Implementing Structured Clinical Templates at a Single Tertiary Hospital: Survey Study.

Area of Science:

• Health Informatics
• Clinical Data Management
• Human-Computer Interaction

Background:

• Electronic health record (EHR) systems lack efficient search and reusability due to poor data structure.
• Structured clinical templates offer a solution but face challenges with data entry convenience.
• Current EHRs primarily focus on reducing paper, neglecting data usability.

Purpose of the Study:

• To evaluate the usability of structured clinical templates by comparing data entry times.
• To assess the impact of structured templates on the efficiency of clinical data management.
• To identify user perceptions and challenges associated with structured data entry.

Main Methods:

• Comparison of data entry times between free-text and structured templates using log data from a Korean tertiary hospital.
• Development and application of 492 clinical content models across 13 clinical templates in EHRs.
• Conducting surveys and focus group interviews with 23 participants from diverse healthcare roles.

Main Results:

• Beginner users initially experienced longer data entry times (up to 70.18% more) with structured templates.
• With practice, users entered data faster than free-text (1.23 to 5.42 minutes quicker).
• Well-designed templates, like those for thyroid cancer pathology reports, showed immediate time savings (14.54%).

Conclusions:

• Initial increases in data entry time can negatively impact user perception of structured data entry (SDE).
• Optimizing clinical template structure is crucial for maximizing the benefits of SDE.
• Prioritizing user experience and ease of data entry is essential for successful structured template development and EHR improvement.