- Email: [email protected]
Integrating patient questionnaire data into electronic medical records
Best Practice & Research Clinical Rheumatology Vol. 21, No. 4, pp. 649–652, 2007 doi:10.1016/j.berh.2007.01.001 available online at http://www.sciencedirect.com
4 Integrating patient questionnaire data into electronic medical records Martin Jan Bergman *
MD, FACR, FACP
Chief of Rheumatology Taylor Hospital, 8 Morton Avenue, Suite 304, Ridley Park, PA 19078-2210, USA
Electronic medical records allow the quick and easy incorporation of data into the medical records. By virtue of their design, questionnaire responses can be entered and used in the electronic environment with little or no effort on the part of the practicing physician. Data can be captured through various means, stored, and then viewed when the patient visits the office. Data can also be shared for use by other physicians in the practice or in large databases. Easy access and availability should allow for greater use of questionnaires by physicians, resulting in better patient care. Key words: electronic medical record; practice management; questionnaires.
The use of electronic medical records (EMR) has significantly changed the way physicians document and record critical patient information. In addition to keeping patient demographics and classic visit information (the ‘SOAP’ note), the record can now be expanded to include other data, such as laboratory results, X-rays, and other important information. One of these additional pieces of information is the results from a patient questionnaire. Exactly how this information is incorporated into the record will depend on both how the questionnaire data are obtained and the type of EMR being used. The questionnaire can be administered by a paper route, through a hand-held device (PDA), electronic pen, lap-top/workstation or even over the internet.1–4 The least expensive choice is to use a paper questionnaire. This modality is also the least intimidating to patients but it might result in a slight increase in the apparent workload for the physician/practitioner, particularly the time and effort needed to manually enter the data into the record. In practice, the patient is given a questionnaire when he or she arrives for the office visit and asked to complete it in the waiting
* Tel.: þ1 610 521 1701; Fax: þ1 610 521 9450. E-mail address: [email protected]. 1521-6942/$ - see front matter ª 2007 Elsevier Ltd. All rights reserved.
650 M. J. Bergman
room, prior to the office visit.5 Patient responses can then be scanned into the computer and kept on file to be viewed as a separate document, or the paper form can be saved in a ‘chart’ (maintaining an electronic and paper record is also known as a ‘hybrid’ record)or the scores can be manually entered into the EMR either as individual scores or as a composite, such as a routine assessment of patient index data (RAPID). The RAPID 3, comprising physical function, pain and global status, takes approximately 10 seconds for the physician/observer to score.6 The additional time to enter the values is also brief, taking < 5 seconds to complete. The use of the hybrid record makes sharing with other physicians more difficult, especially if more than one practice site is involved. However, maintaining the full-page questionnaire permits ‘eyeballing’ of the results, which allows for a non-quantifiable benefit that should not be underestimated. The most efficient method, purely in terms of time needed to obtain and enter the data, is to have the patient enter the data into an electronic device so that it can be transferred directly to the EMR. Using this option, the patient completes the questionnaire by answering the questions in a pre-formatted program. Using a PDA, the patient pages through all of the questions and selects the appropriate answer. Once complete, the device can be wired into the computer system or the results can be ‘beamed’ into the computer using an infrared device. This is one of the least expensive of the electronic options. However, the size of the device and its small screen make it relatively difficult for those who are arthritic, elderly or visually impaired to use. Furthermore, only limited queries can be collected on a palm device and, again, the loss of the ability of the physician to visually scan the patient responses needs to be considered. Desktop computers, laptops or notepad computers can be networked together and used in a similar fashion to PDAs. With the prices of desktops now in the US$500 range7, their use is no longer as prohibitive as it might have been in the past. Of course, the space needed to accommodate a desktop computer might make it a poor choice, especially where space is at a premium. Laptops and notepad computers take up considerably less space and the newer, larger screens make them a comfortable option for most patients and permit the visualization of the completed form. However, the cost of these computers is considerably higher (and the potential for theft becomes an issue as well). Even for a small office, the additional costs could run over US$5000.7 Internet-based EMRs are another option. The patient can be instructed to complete the questionnaire online, prior to the office visit, which means that the data are available to the physician at the time of the visit. This method, however, presupposes that the patient has access to the internet at home and that he or she remembers to complete the questionnaire prior to the scheduled appointment. In offices that use an internet-based EMR, this option could be used as an alternative to the networking option discussed later. It would be used in the same fashion but the information would be routed to the internet EMR site and stored there, rather than on the office computer. Regardless of the method chosen, the decision of how to enter the data into the EMR must also be addressed. The completed questionnaire could simply be stored as a file (paper or electronic), viewed, and scored by the physician at the beginning of the office visit. This, however, would defeat the major purpose for the use of the more expensive equipment: efficiency. A more efficient option is to have the program automatically score the questionnaire and upload the results into the EMR, where both the actual questionnaire responses and the scores could be viewed and evaluated by the physician. Of course, this adds another layer of complexity and expense, as the questionnaire software must
Integrating patient questionnaire data into electronic medical records 651
be made to score the data and the data must be synchronized with the EMR, which might require customization by the vendor. This increase in cost must be weighed against the increased efficiency of data collection, the elimination of paper forms, which require additional filing time and space, as well as the capacity to share the patient information with other practitioners in the practice. This is especially true for practices with multiple practice sites. The method chosen must also be determined by the ability and degree of computer sophistication of the patients being seen, as well as the space requirements, staffing issues and computer sophistication of the physician’s office. Once captured, the data obtained can be used in multiple ways, for multiple purposes. In terms of utility to the practicing physician, having access to this information can lead to relevant clinical decisions.8–10 However, the computerized data lend themselves nicely to linking to and sharing with databases. As an example, the data can be collected in a format used by one of the large databases (institutional databases, National Data Bank for Rheumatic Diseases, CORRONA, or university databases) and transmitted directly to these databases, or they can be reformatted to the database’s requirements before being transmitted. This allows for the rapid collection and dissemination of information regarding patient care, with the hope of obtaining valuable clinical information.11,12 Regardless of how they are obtained, data captured on the computer are valuable only if they are easily accessible and used by the clinician. How this is done depends less on the method by which the data are acquired than on the method whereby they are entered, stored, and viewed in the EMR. The physician can elect to simply enter the values, manually or electronically, during the patient visit. The results are then viewed at the time of the visit. Once entered, the results are also available for use by anyone else who has access to the patient record. This allows continuity of care in group practices where the patient might not see the same healthcare provider at each visit. Comparisons from previous visits are made by ‘paging up or down’ between visits (or looking at prior questionnaires, in the case of the hybrid record). This is the least technical, and probably the least expensive, approach but it is also the least efficient. Also, trends and changes are more difficult to appreciate, making the impact of the data collected somewhat less powerful. The method most familiar to physicians is the ‘flow sheet’. The data, for instance HAQ score, patient global assessment, or DAS28, are entered into a flow sheet at each visit and can be tracked, sequentially, for change. Many EMR programs allow the creation of ‘fields’ to capture data points – electronically or manually – and create a flow sheet. The flow sheet can then be printed or viewed electronically and used to assist in treatment decision-making. Graphing options add a visual dimension to flow sheets. Information entered into the flow sheet can be depicted as a graph and used to show trends, which can serve as indicators of progress or regression both to the physician and to the patient. Both of these functions – flow sheets and graphing – are available on the commercially available products, usually without the need for special programming.13 As with questionnaire completion, the decision of how the data are entered and viewed will depend on many factors, including cost, time, technical sophistication and interest of the physician. The best data and best equipment is of no use if the information is not viewed or interpreted. Regardless of the technique chosen, physicians using EMR should investigate the value of incorporating patient questionnaires into their daily practice routine and into their patient records.
652 M. J. Bergman
REFERENCES 1. Al Ubaydli M. Handheld computers. BMJ (Clinical Research ed.) 2004; 328: 1181–1184. 2. Williams CA, Templin T & Mosley-Williams AD. Usability of a computer-assisted interview system for the unaided self-entry of patient data in an urban rheumatology clinic. Journal of the American Medical Informatics Association 2004; 11: 249–259. 3. Bliven BD, Kaufman SE & Spertus JA. Electronic collection of health-related quality of life data: validity, time benefits, and patient preference. Quality of Life Research 2001; 10: 15–22. 4. Velikova G, Wright EP, Smith AB et al. Automated collection of quality-of-life data: a comparison of paper and computer touch-screen questionnaires. Journal of Clinical Oncology 1999; 17: 998–1007. 5. Pincus T, Yazici Y & Bergman M. Quantitative clinical rheumatology saving time and improving care with a multidimensional health assessment questionnaire: 10 practical considerations. The Journal of Rheumatology 2006; 33(3): 448–454. 6. Pincus T, Bergman M, Yazici Y et al. Time to Score Various Formats of a Multi-Dimensional Health Assessment Questionnaire (MDHAQ): Which Format Would Be Best for Standard Clinical Care?. Washington DC: American College of Rheumatology, 2006. Scientific Meeting–Abstract 1764. 7. http://www.dell.com [accessed 5 October 2006]. 8. Wolfe F & Cathey M. The assessment and prediction of functional disability in rheumatoid arthritis. The Journal of Rheumatology 1991; 18: 1298–1306. 9. Callahan L, Pincus T, Huston III J et al. Measures of activity and damage in rheumatoid arthritis: Depiction of changes and prediction of mortality over five years. Arthritis Care and Research 1997; 10: 381–394. 10. Sokka T, Hakkinen A, Krishnan E & Hannonen P. Similar prediction of mortality by the health assessment questionnaire in patients with rheumatoid arthritis and the general population. Annals of the Rheumatic Diseases 2004; 63: 494–497. 11. Wolfe F, Michaud K, Gefeller O & Choi HK. Predicting mortality in patients with rheumatoid arthritis. Arthritis and Rheumatism 2003; 48(6): 1530–1542. 12. Wolfe F, Freundlich B & Straus WL. Increase in cardiovascular and cerebrovascular disease prevalence in rheumatoid arthritis. The Journal of Rheumatology 2003; 30(1): 36–40. 13. http://www.statsystems.com [accessed 4 October 2006].
4 Integrating patient questionnaire data into electronic medical records Martin Jan Bergman *
MD, FACR, FACP
Chief of Rheumatology Taylor Hospital, 8 Morton Avenue, Suite 304, Ridley Park, PA 19078-2210, USA
Electronic medical records allow the quick and easy incorporation of data into the medical records. By virtue of their design, questionnaire responses can be entered and used in the electronic environment with little or no effort on the part of the practicing physician. Data can be captured through various means, stored, and then viewed when the patient visits the office. Data can also be shared for use by other physicians in the practice or in large databases. Easy access and availability should allow for greater use of questionnaires by physicians, resulting in better patient care. Key words: electronic medical record; practice management; questionnaires.
The use of electronic medical records (EMR) has significantly changed the way physicians document and record critical patient information. In addition to keeping patient demographics and classic visit information (the ‘SOAP’ note), the record can now be expanded to include other data, such as laboratory results, X-rays, and other important information. One of these additional pieces of information is the results from a patient questionnaire. Exactly how this information is incorporated into the record will depend on both how the questionnaire data are obtained and the type of EMR being used. The questionnaire can be administered by a paper route, through a hand-held device (PDA), electronic pen, lap-top/workstation or even over the internet.1–4 The least expensive choice is to use a paper questionnaire. This modality is also the least intimidating to patients but it might result in a slight increase in the apparent workload for the physician/practitioner, particularly the time and effort needed to manually enter the data into the record. In practice, the patient is given a questionnaire when he or she arrives for the office visit and asked to complete it in the waiting
* Tel.: þ1 610 521 1701; Fax: þ1 610 521 9450. E-mail address: [email protected]. 1521-6942/$ - see front matter ª 2007 Elsevier Ltd. All rights reserved.
650 M. J. Bergman
room, prior to the office visit.5 Patient responses can then be scanned into the computer and kept on file to be viewed as a separate document, or the paper form can be saved in a ‘chart’ (maintaining an electronic and paper record is also known as a ‘hybrid’ record)or the scores can be manually entered into the EMR either as individual scores or as a composite, such as a routine assessment of patient index data (RAPID). The RAPID 3, comprising physical function, pain and global status, takes approximately 10 seconds for the physician/observer to score.6 The additional time to enter the values is also brief, taking < 5 seconds to complete. The use of the hybrid record makes sharing with other physicians more difficult, especially if more than one practice site is involved. However, maintaining the full-page questionnaire permits ‘eyeballing’ of the results, which allows for a non-quantifiable benefit that should not be underestimated. The most efficient method, purely in terms of time needed to obtain and enter the data, is to have the patient enter the data into an electronic device so that it can be transferred directly to the EMR. Using this option, the patient completes the questionnaire by answering the questions in a pre-formatted program. Using a PDA, the patient pages through all of the questions and selects the appropriate answer. Once complete, the device can be wired into the computer system or the results can be ‘beamed’ into the computer using an infrared device. This is one of the least expensive of the electronic options. However, the size of the device and its small screen make it relatively difficult for those who are arthritic, elderly or visually impaired to use. Furthermore, only limited queries can be collected on a palm device and, again, the loss of the ability of the physician to visually scan the patient responses needs to be considered. Desktop computers, laptops or notepad computers can be networked together and used in a similar fashion to PDAs. With the prices of desktops now in the US$500 range7, their use is no longer as prohibitive as it might have been in the past. Of course, the space needed to accommodate a desktop computer might make it a poor choice, especially where space is at a premium. Laptops and notepad computers take up considerably less space and the newer, larger screens make them a comfortable option for most patients and permit the visualization of the completed form. However, the cost of these computers is considerably higher (and the potential for theft becomes an issue as well). Even for a small office, the additional costs could run over US$5000.7 Internet-based EMRs are another option. The patient can be instructed to complete the questionnaire online, prior to the office visit, which means that the data are available to the physician at the time of the visit. This method, however, presupposes that the patient has access to the internet at home and that he or she remembers to complete the questionnaire prior to the scheduled appointment. In offices that use an internet-based EMR, this option could be used as an alternative to the networking option discussed later. It would be used in the same fashion but the information would be routed to the internet EMR site and stored there, rather than on the office computer. Regardless of the method chosen, the decision of how to enter the data into the EMR must also be addressed. The completed questionnaire could simply be stored as a file (paper or electronic), viewed, and scored by the physician at the beginning of the office visit. This, however, would defeat the major purpose for the use of the more expensive equipment: efficiency. A more efficient option is to have the program automatically score the questionnaire and upload the results into the EMR, where both the actual questionnaire responses and the scores could be viewed and evaluated by the physician. Of course, this adds another layer of complexity and expense, as the questionnaire software must
Integrating patient questionnaire data into electronic medical records 651
be made to score the data and the data must be synchronized with the EMR, which might require customization by the vendor. This increase in cost must be weighed against the increased efficiency of data collection, the elimination of paper forms, which require additional filing time and space, as well as the capacity to share the patient information with other practitioners in the practice. This is especially true for practices with multiple practice sites. The method chosen must also be determined by the ability and degree of computer sophistication of the patients being seen, as well as the space requirements, staffing issues and computer sophistication of the physician’s office. Once captured, the data obtained can be used in multiple ways, for multiple purposes. In terms of utility to the practicing physician, having access to this information can lead to relevant clinical decisions.8–10 However, the computerized data lend themselves nicely to linking to and sharing with databases. As an example, the data can be collected in a format used by one of the large databases (institutional databases, National Data Bank for Rheumatic Diseases, CORRONA, or university databases) and transmitted directly to these databases, or they can be reformatted to the database’s requirements before being transmitted. This allows for the rapid collection and dissemination of information regarding patient care, with the hope of obtaining valuable clinical information.11,12 Regardless of how they are obtained, data captured on the computer are valuable only if they are easily accessible and used by the clinician. How this is done depends less on the method by which the data are acquired than on the method whereby they are entered, stored, and viewed in the EMR. The physician can elect to simply enter the values, manually or electronically, during the patient visit. The results are then viewed at the time of the visit. Once entered, the results are also available for use by anyone else who has access to the patient record. This allows continuity of care in group practices where the patient might not see the same healthcare provider at each visit. Comparisons from previous visits are made by ‘paging up or down’ between visits (or looking at prior questionnaires, in the case of the hybrid record). This is the least technical, and probably the least expensive, approach but it is also the least efficient. Also, trends and changes are more difficult to appreciate, making the impact of the data collected somewhat less powerful. The method most familiar to physicians is the ‘flow sheet’. The data, for instance HAQ score, patient global assessment, or DAS28, are entered into a flow sheet at each visit and can be tracked, sequentially, for change. Many EMR programs allow the creation of ‘fields’ to capture data points – electronically or manually – and create a flow sheet. The flow sheet can then be printed or viewed electronically and used to assist in treatment decision-making. Graphing options add a visual dimension to flow sheets. Information entered into the flow sheet can be depicted as a graph and used to show trends, which can serve as indicators of progress or regression both to the physician and to the patient. Both of these functions – flow sheets and graphing – are available on the commercially available products, usually without the need for special programming.13 As with questionnaire completion, the decision of how the data are entered and viewed will depend on many factors, including cost, time, technical sophistication and interest of the physician. The best data and best equipment is of no use if the information is not viewed or interpreted. Regardless of the technique chosen, physicians using EMR should investigate the value of incorporating patient questionnaires into their daily practice routine and into their patient records.
652 M. J. Bergman
REFERENCES 1. Al Ubaydli M. Handheld computers. BMJ (Clinical Research ed.) 2004; 328: 1181–1184. 2. Williams CA, Templin T & Mosley-Williams AD. Usability of a computer-assisted interview system for the unaided self-entry of patient data in an urban rheumatology clinic. Journal of the American Medical Informatics Association 2004; 11: 249–259. 3. Bliven BD, Kaufman SE & Spertus JA. Electronic collection of health-related quality of life data: validity, time benefits, and patient preference. Quality of Life Research 2001; 10: 15–22. 4. Velikova G, Wright EP, Smith AB et al. Automated collection of quality-of-life data: a comparison of paper and computer touch-screen questionnaires. Journal of Clinical Oncology 1999; 17: 998–1007. 5. Pincus T, Yazici Y & Bergman M. Quantitative clinical rheumatology saving time and improving care with a multidimensional health assessment questionnaire: 10 practical considerations. The Journal of Rheumatology 2006; 33(3): 448–454. 6. Pincus T, Bergman M, Yazici Y et al. Time to Score Various Formats of a Multi-Dimensional Health Assessment Questionnaire (MDHAQ): Which Format Would Be Best for Standard Clinical Care?. Washington DC: American College of Rheumatology, 2006. Scientific Meeting–Abstract 1764. 7. http://www.dell.com [accessed 5 October 2006]. 8. Wolfe F & Cathey M. The assessment and prediction of functional disability in rheumatoid arthritis. The Journal of Rheumatology 1991; 18: 1298–1306. 9. Callahan L, Pincus T, Huston III J et al. Measures of activity and damage in rheumatoid arthritis: Depiction of changes and prediction of mortality over five years. Arthritis Care and Research 1997; 10: 381–394. 10. Sokka T, Hakkinen A, Krishnan E & Hannonen P. Similar prediction of mortality by the health assessment questionnaire in patients with rheumatoid arthritis and the general population. Annals of the Rheumatic Diseases 2004; 63: 494–497. 11. Wolfe F, Michaud K, Gefeller O & Choi HK. Predicting mortality in patients with rheumatoid arthritis. Arthritis and Rheumatism 2003; 48(6): 1530–1542. 12. Wolfe F, Freundlich B & Straus WL. Increase in cardiovascular and cerebrovascular disease prevalence in rheumatoid arthritis. The Journal of Rheumatology 2003; 30(1): 36–40. 13. http://www.statsystems.com [accessed 4 October 2006].