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

Area of Science:

• Health Informatics
• Clinical Data Management
• Electronic Health Records

Background:

• Electronic health records (EHRs) present opportunities for research and patient care enhancement.
• Extracting usable data from extensive clinical notes in EHRs is challenging, labor-intensive, and costly.
• Existing data transformation strategies often present significant burdens on clinical workflows.

Purpose of the Study:

• To detail the development and implementation of a postencounter form (PEF) system within an EHR.
• To address challenges in utilizing EHR data by creating a system with limited burden on clinical workflows.
• To assess the effectiveness and utility of the PEF system in a clinical setting.

Main Methods:

• Collaborative development of the PEF system integrated into the EHR at the Road Home Program, Rush University Medical Center.
• Implementation of the PEF system to capture data from clinical encounters.
• Monitoring of PEF completion rates and data generation over time.

Main Results:

• The PEF system achieved over 98% completion rate across all clinical encounters within 5 months of implementation.
• Generated over 325,188 unique, readily-accessible data points in under 4 years.
• The PEF system has been deployed to other settings, indicating broader clinical utility.

Conclusions:

• The postencounter form (PEF) system is an effective tool for capturing structured data from EHRs.
• This system significantly enhances data accessibility for research and clinical improvement with minimal workflow impact.
• The PEF system demonstrates potential for widespread clinical application beyond its initial setting.