title: Implementing a Real-Time Electronic Data Capture System to Improve Clinical Documentation in Radiation Oncology.
abstract: OBJECTIVE
  Electronic health records (EHRs) often store information as unstructured text, whereas electronic data capture (EDC) using structured fields is common in clinical trials. We implemented a web-based EDC system for routine clinical care, and describe our experience piloting this system for breast cancer patients receiving radiation therapy.
  
  
  METHODS
  Our institution uses dictation for clinical documentation in a centralized EHR; a separate radiation therapy-specific record-and-verify system contains prescriptions, schedules, and treatment documentation. The implemented EDC system collects patient, tumor, and treatment characteristics using structured data fields and merges it with data from the radiation therapy system to generate template-based notes in the EHR. Mean times to create notes using dictation versus EDC were compared. Users were surveyed about their experience. Acute toxicities were captured using the EDC system, and reported.
  
  
  RESULTS
  The EDC system has been used by 25 providers for 1,296 patients. In the most recent month, 978 clinical notes were generated. The average clinician documentation time over a typical course of radiation was reduced from 22.4 minutes per patient with dictation, to 7.1 minutes with EDC. The user survey response rate was 100%, with 92% of respondents being either satisfied or very satisfied with their experience. The worst acute toxicities were mostly grade 1 (51%) or grade 2 (43%), with rare grade 3 (3%) events.
  
  
  CONCLUSIONS
  We implemented an EDC system for routine clinical use in the breast radiation therapy service that resulted in significant time-savings for clinical documentation and prospective population of a database to facilitate outcomes reporting.
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Hubert Y
authors.initials: HY
authors.lastname: Pan
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Simona F
authors.initials: SF
authors.lastname: Shaitelman
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: George H
authors.initials: GH
authors.lastname: Perkins
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Pamela J
authors.initials: PJ
authors.lastname: Schlembach
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Wendy A
authors.initials: WA
authors.lastname: Woodward
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address: bsmith3@mdanderson.org.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Smith
mesh_terms: D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000532:radiotherapy*; D003199:Computer Systems; D004282:Documentation / Q000379:methods*; D057286:Electronic Health Records / Q000458:organization & administration*; D005260:Female; D006801:Humans; D016247:Information Storage and Retrieval / Q000379:methods*; D020407:Internet / Q000458:organization & administration; D062527:Meaningful Use / Q000458:organization & administration; D008498:Medical Record Linkage / Q000379:methods; D018787:Radiation Oncology; D011873:Radiology Information Systems / Q000458:organization & administration*; D013781:Texas
keywords: Radiation oncology; electronic data capture; electronic health records