Electronic medical record: data collection and reporting for spinal cord injury

Spinal Cord Series and Cases, 2018 · DOI: https://doi.org/10.1038/s41394-018-0106-3 · Published: June 1, 2018

Spinal Cord Injury Healthcare Research Methodology & Design

Simple Explanation

This paper discusses the implementation of standardized spinal cord injury (SCI) data collection tools within the Epic Electronic Medical Record (EMR) system. The goal is to standardize data collection across different institutions to facilitate research and collaboration, both locally and globally. The authors describe how tools like the International Standards for Neurological Classification of SCI (ISNCSCI) and various International SCI Data Sets were integrated into Epic.

Study Duration

Not specified

Participants

Not specified

Evidence Level

Case Report

Key Findings

1
The ISNCSCI algorithm is accessible through a link within Epic, allowing clinicians to calculate the neurological level of injury.
2
The International SCI Core Data Set and 13 International SCI Basic Data Sets are nearly completely implemented in the Danish version of Epic as SmartForms.
3
Fourteen functional measures, including the Spinal Cord Independence Measure III, are implemented as flowsheets.

Research Summary

The study presents the implementation of International Spinal Cord Injury (SCI) Data Sets and other structured SCI tools in the Electronic Medical Record (EMR) Epic. The objective is to describe the implementation of SCI tools in Epic at Rigshospitalet, University of Hospital, Capital Region of Denmark. The possibility of entering international recognized structured data into the EMR gives better possibility for data sharing across SCI centers worldwide.

Practical Implications

Improved Data Sharing

Standardized data entry in EMRs facilitates data sharing among SCI centers globally, enabling more effective collaboration and research.

Streamlined Research

Collecting standardized data within the EMR simplifies data retrieval for administrative and research purposes, making multicenter trials more feasible.

Enhanced Clinical Practice

Consistent data collection using internationally recognized standards ensures comprehensive patient evaluation, monitoring, and treatment.

Study Limitations

1
Implementation of internationally recognized structured SCI data seems less common.
2
Some International SCI Basic Data Sets are either awaiting implementation or only partly implemented.
3
Interfacing with external registries and databases requires discussions with each organization’s Epic contacts and data infrastructure champions on the feasibility of such a data exchange.

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