s Health NHS Trust. NB had financial support from the Isaac Schapera Trust Fund for the submitted work. AML received support from the NIHR Cardiovascular Biomedical Research Unit at Barts Health NHS Trust and from the “SmartHeart” EPSRC programme grant (EP/P001009/1). AT and MRB received funding from the Medical Research Council (MR/K006584/1).

    • Competing interests None declared.

    • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

    • Ethics approval According to institutional policy and the UK Health Departments’ Research Ethics Service, this work met criteria for clinical service provision exempt from ethics review.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement All data generated or analysed during this study are included in this published article (and its supplementary information files).