ArticleJMIR medical informatics2020
Implementing Structured Clinical Templates at a Single Tertiary Hospital: Survey Study.
Article in JMIR medical informatics, 2020. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 5 papers, 1 of them a synthesis that pooled it.
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Who cites it
5 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Safety and usability of oncology information systems - a systematic review.Frontiers in oncology · 2024Pooled it
- Clinicians' Perspectives on the Telehealth Serious Illness Care Program for Older Adults With Myeloid Malignancies: Single-Arm Pilot Study.JMIR formative research · 2024Article
- Improving quality of care by standardising patient data collection in electronic medical records in an oncology department in Spain.BMJ open quality · 2024Article
- Additional Value From Free-Text Diagnoses in Electronic Health Records: Hybrid Dictionary and Machine Learning Classification Study.JMIR medical informatics · 2024Article
- Establishing an effective clinical data collecting tool for optimal evaluation of native and allograft renal biopsies.Heliyon · 2023Article
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4 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundElectronic health record (EHR) systems have been widely adopted in hospitals. However, since current EHRs mainly focus on lowering the number of paper documents used, they have suffered from poor search function and reusability capabilities. To overcome these drawbacks, structured clinical templates have been proposed; however, they are not widely used owing to the inconvenience of data entry.
objectiveThis study aims to verify the usability of structured templates by comparing data entry times.
methodsA Korean tertiary hospital has implemented structured clinical templates with the modeling of clinical contents for the last 6 years. As a result, 1238 clinical content models (ie, body measurements, vital signs, and allergies) have been developed and 492 models for 13 clinical templates, including pathology reports, were applied to EHRs for clinical practice. Then, to verify the usability of the structured templates, data entry times from free-texts and four structured pathology report templates were compared using 4391 entries from structured data entry (SDE) log data and 4265 entries from free-text log data. In addition, a paper-based survey and a focus group interview were conducted with 23 participants from three different groups, including EHR developers, pathology transcriptionists, and clinical data extraction team members.
resultsBased on the analysis of time required for data entry, in most cases, beginner users of the structured clinical templates required at most 70.18% more time for data entry. However, as users became accustomed to the templates, they were able to enter data more quickly than via free-text entry: at least 1 minute and 23 seconds (16.8%) up to 5 minutes and 42 seconds (27.6%). Interestingly, well-designed thyroid cancer pathology reports required 14.54% less data entry time from the beginning of the SDE implementation. In the interviews and survey, we confirmed that most of the interviewees agreed on the need for structured templates. However, they were skeptical about structuring all the items included in the templates.
conclusionsThe increase in initial elapsed time led users to hold a negative opinion of SDE, despite its benefits. To overcome these obstacles, it is necessary to structure the clinical templates for optimum use. In addition, user experience in terms of ease of data entry must be considered as an essential aspect in the development of structured clinical templates.
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