Electronic data capture systems significantly speed up documentation

While many electronic health records store data as unstructured text, an electronic data capture (EDC) system can save that data in a structured format and immediately populate patient databases. And implementing such an EDC system to capture data from clinical encounters can significantly speed up documentation, according to a recent study published by the Journal of the American College of Radiology.

Benjamin D. Smith, MD, and colleagues from the University of Texas MD Anderson Cancer Center implemented an EDC system into the facility’s department of radiation oncology, tracking its impact on the care of more than 1,200 breast cancer patients.

Overall, the team found that the system reduced documentation from 22.4 minutes per patient to 7.1 minutes per patient.

“With the current emphasis on delivering value-based health care, an EDC system such as the one described can assist in both reducing cost and quantifying value,” the authors wrote. “By extracting structured data from various systems, and reusing information previously entered in the EDC, to populate template-based notes, the time spent on documentation was reduced by 68 percent, or 15.3 minutes per patient. Assuming 200 patients are treated per physician per year, the absolute total time-savings using the EDC would be 50 hours per physician per year on documentation.”

Providers who used the EDC system reported high satisfaction overall.

A total of 25 providers used the system, and 23 of them said they were “satisfied” or “very satisfied.” Eighty-four percent of the providers rated the ease of data entry as “good” or “excellent.”

In addition, a majority of respondents said they “agreed” or “strongly agreed” that use of the EDC system improved documentation efficiency (96 percent), workflow (92 percent), and accuracy (84 percent).

Smith et al. added that instantly having patient data in a structured format has more benefits than saving providers time.

“An additional benefit of template-based note generation is the standardization of data capture across the practice,” the authors wrote. “Review of the collected data elements with billing specialists could help ensure that data capture is adequate to maintain compliance with billing codes and future standards, such as the International Classification of Diseases, 10th edition. In addition to basic outcomes reporting, the EDC database provides an opportunity for further analysis or initiatives. For example, a report on patient demographics lends insight into the practice’s patient population and practice patterns.”

The authors concluded the study by looking at the next step of their research: experimenting with EDC systems elsewhere within their institution.

“As this EDC implementation was specific to the breast radiation oncology service, a pertinent question is its generalizability to other disease sites and practices,” the authors wrote. “Our current plans are to use this initial experience and adopt similar customized templates for other disease sites within the radiation oncology department, and for integration with our new hospital electronic medical record.”