BIO23-023: Supporting the Capture of Structured Data for Patients With Cancer Using Cancer-Specific Note Templates

Introduction: Clinical documentation is an integral part of patient care that supports provider communication, care coordination, billing, research, and other administrative tasks. Structured data elements in Electronic Health Records (EHR) are essential to leverage the automation and analytical potentials of EHR. Here, we report an initiative to improve structured data capture via development of SmartForms™ embedded in cancer-specific note templates. Methods: The initiative was conducted at University of Wisconsin Carbone Cancer Center. The EHR vendor is Epic® (Epic Systems; Verona, WI, USA). The study was exempt from Institutional Review Board review. We developed a note template aiming to promote a standardized note structure which utilizes patient and disease specific information available in the EHR and facilitates capturing of encounter specific structured data. The mCODE initiative was the reference to identify desirable structured data elements, and NoteWriter™ was the template of choice utilizing SmartForms™ to facilitate structured data capture. Pre-existing data could be pulled from the Problem List, Staging module, Oncology History, Active Treatment, and Therapy Plan. A cancer specific SmartForm™ was created to capture encounter level disease and treatment specific data elements such as treatment setting and intent, response to treatment, disease extent, and performance status. Initial versions of the templates were piloted by super users and re-engineered by a team of physician informaticists. Demonstration and training were provided to other faculty and practitioners before clinic wide implementation. The use of this note template is voluntary and not incentivized. After the initial launch in March 2019, we optimized the template in April 2020 to incorporate the required telemedicine-specific language and consenting. We also added a new smart form to support documentation of the Medical Decision Making elements for billing based on the Center for Medicare and Medicaid Services coding changes. Conclusion: With the implementation of cancer-specific note templates, we facilitated structured data capture on cancer-specific data such as treatment setting and intent, metastatic disease state, response to treatment, and performance status. Structured data can improve the accuracy of institutional reports, best practice advisory (BPA) and decision support tools, and identification of potential clinical trial options for patients with cancer.