DEPARTMENT
Research
Data Collection Using the Electronic Health Record: Lessons Learned From the Chart Review Process Regena Spratling, PhD, RN, CPNP, & Erin Powers, BSN, RN
KEY WORDS Chart review, research, electronic health record
The patient chart provides a wealth of information on patient care for health care providers and for research and quality improvement projects. However, the chart review process poses some challenges. This article reports on challenges associated with a chart review focused on children who require medical technology including ventilators, tracheostomy tubes, and feeding Section Editor Rita H. Pickler, PhD, RN, PNP-BC, FAAN Center for Professional Excellence Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio Regena Spratling, Assistant Professor, Byrdine F. Lewis School of Nursing and Health Professions, Georgia State University, Atlanta, GA. Erin Powers, Graduate Student, Georgia State University, Atlanta, GA. Conflicts of interest: None to report. Correspondence: Regena Spratling, PhD, RN, CPNP, Byrdine F. Lewis School of Nursing and Health Professions, Georgia State University, Atlanta, GA 30342; e-mail: [email protected]. J Pediatr Health Care. (2015) 29, 294-296. 0891-5245/$36.00 Copyright Q 2015 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. Published online February 9, 2015. http://dx.doi.org/10.1016/j.pedhc.2015.01.005
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tubes and suggests ways to better use patient charts as a source of data. THE CHART REVIEW PROCESS Children who require medical technology are considered a small, vulnerable group within the larger population of children with special health care needs, but as a group they use a disproportionate amount of health care resources and have frequent emergency department (ED) visits and hospitalizations (Berry et al., 2009; Burns et al., 2010; Child and Adolescent Health Measurement Initiative, 2011; Simon et al., 2010). A retrospective chart review of patient information data from a pediatric health care system was conducted to examine factors affecting the health care utilization of these patients who require medical technology. Participants were children and adolescents in a technology-dependent pulmonary clinic in the southeastern United States. The children cared for in the clinic range in age from 4 months to 21 years. Sociodemographic and clinical factors affecting health care utilization during the past 3 years were examined for current active clinic patients. A data collection form, also known as a data abstraction form, was developed and used to collect specific data from the charts. Patient data included demographic information, medical diagnosis, prescribed technology, ED visits, and hospitalizations. The goal was to gain a better understanding of this understudied population and provide information for future interventions from an electronic health record. Data collection was primarily performed by trained graduate research assistants. The research assistants were approved as study personnel by the Institutional Review Board and completed required training by the health care system on technical (i.e., steps in accessing Journal of Pediatric Health Care
and reviewing charts) and ethical (i.e., confidentiality and protection of patient information) aspects of chart access. The principal investigator and research assistants were granted read-only access to the electronic health record. The principal investigator completed an initial review of 10 charts to confirm the feasibility of the data abstraction form and retrospective chart review, then trained the research assistants on the specific patient information data to collect and the various locations of data. The principal investigator maintained contact with the assistants in person and via phone and e-mail to address any questions or issues that arose with data collection. The privacy of participants was maintained through data collection in locations where patient information could not be witnessed or inadvertently intercepted or viewed. In addition, the data collected were limited to the minimum amount necessary to identify the factors affecting health care utilization by the participants. Confidentiality was maintained through the use of a patient-specific identification number on the data abstraction form. No participants’ data were identifiable by name at any stage of the data analysis or in the dissemination of study information. CHALLENGES IN THE CHART REVIEW PROCESS Challenges encountered in the chart review process created obstacles for data collection and slowed study progress. These issues were both anticipated and unanticipated. The challenges included (a) patient information entry variations by provider, (b) missing data and incomplete charts, (c) documentation not compiled in a single encounter, (d) issue with data access, remote access, and large data files, and (e) encounters outside of the health care system not captured in the chart review. Data Entry Variations by Provider Health care providers entered patient information while at the point of care for each patient in the health care system. Early in the chart review process, the authors and research assistants noted that providers’ data entries varied in where the data were located in the record, as well as in the use of terminology. These variations appeared to be dependent in part on the actual point of care— that is, hospital versus clinic. No policies existed to govern the format of provider information or the actual part of the chart where information was to be recorded. Thus, providers made their own choices about what patient information to enter and where to enter it. For example, some providers wrote a narrative summary of the patient encounter, whereas others selected from prepopulated choices for chief complaint and diagnosis. As a result, various chart locations needed to be accessed to obtain the data. Additionally, providers varied in the terms they used for the information. For example, one provider used the term ‘‘respiratory distress,’’ whereas another provider used the term ‘‘difficulty breathing.’’ www.jpedhc.org
These terms were recorded in the data abstraction form, and the data were analyzed individually. Additionally, the data were collapsed into the larger term ‘‘respiratory issues,’’ providing a broader view of common problems for this population of children. Slight differences existed between the structure of the electronic health record in the ED and the record structure in the remainder of the health care system, and thus ED notes differed from the other documentation in the chart. Compounding the challenge, during the chart review the ED underwent a computer system change in order to integrate the ED charting in the health care system as a whole; the change maintained some variations within the chart. Missing Data and Incomplete Charts A few charts had missing patient information data or were incomplete. Fortunately, these charts were rare, and the problem of missing data was addressed in the analysis. Goodman, Schindler, Washington, Bogie, and Ho (2014) and Brennan and Callaway (2014) also cited missing data as a challenge in their chart review of factors related to pressure ulcer development and in a chart review of breastfeeding mothers. Although researchers can develop protocols to address the challenges of missing data, perhaps more problematic is the challenge created for health care providers and patients when chart data are incomplete or inconsistently recorded. Documentation Not Compiled in a Single Encounter Some documentation was found in separate files in the chart. For example, radiology and operative reports were separate from the overall encounter chart. Also, any paper documents were scanned and loaded as separate encounters. Thus, a single encounter might contain multiple listings of various documents. A single encounter was considered an ED visit and/or hospitalization labeled by date of admission through date of discharge. These dates were not recorded to maintain deidentifiable data and protect the privacy of participants. Issues With Data Access, Remote Access, and Large Data Files For the chart review, the authors and research assistants were granted access to patient data files and remote access, using a secure connection and computer. This type of access was convenient and made it possible for the authors and research assistants to review charts simultaneously and address any issues with data collection. However, some large data files were difficult to access, particularly those that documented lengthy hospital stays, numerous ED visits, and/or numerous notes by various disciplines. Large data files were common among initial encounters when the tracheostomy was first placed or when there was a lengthy admission May/June 2015
295
after premature birth or injury. In these circumstances, extended periods were needed for downloads (as much as an hour), and often multiple attempts had to be made to successfully download the entire file. This problem occurred despite consultations with information technology experts at the health care system and the author’s university. Encounters Outside of Health Care System Not Captured One weakness of the chart review was the inability to capture data from health care encounters outside the health care system study site, which made a view of health care by a particular patient or group more of an estimate than an exact depiction. This situation also inhibits communication of patient health status outside of the health care system and continuity of care. RECOMMENDATIONS/STRATEGIES FOR THE FUTURE Lessons learned from this retrospective chart review highlight the need for a clear means of collecting or abstracting data for research and quality improvement using electronic health records and consistency in both patient information data entry by health care providers and data collection procedures by researchers. Abstracting Data for Research and Quality Improvement Using Electronic Health Records Much of the focus of the electronic health record is on the entry of patient information data by the health care provider, as it should be in order to provide the best care for patients. However, mechanisms should also be considered for abstracting the data once it is The use of a data entered for the purabstraction form poses of research and quality improvement. and consistent data Often few options exist collection beyond a manual decisions and review. Roth, Lim, Pevnick, Asch, and procedures is McGlynn (2009) noted critical to rigor in the lack of accessible chart review patient information that are considered studies. quality indicators in electronic health records. The use of a data abstraction form and consistent data collection decisions and procedures is critical to rigor in chart review studies. A collaborative approach to electronic health record development using information systems staff and health care providers, with development of a data dictionary, a list of terms, and definitions, has been found to be useful in enabling abstraction of data in trauma centers (D’Huyvetter, Lang, Heimer, and Cogbill, 2014). 296
Volume 29 Number 3
Consistency in Data Entry By Health Care Providers and Data Collection Procedures By Researchers Consistency in patient information data entry by health care providers is essential. Permitting the same data to be entered in multiple ways leads to wide variations and challenges not only in data collection for research purposes but in day-to-day care in the health care system. Goodman et al. (2014) found that the introduction of note templates reduced bias and variations in charting and reduced the incidence of missing data. Standardizing data entry processes and limiting variations in the chart can provide for ease of access and use of data. Harshberger and colleagues (2011) noted a high rate of complete documentation and satisfaction with electronic health records; however, they also noted a need for continual evaluation and enhancements for ease of use by health care providers. CONCLUSION Patient chart reviews are an effective source of data for research and quality improvement projects. However, challenges in the review process can hinder the discovery of meaningful data to advance knowledge and improve patient outcomes. The sharing of these challenges by researchers can aid others in the chart review process and in anticipating challenges in conducting research. REFERENCES Berry, J., Graham, D., Graham, R., Zhou, J., Putney, H., O’Brien, J., . Goldmann, D. (2009). Predictors of clinical outcomes and hospital resource use of children after tracheotomy. Pediatrics, 124(2), 563-572. Brennan, R., & Callaway, S. (2014). Innovations in practice: Supporting the breastfeeding dyad in labor & delivery. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 43(Suppl. 1), S62-S63. Burns, K., Casey, P., Lyle, R., Bird, T., Fussell, J., & Robbins, J. (2010). Increasing prevalence of medically complex children in US hospitals. Pediatrics, 126(4), 638-646. Child and Adolescent Health Measurement Initiative. (2011). Data Resource Center on Child and Adolescent Health. Retrieved from http://childhealthdata.org/ D’Huyvetter, C., Lang, A. M., Heimer, D. M., & Cogbill, T. H. (2014). Efficiencies gained by using electronic medical record and reports in trauma documentation. Journal of Trauma Nursing, 21(2), 68-71. Goodman, B. L., Schindler, A. A., Washington, M. M., Bogie, K. M., & Ho, C. H. (2014). Factors in rehospitalisation for severe pressure ulcer care in spinal cord injury/disorders. Journal of Wound Care, 23(4), 165-175. Harshberger, C. A., Harper, A. J., Carro, G. W., Spath, W. E., Hui, W. C., Lawton, J. M., & Brockstein, B. E. (2011). Outcomes of computerized physician order entry in an electronic health record after implementation in an outpatient oncology setting. Journal of Oncology Practice, 7(4), 233-237. Roth, C., Lim, Y., Pevnick, J., Asch, S., & McGlynn, E. (2009). The challenge of measuring quality of care from the electronic health record. American Journal of Medical Quality, 24(5), 385-394. Simon, T., Berry, J., Feudtner, C., Stone, B., Xiaoming, S., Bratton, S., . Srivastava, R. (2010). Children with complex chronic conditions in inpatient hospital settings in the United States. Pediatrics, 126(4), 647-655.
Journal of Pediatric Health Care
Research
Data Collection Using the Electronic Health Record: Lessons Learned From the Chart Review Process Regena Spratling, PhD, RN, CPNP, & Erin Powers, BSN, RN
KEY WORDS Chart review, research, electronic health record
The patient chart provides a wealth of information on patient care for health care providers and for research and quality improvement projects. However, the chart review process poses some challenges. This article reports on challenges associated with a chart review focused on children who require medical technology including ventilators, tracheostomy tubes, and feeding Section Editor Rita H. Pickler, PhD, RN, PNP-BC, FAAN Center for Professional Excellence Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio Regena Spratling, Assistant Professor, Byrdine F. Lewis School of Nursing and Health Professions, Georgia State University, Atlanta, GA. Erin Powers, Graduate Student, Georgia State University, Atlanta, GA. Conflicts of interest: None to report. Correspondence: Regena Spratling, PhD, RN, CPNP, Byrdine F. Lewis School of Nursing and Health Professions, Georgia State University, Atlanta, GA 30342; e-mail: [email protected]. J Pediatr Health Care. (2015) 29, 294-296. 0891-5245/$36.00 Copyright Q 2015 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. Published online February 9, 2015. http://dx.doi.org/10.1016/j.pedhc.2015.01.005
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tubes and suggests ways to better use patient charts as a source of data. THE CHART REVIEW PROCESS Children who require medical technology are considered a small, vulnerable group within the larger population of children with special health care needs, but as a group they use a disproportionate amount of health care resources and have frequent emergency department (ED) visits and hospitalizations (Berry et al., 2009; Burns et al., 2010; Child and Adolescent Health Measurement Initiative, 2011; Simon et al., 2010). A retrospective chart review of patient information data from a pediatric health care system was conducted to examine factors affecting the health care utilization of these patients who require medical technology. Participants were children and adolescents in a technology-dependent pulmonary clinic in the southeastern United States. The children cared for in the clinic range in age from 4 months to 21 years. Sociodemographic and clinical factors affecting health care utilization during the past 3 years were examined for current active clinic patients. A data collection form, also known as a data abstraction form, was developed and used to collect specific data from the charts. Patient data included demographic information, medical diagnosis, prescribed technology, ED visits, and hospitalizations. The goal was to gain a better understanding of this understudied population and provide information for future interventions from an electronic health record. Data collection was primarily performed by trained graduate research assistants. The research assistants were approved as study personnel by the Institutional Review Board and completed required training by the health care system on technical (i.e., steps in accessing Journal of Pediatric Health Care
and reviewing charts) and ethical (i.e., confidentiality and protection of patient information) aspects of chart access. The principal investigator and research assistants were granted read-only access to the electronic health record. The principal investigator completed an initial review of 10 charts to confirm the feasibility of the data abstraction form and retrospective chart review, then trained the research assistants on the specific patient information data to collect and the various locations of data. The principal investigator maintained contact with the assistants in person and via phone and e-mail to address any questions or issues that arose with data collection. The privacy of participants was maintained through data collection in locations where patient information could not be witnessed or inadvertently intercepted or viewed. In addition, the data collected were limited to the minimum amount necessary to identify the factors affecting health care utilization by the participants. Confidentiality was maintained through the use of a patient-specific identification number on the data abstraction form. No participants’ data were identifiable by name at any stage of the data analysis or in the dissemination of study information. CHALLENGES IN THE CHART REVIEW PROCESS Challenges encountered in the chart review process created obstacles for data collection and slowed study progress. These issues were both anticipated and unanticipated. The challenges included (a) patient information entry variations by provider, (b) missing data and incomplete charts, (c) documentation not compiled in a single encounter, (d) issue with data access, remote access, and large data files, and (e) encounters outside of the health care system not captured in the chart review. Data Entry Variations by Provider Health care providers entered patient information while at the point of care for each patient in the health care system. Early in the chart review process, the authors and research assistants noted that providers’ data entries varied in where the data were located in the record, as well as in the use of terminology. These variations appeared to be dependent in part on the actual point of care— that is, hospital versus clinic. No policies existed to govern the format of provider information or the actual part of the chart where information was to be recorded. Thus, providers made their own choices about what patient information to enter and where to enter it. For example, some providers wrote a narrative summary of the patient encounter, whereas others selected from prepopulated choices for chief complaint and diagnosis. As a result, various chart locations needed to be accessed to obtain the data. Additionally, providers varied in the terms they used for the information. For example, one provider used the term ‘‘respiratory distress,’’ whereas another provider used the term ‘‘difficulty breathing.’’ www.jpedhc.org
These terms were recorded in the data abstraction form, and the data were analyzed individually. Additionally, the data were collapsed into the larger term ‘‘respiratory issues,’’ providing a broader view of common problems for this population of children. Slight differences existed between the structure of the electronic health record in the ED and the record structure in the remainder of the health care system, and thus ED notes differed from the other documentation in the chart. Compounding the challenge, during the chart review the ED underwent a computer system change in order to integrate the ED charting in the health care system as a whole; the change maintained some variations within the chart. Missing Data and Incomplete Charts A few charts had missing patient information data or were incomplete. Fortunately, these charts were rare, and the problem of missing data was addressed in the analysis. Goodman, Schindler, Washington, Bogie, and Ho (2014) and Brennan and Callaway (2014) also cited missing data as a challenge in their chart review of factors related to pressure ulcer development and in a chart review of breastfeeding mothers. Although researchers can develop protocols to address the challenges of missing data, perhaps more problematic is the challenge created for health care providers and patients when chart data are incomplete or inconsistently recorded. Documentation Not Compiled in a Single Encounter Some documentation was found in separate files in the chart. For example, radiology and operative reports were separate from the overall encounter chart. Also, any paper documents were scanned and loaded as separate encounters. Thus, a single encounter might contain multiple listings of various documents. A single encounter was considered an ED visit and/or hospitalization labeled by date of admission through date of discharge. These dates were not recorded to maintain deidentifiable data and protect the privacy of participants. Issues With Data Access, Remote Access, and Large Data Files For the chart review, the authors and research assistants were granted access to patient data files and remote access, using a secure connection and computer. This type of access was convenient and made it possible for the authors and research assistants to review charts simultaneously and address any issues with data collection. However, some large data files were difficult to access, particularly those that documented lengthy hospital stays, numerous ED visits, and/or numerous notes by various disciplines. Large data files were common among initial encounters when the tracheostomy was first placed or when there was a lengthy admission May/June 2015
295
after premature birth or injury. In these circumstances, extended periods were needed for downloads (as much as an hour), and often multiple attempts had to be made to successfully download the entire file. This problem occurred despite consultations with information technology experts at the health care system and the author’s university. Encounters Outside of Health Care System Not Captured One weakness of the chart review was the inability to capture data from health care encounters outside the health care system study site, which made a view of health care by a particular patient or group more of an estimate than an exact depiction. This situation also inhibits communication of patient health status outside of the health care system and continuity of care. RECOMMENDATIONS/STRATEGIES FOR THE FUTURE Lessons learned from this retrospective chart review highlight the need for a clear means of collecting or abstracting data for research and quality improvement using electronic health records and consistency in both patient information data entry by health care providers and data collection procedures by researchers. Abstracting Data for Research and Quality Improvement Using Electronic Health Records Much of the focus of the electronic health record is on the entry of patient information data by the health care provider, as it should be in order to provide the best care for patients. However, mechanisms should also be considered for abstracting the data once it is The use of a data entered for the purabstraction form poses of research and quality improvement. and consistent data Often few options exist collection beyond a manual decisions and review. Roth, Lim, Pevnick, Asch, and procedures is McGlynn (2009) noted critical to rigor in the lack of accessible chart review patient information that are considered studies. quality indicators in electronic health records. The use of a data abstraction form and consistent data collection decisions and procedures is critical to rigor in chart review studies. A collaborative approach to electronic health record development using information systems staff and health care providers, with development of a data dictionary, a list of terms, and definitions, has been found to be useful in enabling abstraction of data in trauma centers (D’Huyvetter, Lang, Heimer, and Cogbill, 2014). 296
Volume 29 Number 3
Consistency in Data Entry By Health Care Providers and Data Collection Procedures By Researchers Consistency in patient information data entry by health care providers is essential. Permitting the same data to be entered in multiple ways leads to wide variations and challenges not only in data collection for research purposes but in day-to-day care in the health care system. Goodman et al. (2014) found that the introduction of note templates reduced bias and variations in charting and reduced the incidence of missing data. Standardizing data entry processes and limiting variations in the chart can provide for ease of access and use of data. Harshberger and colleagues (2011) noted a high rate of complete documentation and satisfaction with electronic health records; however, they also noted a need for continual evaluation and enhancements for ease of use by health care providers. CONCLUSION Patient chart reviews are an effective source of data for research and quality improvement projects. However, challenges in the review process can hinder the discovery of meaningful data to advance knowledge and improve patient outcomes. The sharing of these challenges by researchers can aid others in the chart review process and in anticipating challenges in conducting research. REFERENCES Berry, J., Graham, D., Graham, R., Zhou, J., Putney, H., O’Brien, J., . Goldmann, D. (2009). Predictors of clinical outcomes and hospital resource use of children after tracheotomy. Pediatrics, 124(2), 563-572. Brennan, R., & Callaway, S. (2014). Innovations in practice: Supporting the breastfeeding dyad in labor & delivery. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 43(Suppl. 1), S62-S63. Burns, K., Casey, P., Lyle, R., Bird, T., Fussell, J., & Robbins, J. (2010). Increasing prevalence of medically complex children in US hospitals. Pediatrics, 126(4), 638-646. Child and Adolescent Health Measurement Initiative. (2011). Data Resource Center on Child and Adolescent Health. Retrieved from http://childhealthdata.org/ D’Huyvetter, C., Lang, A. M., Heimer, D. M., & Cogbill, T. H. (2014). Efficiencies gained by using electronic medical record and reports in trauma documentation. Journal of Trauma Nursing, 21(2), 68-71. Goodman, B. L., Schindler, A. A., Washington, M. M., Bogie, K. M., & Ho, C. H. (2014). Factors in rehospitalisation for severe pressure ulcer care in spinal cord injury/disorders. Journal of Wound Care, 23(4), 165-175. Harshberger, C. A., Harper, A. J., Carro, G. W., Spath, W. E., Hui, W. C., Lawton, J. M., & Brockstein, B. E. (2011). Outcomes of computerized physician order entry in an electronic health record after implementation in an outpatient oncology setting. Journal of Oncology Practice, 7(4), 233-237. Roth, C., Lim, Y., Pevnick, J., Asch, S., & McGlynn, E. (2009). The challenge of measuring quality of care from the electronic health record. American Journal of Medical Quality, 24(5), 385-394. Simon, T., Berry, J., Feudtner, C., Stone, B., Xiaoming, S., Bratton, S., . Srivastava, R. (2010). Children with complex chronic conditions in inpatient hospital settings in the United States. Pediatrics, 126(4), 647-655.
Journal of Pediatric Health Care
