title: Feasibility of integrating research data collection into routine clinical practice using the electronic health record.
abstract: OBJECTIVE
  The electronic health record is becoming central to routine medical practice and has the potential to facilitate large scale clinical research. We evaluated the completeness and accuracy of data collection using designated research fields integrated into a semistructured clinical note. We hypothesized that prospective research data collection as part of routine clinical charting is feasible, with a high rate of utilization (greater than 80%) and accuracy (kappa greater than 0.80).
  
  
  METHODS
  Infants with congenital hydronephrosis were followed prospectively at a single institution. Existing functionality in the electronic health record was used for data collection by creation of 28 different data elements captured from a hydronephrosis note or phrase template. Completeness (percent utilization) was calculated and accuracy was assessed by comparing the structured data to manual chart review. Comparisons were conducted using the chi-square test, with 2-tailed p values <0.05 considered statistically significant.
  
  
  RESULTS
  A total of 80 patients were eligible for manual chart review. Data were recorded through template use in 64 patients for an overall completeness of 80.0%. Of 28 elements 17 (60%) demonstrated "almost perfect" agreement (kappa greater than 0.80), and all variables reached at least "moderate" agreement (greater than 0.40).
  
  
  CONCLUSIONS
  Integrating research fields into routine clinical practice is feasible by using semistructured clinical templates within an electronic health record. High completion and accuracy rates were captured from a variety of fields within a hydronephrosis template.
authors.affiliation: Division of Urology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Pediatric Urology, Children's Hospital Colorado, Aurora, Colorado.
authors.forename: David J
authors.initials: DJ
authors.lastname: Chalmers
authors.affiliation: Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado.
authors.forename: Sara J
authors.initials: SJ
authors.lastname: Deakyne
authors.affiliation: Children's Outcomes Research Program, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
authors.forename: Marisa L
authors.initials: ML
authors.lastname: Payan
authors.affiliation: Children's Outcomes Research Program, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
authors.forename: Michelle R
authors.initials: MR
authors.lastname: Torok
authors.affiliation: Department of Pediatrics, Section of Pediatric Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Kahn
authors.affiliation: Division of Urology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Pediatric Urology, Children's Hospital Colorado, Aurora, Colorado. Electronic address: vijaya.vemulakonda@childrenscolorado.org.
authors.forename: Vijaya M
authors.initials: VM
authors.lastname: Vemulakonda
mesh_terms: D035843:Biomedical Research / Q000706:statistics & numerical data*; D003120:Colorado; D003625:Data Collection / Q000379:methods*; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006869:Hydronephrosis / Q000628:therapy*; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011446:Prospective Studies
keywords: data collection; electronic health records; research