Improving the Accuracy of Electronic Patient Records
8 October 2015 Last updated:
22 October 2015
Improving the Accuracy of Electronic Patient Records
This project implemented training and staff communication to improve the accuracy and amount of data collected in the electronic patient record (ePR), with a focus on pathology International Classification of Diseases (ICD) code, disease stage, tumour laterality, date of diagnosis, performance status and acute radiation toxicity.
To ensure that all patients starting a course of radiation therapy (RT) at Crown Princess Mary Cancer Centre (CPMCC) have an accurate and complete ePR, to meet quality assurance audit requirements and improve patient outcomes.
- Minimises the risk of errors, as the information required to make decisions about diagnosis and treatment of a patient is held in one record and available to all staff at CPMCC involved in their care.
- Enables a real-time review of RT plans.
- Reduces the frustration of recording the same information multiple times.
- Improves efficiency of staff, who can seek information from one source during patient consultations.
- Allows clinicians to track RT toxicity and provide to all doctors in a weekly summary, which can result in positive changes to patient management, such as less frequent reviews during treatment.
- Allows radiation oncologists to review more cases for peer-review audit and feedback (revalidation audit), meeting Royal Australian and New Zealand College of Radiologists Continuing Professional Development requirements and Radiation Oncology Practice Standards, which are currently voluntary.
- Facilitates research activities, with ongoing peer-review that will identify quality improvement activities and allow CPMCC to quickly and accurately assess the number of patients suitable for new trials (tumour pathology, stage and patient performance status are standard eligibility criteria), to avoid opening trials that cannot recruit adequate patient numbers.
- Allows rapid reporting of core tumour and patient data to Cancer Institute NSW and NSW Ministry of Health (Radiotherapy Management Information System).
Start date: October 2014.
Implementation - The initiative is currently being implemented.
The collection of patient information is required for radiation oncology quality assurance audits, as well as reports for Cancer Institute NSW and other bodies intending to improve patient outcomes. It is also important for clinicians’ use during patient consultations, as well as research opportunities.
Prior to this project, different groups of staff within CPMCC (coders, radiation oncologists, radiation therapists and a quality officer) were collecting patient-related data in different places for different purposes. There was no apparent communication between the groups and little awareness of who was collecting data for which purpose. Data was also collected by multidisciplinary team coordinators, although it was not clear to oncologists where this data was stored or for what purpose.
It was recommended that the recently-introduced ePR act as the repository for relevant information required by various groups. At the time, an inability to extract information from the ePR meant that audits were time consuming, tedious and reduced the amount of patients that could be audited. The aim of the project was to improve the accuracy of data entered into the ePR and ensure it can be retrieved accurately and efficiently.
- A working group comprising radiation oncologists, radiation therapists, physicists, clinical trial coordinators, a multidisciplinary team coordinator, nursing unit manager, coder and information technology personnel identified the six core parameters required for audit and reporting. These were:
- pathology ICD code
- disease stage
- tumour site and laterality
- date of diagnosis
- patient performance status (Eastern Cooperative Oncology Group) at time of RT
- acute radiation toxicity.
- A baseline survey was distributed to radiation oncologists and radiation therapists in November 2014. Results suggested the main obstacles to data collection were lack of knowledge about the ePR software and lack of training.
- Baseline data was collected for the October 2014 cohort of patients starting a course of RT and compared to a cohort of patients starting RT in March and mid-May to mid-June 2015.
- Between data collection periods, radiation oncologists, registrars and fellows were educated about the initiative and trained to use the ePR appropriately. This included individual tutorials led by a radiation therapy ‘super user’ on how to input data into the ePR, as well as additional training by the ePR vendor to enable data managers to extract data from some fields.
- Fields in the ePR were adjusted by the information technology team based on feedback from oncologists and radiation therapists, to facilitate data collection and extraction.
- Scripts were developed to enable teams to efficiently run reports from the ePR.
- ‘Cheat Sheets’ were developed for doctors’ offices to encourage them to update the ePR and enter information in the correct fields.
- Monthly RT quality assurance and morbidity and mortality meetings provided an opportunity to gather feedback on the data collection process and drive improvements.
- RT quality assurance meetings were reorganised into tumour group streams and held weekly or fortnightly to enable teams to audit more cases.
- Western Sydney Local Health District
- Sydney West Cancer Network
- Crown Princess Mary Cancer Centre
- Nepean Cancer Care Centre
- Blacktown Cancer Centre (future initiative)
Clinical Leadership Program, Clinical Excellence Commission
A baseline survey collected information about radiation oncologists’ and radiation therapists’ knowledge of RT reporting and audit requirements in November 2014. This was repeated in July 2015. Baseline information was collected on the completeness and accuracy of core data in the patient ePR, as well as time required to extract this information.
Recording of the six chosen parameters overall improved during the study but the only parameters recorded in 100% of cases were tumour site, date of diagnosis and performance status. At the end of the project, laterality, pathology code and stage were still only reported in 40-60% of cases, in an easily extracted form. Acute RT toxicity was more poorly recorded even at the end of the project. Accuracy of recording information was poor at the start of the project and improved for all parameters except stage. The most accurately recorded parameter was performance status, although this achieved just over 80% rather than 100% by the end of the project. The most important and unplanned finding from the project was that the time to extract data from the ePR reduced from more than 20 hours to less than one hour.
Continuous improvement will occur through regular quality assurance meetings for radiation oncologists, which have been extended in number and scope as a result of this project.
- It has taken time and large group of people across cancer services to institute this change. Using everyone’s time respectfully is essential; using smaller group meetings rather than whole team meetings worked well.
- Some staff specialists claimed to be unaware that an initiative was underway to improve data in the ePR. It was clear that communication within the radiation oncology team across two (and soon three) sites needed improvement. This has led to a review of communications and recommendations for improvement, as well as greater awareness of these needs by the Director.
- Constant feedback and repetition to staff about the purpose of the initiative was necessary to engage everyone.
- Older staff specialists were not enthusiastic about the initiative, but younger staff along with registrars and fellows could see the value of change and their enthusiasm influenced others. Demonstration of how the initiative can help patients and their care has also improved engagement.
- Team members have different needs and commitments which can hamper engagement. The pace of a project can depend on a small number of people and in that case, time and encouragement needs to be devoted to these people.
- Competitiveness between cancer centre sites was healthy and led to the initiative being adopted at least 12 months earlier at Nepean Cancer Centre than expected.
- Lymberiou T, Glauszka S, Lee G et al. Predictors of breast radiotherapy plan modifications: Quality assurance rounds in a large cancer center. Radiotherapy & Oncology 2015; 114(1): 17-21.
- Faculty of Radiation Oncology. 2013 RANZCR Peer Review Audit Tool for Radiation Oncology: Version 2. The Royal Australian and New Zealand College of Radiologists; 2013.
- The Royal Australian & New Zealand College of Radiologists, The Faulty of Radiation Oncology, Australian Institute of Radiography, The Australian Institute of Physical Scientists & Engineers in Medicine. Tripartite Radiation Oncology Practice Standards; 2011.
- Manley S, Last A, Fu K et al. Regional cancer centre demonstrates voluntary conformity with the national Radiation Oncology Practice Standards. Journal of Medical Radiation Sciences 2015; 62(2): 152-159.
Dr Verity Ahern
Director, Sydney West Radiation Oncology Network
Western Sydney Local Health District
Phone: 02 9845 6489
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