Automated Data Extraction: Merging Clinical Care with Real-Time Cohort-Specific Research and Quality Improvement Data

• Published in: Journal of pediatric surgery Vol. 52; no. 1; pp. 149 - 152
• Main Authors: Hebal, Ferdynand, Nanney, Elizabeth, Stake, Christine, Miller, M.L, Lales, George, Barsness, Katherine A
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.01.2017
• Subjects: Aged; Automated data extraction; Automatic Data Processing - standards; Biomedical Research; Clinical documentation; Documentation - standards; Electronic data capture; Electronic documentation; Electronic Health Records; Humans; Middle Aged; Pediatrics; Quality Improvement; Retrospective Studies; Surgery; Templated notes; templated notes; Electronic Data Capture; clinical documentation; Electronic documentation; Automated data extraction; Clinical documentation; Templated notes; Electronic data capture
• ISSN: 0022-3468; 1531-5037
• DOI: 10.1016/j.jpedsurg.2016.10.040

Abstract Background/purpose Although prohibitively labor intensive, manual data extraction (MDE) is the prevailing method used to obtain clinical research and quality improvement (QI) data. Automated data extraction (ADE) offers a powerful alternative. The purposes of this study were to 1) assess the feasibility of ADE from provider-authored outpatient documentation, and 2) evaluate the effectiveness of ADE compared to MDE. Methods A prospective collection of data was performed on 90 ADE-templated notes (N = 71 patients) evaluated in our bowel management clinic. ADE captured data were compared to 59 MDE notes (N = 51) collected under an IRB-exempt review. Sixteen variables were directly comparable between ADE and MDE. Results MDE for 59 clinic notes (27 unique variables) took 6 months to complete. ADE-templated notes for 90 clinic notes (154 unique variables) took 5 min to run a research/QI report. Implementation of ADE included eight weeks of development and testing. Pre-implementation clinical documentation was similar to post-implementation documentation (5–10 min). Conclusions ADE-templated notes allow for a 5-fold increase in clinically relevant data that can be captured with each encounter. ADE also results in real-time data extraction to a research/QI database that is easily queried. The immediate availability of these data, in a research-formatted spreadsheet, allows for rapid collection, analyses, and interpretation of the data. Level of Evidence IV Type of Study Retrospective Study