JMIR Publications

ABSTRACT

Background:

Electronic health record (EHR) systems have been widely adopted in hospitals. However, since the current EHRs mainly focus on removing paper documents, they have suffered from poor search function and reusability capabilities. To overcome these drawbacks, structured clinical templates have been proposed; however, they are not widely used owing to the inconvenience of data entry.

Objective:

This study aims to verify the usability of structured templates by comparing data entry times.

Methods:

A Korean tertiary hospital has implemented structured clinical templates with modeling of clinical contents for the last four years. As a result, 1,238 clinical contents models, i.e., body measurements, vital signs, and allergies, have been developed and 492 models for 13 clinical templates, including pathology reports, were applied in EHR for clinical practice. Then, to verify the usability of the structured templates, data entry times from free texts and five structured pathology report templates were compared using 4,391 entries from structured data entry (SDE) log data and 4,265 entries from free text log data. In addition, a paper-based survey and a focus group interview were conducted with 23 participants from three different groups, including EHR developers, pathology transcriptionists, and clinical data extraction team members.

Results:

Based on the analysis of the data entry elapsed time, in most cases, the beginning users of the structured clinical templates required an average of 11.54% more time for data entry. However, as users became accustomed to the templates, they were able to enter data more quickly than free text entry (15.24%, 2 minutes 30 seconds). Interestingly, well-designed thyroid cancer pathology reports required 11.7% less data entry time from the beginning of the SDE implementation. In interviews and surveys, we confirmed that most of the interviewees agreed on the need for structured templates. However, they were skeptical about structuring all the items included in the templates.

Conclusions:

The increase in initial elapsed time led users to hold a negative opinion of SDE, despite the benefits of SDE adoption. To overcome these obstacles, it is necessary to structure the clinical templates for optimum use. In addition, user experience (UX) in terms of ease of data entry must be considered as an essential aspect in the development of structured clinical templates.