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Use of an Electronic Medical Record “Dotphrase” Data Template for a Prospective Head Injury Study

Author(s): Steven R. Offerman | Adina S. Rauchwerger | Daniel K. Nishijima | Dustin W. Ballard | Uli K. Chettipally | David R. Vinson | Mary E. Reed | James F. Holmes

Journal: Western Journal of Emergency Medicine
ISSN 1936-900X

Volume: 14;
Issue: 2;
Start page: 109;
Date: 2013;
Original page

Keywords: emergency medicine | emergency department | electronic medical record | dotphrase

Introduction: The adoption of electronic medical records (EMRs) in emergency departments (EDs)has changed the way that healthcare information is collected, charted, and stored. A challenge forresearchers is to determine how EMRs may be leveraged to facilitate study data collection efforts. Ourobjective is to describe the use of a unique data collection system leveraging EMR technology and tocompare data entry error rates to traditional paper data collection.Methods: This was a retrospective review of data collection methods during a multicenter studyof ED, anti-coagulated, head injury patients. On-shift physicians at 4 centers enrolled patients andprospectively completed data forms. These physicians had the option of completing a paper data formor an electronic “dotphrase” (DP) data form. A feature of our Epic®-based EMR is the ability to useDPs to assist in medical information entry. A DP is a preset template that may be inserted into the EMRwhen the physician types a period followed by a code phrase (in this case “.ichstudy”). Once the studyDP was inserted at the bottom of the electronic ED note, it prompted enrolling physicians to answerstudy questions. Investigators then extracted data directly from the EMR.Results: From July 2009 through December 2010, we enrolled 883 patients. DP data forms were usedin 288 (32.6%; 95% confidence interval [CI] 29.5, 35.7%) cases and paper data forms in 595 (67.4%;95% CI 64.3, 70.5%). Sixty-six (43.7%; 95% CI 35.8, 51.6%) of 151 physicians enrolling patients usedDP data entry at least once. Using multivariate analysis, we found no association between physicianage, gender, or tenure and DP use. Data entry errors were more likely on paper forms (234/595,39.3%; 95% CI 35.4, 43.3%) than DP forms (19/288, 6.6%; 95% CI 3.7, 9.5%), difference in error rates32.7% (95% CI 27.9, 37.6%, P < 0.001).Conclusion: DP data collection is a feasible means of data collection. DP data forms maintain all studydata within the secure EMR environment, obviating the need to maintain and collect paper data forms.This innovation was embraced by many of our emergency physicians and resulted in lower data entryerror rates.

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