JMIR Publications

ABSTRACT

Background:

The delivery of standardized self-report assessments is essential for measurement-based care (MBC) in mental health. Paper-based methods of MBC data collection may result in transcription errors, missing data, and other data quality issues when entered into the patient electronic health record (EHR).

Objective:

To address these issues, a dedicated instance of REDCap, a free, widely used electronic data capture platform, was established to enable the deployment of digitized self-assessments in clinical care pathways to inform clinical decision making.

Methods:

REDCap was integrated with the primary clinical information system to facilitate real-time transfer of discrete data and descriptive reports from REDCap into the EHR. Both technical and administrative components were required for complete implementation. A technology acceptance survey was also administered to capture physician and clinician attitudes towards the new system.

Results:

Integration of REDCap with the EHR transitioned clinical workflows from paper-based to electronic data collection. This resulted in significant time-savings, improved data quality and valuable real-time information delivery. Digitization of self-report assessments at each appointment contributed to clinic-wide implementation of the Major Depressive Disorder Integrated Care Pathway (MDD-ICP). This digital transformation facilitated a 4-fold increase in physician adoption of this ICP workflow and a 3-fold increase in patient enrollment resulting in an overall significant increase in MDD-ICP capacity. Physician and Clinician attitudes were overall positive with almost all respondents agreeing that the system was useful to their work.

Conclusions:

REDCap provided an intuitive patient interface for collection of self-report measures, real-time access to results to inform clinical decisions, and an extensible backend for systems integration. The approach scaled effectively and expanded to high-impact clinics throughout the hospital, allowing for broad deployment of complex workflows and standardized assessments leading to accumulation of harmonized data across clinics and care pathways. REDCap is a flexible tool that can be effectively leveraged to facilitate automatic transfer of self-report data to the EHR. However, thoughtful governance is required to complement the technical implementation to ensure that data standardization, data quality, patient safety, and privacy are maintained.