erecord and You: Using the Electronic Health Record for Clinical Research

Transcription

1 erecord and You: Using the Electronic Health Record for Clinical Research Adam Tatro, MS, RN Clinical Research Informatist Clinical and Translational Science Institute University of Rochester

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3 Agenda What an EHR can do for you What is new in the EHR for you Where things are going How is data stored in erecord Data flow considerations CFR Part 11 Compliance Available resources

4 Great Chart Chase Perspective

5 Question 1 What can the Electronic Health Record do for you as a clinical researcher?

6 What an EHR can do for you Collection of data Patient Reported Outcomes - MyChart Recruitment tools Referring patients for screening In Basket Communication tools To research staff and other clinicians In Basket Repository of clinical data i2b2 REDCap integration Direct feeds from erecord to REDCap

7 What an EHR can do for you Flag Patients for Research Associate patients to studies Notifications of ED visits Automatic notifications of ED admissions Mining of Notes SmartData Forms/ SmartData Elements

8 What is new in the EHR Chart Search Search like Google in a patient s chart Can search for: Problem Lists Notes Medications Labs Imaging Tab within Chart Review Procedure Tab within Chart Review Other Orders within Chart Review What cannot search for: Treatment Plans Therapy Plans Visit Diagnosis Consent Notes Other non-clinical notes that do not appear on the Notes tab of Chart Review, such as MAR notes, discharge instructions, or patient education comments

9 What is new in the EHR Find Information Fast with Chart Search

10 ORCA What is new in the EHR OR, Anesthesia, and Cardiology are in erecord PICIS and Pronto out erecord in More data in erecord Seeing the OR Schedule Anesthesia Record legible

11 ORCA What is new in the EHR Anesthesia Record legible Viewable in Chart Review, Patient Summary, & Snapshot

12 What is new in the EHR External study monitor access changes Deactivated between visits erecord External Reviewer Request ) At least 3 days before visit and include Study Name (include CTO#) Study Monitor name Dates of needed access Will need PI and Program Admin sign off for new studies or new monitors How Do I... > Get erecord Access? > External Auditors

13 What the future holds Recruitment Automated alerts through In Basket & MyChart More options for documenting Research note type Operational Support Reporting Workbench i.e. appointment Faxing Consent forms Dashboards Notifications of Inpatient Visits Automatic notifications of inpatient admissions

14 Question 2 Why can you get some data in some places and not in other?

15 How data is stored Discrete (structured) Non-Discrete (unstructured) Discrete = Clicks Non-Discrete = free text Patient level Problem Lists, Medications, Allergies Encounter level Assessments, Vitals Different Systems

16 Where data is Encounter Level Patient Summary, Snapshot, MAR, Synopsis Patient Level Problem List, Allergies, Chart Review, Results Review

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18 Question 3 Who can see what where?

19 Data flow considerations In erecord = all can see Images Cardiology studies Labs MyChart Labs/some imaging = immediately Pathology, pap smears, rest of imaging = 14 day delay Life altering (STDs, HIV, Pregnancy, Drug Screens) = blocked Other Epic institutions Care Everywhere Other institutions/ offices RHIO Insurance PCP offices

20 Question 4 Is erecord Part 11 Compliance?

21 CFR Part 11 Compliance Not CFR Part 11 compliance but EHRs are not assessed for CFR Part 11 compliance So send checklists to Research Help

22 Question 5 Where can I go for help?

23 Available resources Research Request Dashboard Research Help Desk ISD Help Desk

24 Available resources erecord Resource Library

25 Questions

26 Perspective Funny EHR Notes 1961 EHR