Smartphrases: Streamlining Electronic Documentation of Patient Data for CIBMTR Reporting and Clinical Research Compliance

BACKGROUND: The University of Virginia (UVA) Stem Cell Transplant (SCT) Program has performed 28 allogeneic and 39 autologous transplants since opening in January 2012. Full implementation of the electronic medical record (EMR) occurred in March 2011 at UVA. The EMR has been the only source of patient documentation since SCT Program inception. The SCT Program has experienced inefficiencies in CIBMTR data extraction and intermittent noncompliance with clinical research documentation. SmartPhrases (SP) were developed to streamline patient care documentation, improve data extraction, and increase clinical trial documentation compliance.

METHODS: A working group that included a physician, transplant coordinator, data manager, and clinical research coordinator identified information required for CIBMTR reporting and clinical trial documentation. The group evaluated EMR progress notes to identify clinical research and CIBMTR documentation that is routinely missing during data extraction. The group decided SP functionality of the EMR had the potential to provide convenient and consistent data prompts to ensure efficient data extraction and consistent documentation. SP allow you to type a few characters that automatically expand into a custom phrase, paragraph, or template previously created (Figure 1).

RESULTS: A SP database was created to provide prompts for 5 areas of patient care: consenting, transplant work up, transplant data, post-transplant follow up, and other. The group created SP texts and presented to the SCT Program for implementation in July 2012. A total of 36 SP were implemented, of which 20 are being consistently used in the areas of consenting, transplant work-up, and transplant data. In addition, 5 SP are used in the SCT Program Standard Operating Procedures. The efficiency in CIBMTR pre-transplant essential data (TED) and post-TED extraction has improved. Since the implementation of SP, informed consent documentation compliance has increased. However, SP have not been universally adopted, and not all SP are being utilized. No SP in the area of transplant follow up are being utilized. SCT Program members have indicated the need to consolidate transplant data SP for ease of use, and to fine tune transplant work up SP to improve data prompts.

CONCLUSION: Initial assessments demonstrate the feasibility of incorporating SP technology into patient care workflows. Integration of SP into our standard practices has improved CIBMTR data extraction, documentation of patient information, and Good Clinical Practices conduct of clinical research.  The SP database should be revised to incorporate team feedback and encourage usage, particularly in the area of transplant follow up. We intend to audit the use of SP and identify barriers to 100% practice.

Figure 1: SP automated expansion into customary text