The Postencounter Form System: Viewpoint on Efficient Data Collection Within Electronic Health Records.

Philip Held,Michael B Brennan,Angela C Glover,Shannon Sims,Randy A Boley,Bala N Hota,Brian D Patty,Rebecca Van Horn,Mark H Pollack,Imran Desai,Walter G Faig,Alyson K Zalta,S Shafiq Rab,John A O'Toole,Niranjan S Karnik,Jawad Khan

doi:10.2196/17429

Abstract

Electronic health records (EHRs) offer opportunities for research and improvements in patient care. However, challenges exist in using data from EHRs due to the volume of information existing within clinical notes, which can be labor intensive and costly to transform into usable data with existing strategies. This case report details the collaborative development and implementation of the postencounter form (PEF) system into the EHR at the Road Home Program at Rush University Medical Center in Chicago, IL to address these concerns with limited burden to clinical workflows. The PEF system proved to be an effective tool with over 98% of all clinical encounters including a completed PEF within 5 months of implementation. In addition, the system has generated over 325,188 unique, readily-accessible data points in under 4 years of use. The PEF system has since been deployed to other settings demonstrating that the system may have broader clinical utility.

Highlights

BackgroundThe increasing use of electronic health records (EHR) across medical systems offers unique opportunities for research and quality improvement, and has the potential to significantly improve patient care [1]
In this case study we described the development and implementation of the postencounter form (PEF) system, which can be used to quickly and accurately capture clinically relevant data in a comprehensive yet efficient, adaptable, easy-to-use, accessible, and cost-effective way
Given the challenges associated with manual extraction of clinical progress note content or the use of more advanced and costly processes such as natural language processing (NLP), it was important to identify ways that clinical data could be captured and made immediately usable for analytic purposes

Summary

Background

The increasing use of electronic health records (EHR) across medical systems offers unique opportunities for research and quality improvement, and has the potential to significantly improve patient care [1]. Postencounter forms (PEFs) are flow sheets that can be attached to each clinical encounter and enable clinicians to quickly, accurately, and completely document relevant treatment information that can be extracted for analytic purposes. For behavioral health, this may include information about interventions used during sessions, minutes spent providing the interventions, clinical severity and progress, referrals provided, or termination status. The adaptability and convenience of PEFs allow organizations and providers to and accurately capture information relevant to their specific needs In this case report, we documented the development and implementation of the PEF system in the Road Home Program at Rush University Medical Center. This system was disseminated to other departments within the academic medical center

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Discussion