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The Development and Validation of Data Elements and Process Steps for an Electronic Health Record for Hand Surgery
Lauren M Shapiro1, James Chang2, Paige M Fox2
1Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, United States.
Journal of Hand and Microsurgery
|December 28, 2023
Summary
This study validated essential data elements and process steps for using electronic health records (EHRs) during hand surgery outreach trips to low- and middle-income countries (LMICs), aiming to enhance patient care quality and safety.
Area of Science:
- Global Surgery
- Health Informatics
- Medical Technology
Background:
- Low- and middle-income countries (LMICs) face a significant surgical burden.
- Surgical outreach to LMICs is increasing to address global health disparities.
- Electronic health records (EHRs) are crucial for care quality in high-income countries but lack standardized use in outreach settings.
Purpose of the Study:
- To validate essential data elements for EHR use in hand surgery outreach.
- To define standardized process steps for EHR implementation during global surgical trips.
- To establish a foundation for improving patient data management and safety in LMICs.
Main Methods:
- Conducted a literature review to identify existing data collection practices in surgical outreach.
- Developed a future-state process map for EHR data collection via literature review and expert interviews.
- Utilized a modified RAND/UCLA Delphi process with an expert consortium to evaluate data elements and process steps.
Main Results:
- Validated a comprehensive set of 65 data elements crucial for hand surgery outreach.
- Identified and validated 24 key process steps for EHR utilization in these settings.
- The validated elements and steps are designed for seamless integration into EHR systems.
Conclusions:
- The validated portfolio provides a robust framework for piloting EHRs in hand surgery outreach to LMICs.
- Implementing EHRs during outreach can significantly improve the safety and quality of patient care.
- These findings offer guidance for EHR development and implementation across various surgical specialties in global health initiatives.
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