Using adaptive turnaround documents to electronically acquire structured data in clinical settings.

Using Adaptive Turnaround Documents to Electronically Acquire Structured Data in Clinical Settings Paul G. Biondich, M.D., M.S., Vibha Anand, M.S., Stephen M. Downs, M.D., M.S., Clement J. McDonald, M.D. Regenstrief Institute for Health Care and Children’s Health Services Research, Indiana University School of Medicine, Indianapolis, IN computer users often hinders this form of direct data entry [6]. Abstract: We developed adaptive turnaround documents (ATDs) to address longstanding challenges inherent in acquiring structured data at the point of care. These computer-generated paper forms both request and receive patient tailored information specifically for electronic storage. In our pilot, we evaluated the usability, accuracy, and user acceptance of an ATD designed to enrich a pediatric preventative care decision support system. The system had an overall digit recognition rate of 98.6% (95% CI: 98.3 to 98.9) and a marksense accuracy of 99.2% (95% CI: 99.1 to 99.3). More importantly, the system reliably extracted all data from 56.6% (95% CI: 53.3 to 59.9) of our pilot forms without the need for a verification step. These results translate to a minimal workflow burden to end users. This suggests that ATDs can serve as an inexpensive, workflow-sensitive means of structured data acquisition in the clinical setting. Introduction: Data within an electronic medical record (EMR) is most useful when stored in a structured format. We focus significant developmental resources within our own health care network to develop interfaces which efficiently capture and structure such information [1]. We have had some success in our efforts [2, 3], but are continually evaluating new ways to address the longstanding challenge of structured data entry. Additional obstacles exist when attempting to directly acquire structured data from patients and support staff prior to clinical encounters. The body of research that focuses on non-practitioner data acquisition highlights some of these particular challenges. Not only are most computer-based systems expensive and difficult to maintain, but their relatively fixed location impedes workflow [4, 5]. More importantly, the “digital divide” that exists among novice We attempt to address these challenges by utilizing computer-interpreted paper forms. Paper continues to be widely used because it is an excellent transactional medium. It’s familiar, easy to work with, fully enabled, portable, and cheap [7]. Our previous research [8] has demonstrated the potential utility optical character recognition (OCR) technology would have when extended to the patient population. Advances in both computer hardware and OCR software packages allow us to utilize the many positive transactional features of paper while ultimately storing handwritten responses in a structured electronic format. In this way, paper is used as a turnaround document, which has the sole purpose of capturing information for electronic storage. The paper form that we have designed has grown into a truly adaptive interface with computer systems. Patient specific content and prompts can be dynamically generated by a rules engine and printed on paper forms in real-time. Hand entered responses can then be automatically read back into the computer system through formsbased OCR software and referenced back to the patient’s EMR. As part of our pilot evaluation of this technology, we examined how these adaptive turnaround documents (ATDs) would function in the real-world clinical setting of a high volume outpatient pediatric clinic. In particular, we wanted to measure the utilization rates of the forms, the accuracy of the recognition software, and the extra work requirements for the end users. Background: The Child Health Improvement through Computer Automation (CHICA) system is designed to provide preventative care decision support and easy access to pertinent clinical data AMIA 2003 Symposium Proceedings − Page 86 in outpatient clinical settings [9]. This paperbased system ultimately provides pediatricians with a highly tailored encounter form which provides reminders based on the patient’s specific health status. This same form also serves as the documentation of the visit. We designed this system to generate an ATD for both the parents and support staff upon a child’s arrival to the clinic, so that we could deliver high quality, real-time data to the system for improved decision support. Methods: We obtained approval for the study from the Indiana University Institutional Review Board which also serves as the IRB for Wishard Hospital and the Indiana University Medical Group (IUMG) clinics. Form Design: Sensitive to the work flow demands of a busy pediatric practice, the pilot form design was based mostly on the input of its end users (figure 1). The document is divided into two main sections. The top section is dedicated to the nursing and support staff. There is a section for patient identification, and the remainder of this area consists of fields for numeric value entry. Each potential measurement has implied units and a series of large boxes to capture each digit of the recorded value. There is also an optional “required” flag for each field that alerts staff when particular measurements are necessary to either address routine well care requirements at a given age or to readdress previously abnormal values. The bottom section consists of a questionnaire for direct patient entry. The CHICA database contains a large set of patient questions which are represented as rules in Arden Syntax. This allows us to assign priority scoring and conditional logic to narrow the scope of potential Figure 1: A completed ATD. This pre-screening form was developed to better inform our pediatric decision support system at the point of care. The top section is specific to nurses and support staff. Vital signs and other measurements are recorded in their associated field on the form. The bottom section is directed toward the particular patient. Up to twenty questions tailored to the patient’s medical history are answered by filling in the corresponding bubble located to the left of each question. AMIA 2003 Symposium Proceedings − Page 87 questions that are asked. As a result, the parent or adolescent is given the twenty most clinically relevant questions upon arrival to the clinic. They are asked to denote their answers by filling in the corresponding “yes” or “no” answer bubble with a pen or pencil. The form generation software encodes formspecific identifiers along the bottom of the page. These barcodes are used to link the particular ATD back to the corresponding patient database record once it’s scanned. We created a template of this design using the “Designer” application within the Teleform software suite by Cardiff Software (Vista, California, http://www.cardiff.com).. Data Collection: We conducted the study in the IUMG Pediatric Clinics, located in downtown Indianapolis. The pilot ATDs were auto (...truncated)