Standardizing Care of Neuro-oncology Patients Using a Customized Electronic Medical Record Toolkit

Abstract

Objective: To develop and implement a customized toolkit within the electronic medical record (EMR) to standardize care of patients with brain tumors.

Patients and methods: We built a customized structured clinical documentation support toolkit to capture standardized data at office visits. We detail the process by which this toolkit was conceptualized and developed. Toolkit development was a physician-led process to determine a work flow and necessary elements to support best practices as defined by the neuro-oncology clinical team.

Results: We have developed in our EMR system a customized work flow for clinical encounters with neuro-oncology patients. In addition to providing a road map for clinical care by our neuro-oncology team, the toolkit is designed to maximize discrete data capture. Several hundred fields of discrete data are captured through the toolkit in the context of our routine office visits. We describe the characteristics of patients seen at our clinic, the adoption of the toolkit, current initiatives supported by the toolkit, and future applications.

Conclusion: The EMR can be effectively structured to standardize office visits and improve discrete data capture. This toolkit can be leveraged to support quality improvement and practice-based research initiatives at the point of care in a neuro-oncology practice.

Keywords: AED, antiepileptic drug; CES-D, Center for Epidemiologic Studies Depression scale; EDW, Enterprise Data Warehouse; EMR, electronic medical record; GAD-7, General Anxiety Disorder 7-item scale; MDASI-BT, MD Anderson Symptom Inventory-Brain Tumor; NorthShore, NorthShore University HealthSystem; SCDS, structured documentation support toolkit.

Figure

Screenshots of the neuro-oncology structured clinical documentation support toolkit within the electronic medical record. A-B, MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT). C-F, Short Test of Mental Status. G, Current medications. H, Prior diagnosis notes. HPI = history of present illness; MGMT = methyl guanine methyl transferase; ROS = review of symptoms; RX = medical prescription. © 2020 Epic Systems Corporation, used with permission.

Figure

Screenshots of the neuro-oncology structured clinical documentation support toolkit within the electronic medical record. A-B, MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT). C-F, Short Test of Mental Status. G, Current medications. H, Prior diagnosis notes. HPI = history of present illness; MGMT = methyl guanine methyl transferase; ROS = review of symptoms; RX = medical prescription. © 2020 Epic Systems Corporation, used with permission.

Figure

Screenshots of the neuro-oncology structured clinical documentation support toolkit within the electronic medical record. A-B, MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT). C-F, Short Test of Mental Status. G, Current medications. H, Prior diagnosis notes. HPI = history of present illness; MGMT = methyl guanine methyl transferase; ROS = review of symptoms; RX = medical prescription. © 2020 Epic Systems Corporation, used with permission.

Figure

Screenshots of the neuro-oncology structured clinical documentation support toolkit within the electronic medical record. A-B, MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT). C-F, Short Test of Mental Status. G, Current medications. H, Prior diagnosis notes. HPI = history of present illness; MGMT = methyl guanine methyl transferase; ROS = review of symptoms; RX = medical prescription. © 2020 Epic Systems Corporation, used with permission.