Addressing the Need for Standardized Adverse Event (AE) Documentation within the Electronic Medical Record (EMR)

Addressing the Need for Standardized Adverse Event (AE) Documentation within the Electronic Medical Record (EMR)

 

Background: Accurate reporting of adverse events (AEs) facilitates analyses of new and approved therapies and is a federal requirement for clinical research. Healthcare professionals utilize the Common Terminology Criteria for Adverse Events (CTCAE) for this reporting. Our group reviewed the documentation within our hospital's EMR Epic® for a subset of over 100 transplants performed in 2012-2013 and collected data for toxicities meeting grades 3 or higher into a shared project-specific Access® database which is tied to the program BMT database. We then imported the CTCAE from a spreadsheet into drop down menus to decrease the likelihood of entry errors and to standardize the data at the time of first entry. As we reviewed the documentation in Epic®, it became clear that a lack of standardized terminology made it difficult for the consistent and accurate documentation of this data within the medical records.

Conclusion: As a result of our experience with our data project, current efforts are underway to have a dynamic and user-friendly CTCAE template with drop down menus and descriptive grading criteria built into Epic® for AE documentation by the clinical team. We anticipate that the CTCAE documentation capability currently being built will standardize and improve the documentation of this important data. In addition, because this template will utilize discrete fields, the BMT program will be able to run reports on documented toxicities with ease, thereby saving staff time and resources by eliminating the need for other team members to re-enter Epic® and search each record for this data.

Figure 1. Our project-specific database utilized CTCAE drop down menus to improve the collection of adverse event data. This capability will be enhanced and built into our EMR, Epic®.