Difference between revisions of "Structured Data Capture"

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==Benefits==
 
==Benefits==
''<If the profile can improve Cost, Safety, Quality or Efficiency then list the specific examples of that benefit (e.g. error reduction, increased throughput) and how they come about (e.g. SWF reduces patient errors due to mistyped demographics at the modality by transfering demographics electronically from the Order Filler). Consider using a bullet list for readability. Such benefits help users and vendors make the business case for the profile.  If the profile does not improve any aspect of Cost, Safety, Quality or Efficiency feel free to talk about something else here.>''
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Health care providers and others use various sources and methods to capture and synthesize patient-level data, EHRs have been recognized as the data source with the highest potential to provide timely and relevant data in a form that is quickly usable for quality and safety improvement, population health, and research (sometimes labeled "secondary" use or "reuse"). EHR data obtained during episodes of care will become increasingly valuable to healthcare organizations striving to leverage electronic information to drive efficiency and quality. Of particular interest are efforts to leverage clinical data captured during episodes of care and link the clinical data to supplemental data collected for other purposes including: 1) clinical research, 2) patient-safety event reporting, 3) public health reporting, and 4) determination of coverage. Once captured, aggregated and analyzed, these combined data can be used to identify trends, predict outcomes and influence patient care, drug development and therapy choices. Linking EHR data with other data in a uniform and structured way could accelerate quality and safety improvement, population health and research.
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The SDC profile is a standard for exchanging structured data, whether it is used for a clinical trial, determination of coverage, or to report on a patient safety event, which can be collected in a timely manner, then readily compared and aggregated improving the overall quality, value and utility of these data. The identification and harmonization of standards for structured data capture within EHRs will not only help achieve this vision, but they will also help to:
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• Reduce data collection burden on health care providers by enabling secure, single-point data entry that populates to multiple systems
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• Decrease the need to make site-specific modifications to EHR system capabilities to enable participation in important reporting and research activities
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• Lower the barriers to volunteer adverse event reporting on medical products to public health agencies leading to improvements in population health
  
 
==Details==
 
==Details==

Revision as of 11:16, 14 September 2017

Summary

The Structured Data Capture (SDC) Profile provides an infrastructure for capturing, exchanging and using patient data within electronic health record (EHR) systems for clinical research, adverse event reporting and public health reporting. The utility of EHR data for supplemental purposes has been limited due to a lack of uniformity in the terminology and definitions of data elements across EHRs. This limitation is compounded by the fact that in a typical clinician workflow patient information is often recorded in an unstructured free-text format well after the episodes of care.

The SDC Profile provides specifications to enable an EHR system, or other application, to retrieve a structured data capture form and submit data from a completed form. The SDC Profile utilizes transactions from the IHE ITI Retrieve Form for Data Capture (RFD) Profile and an ISO/IEC 19763-13 based form definition, for requesting and receiving forms, and submitting data captured in forms in a standardized and structured format.

Benefits

Health care providers and others use various sources and methods to capture and synthesize patient-level data, EHRs have been recognized as the data source with the highest potential to provide timely and relevant data in a form that is quickly usable for quality and safety improvement, population health, and research (sometimes labeled "secondary" use or "reuse"). EHR data obtained during episodes of care will become increasingly valuable to healthcare organizations striving to leverage electronic information to drive efficiency and quality. Of particular interest are efforts to leverage clinical data captured during episodes of care and link the clinical data to supplemental data collected for other purposes including: 1) clinical research, 2) patient-safety event reporting, 3) public health reporting, and 4) determination of coverage. Once captured, aggregated and analyzed, these combined data can be used to identify trends, predict outcomes and influence patient care, drug development and therapy choices. Linking EHR data with other data in a uniform and structured way could accelerate quality and safety improvement, population health and research.

The SDC profile is a standard for exchanging structured data, whether it is used for a clinical trial, determination of coverage, or to report on a patient safety event, which can be collected in a timely manner, then readily compared and aggregated improving the overall quality, value and utility of these data. The identification and harmonization of standards for structured data capture within EHRs will not only help achieve this vision, but they will also help to: • Reduce data collection burden on health care providers by enabling secure, single-point data entry that populates to multiple systems • Decrease the need to make site-specific modifications to EHR system capabilities to enable participation in important reporting and research activities • Lower the barriers to volunteer adverse event reporting on medical products to public health agencies leading to improvements in population health

Details

<A few paragraphs, if appropriate, providing more details (mostly in user-speak, not tech-speak) on what the profile does and how it works.>

<If the user might be familiar with the mechanisms used by the profile, you can mention them here. E.g. Evidence Documents is based on DICOM Structured Report (SR) Templates.>

<If the user might have an appreciation for the problems addressed in the profile, you can mention them here, but keep it short. E.g. Mapping HL7 Order fields to DICOM Modality Worklist attributes can be inconsistent in the marketplace, so Scheduled Workflow provides vendors with more detailed instructions.>

Systems Affected

<List (in user terms) the types of systems they might expect to have implemented actors from this profile, e.g. RIS, PACS, HIS, CAD Workstation, etc. and for each, how it would participate.>

  • PACS systems may store, manage, and/or display Evidence Documents.
  • Display systems may query, retrieve and display Evidence Documents.
  • Reporting workstations may retrieve, process and include details from Evidence Documents in reports

Actors & Transactions:

<Insert an actor-transaction diagram, and or list of Content Definitions>

Specification

Profile Status: Final Text <Replace "Final Text" with "Trial Implementation" or "Public Comment" as appropriate.>

Documents:

<Provide direct links to the specific volumes or supplements, and list the volume sections relevant to this profile. This is a simple inventory of official normative and informative text. If you would like to provide a reading guide or walkthrough of what is in each of the different sections for implementers or users, do that in the Profile FAQ or the Profile Implementation Page linked below. If the profile uses transactions from multiple Tech. Frameworks, repeat the structure below.>

IHE Radiology Technical Framework:

  • Vol. 1 - Section 5 (SWF Profile)
  • Vol. 2 - Sections 4.8 to 4.10, 4.14 to 4.19, and 4.23
  • Vol. 3 - Appendix E

Underlying Standards:

<list all the standards on which the profile is based; if possible with links to sources>

See Also

<The following sections can be left out if there is nothing to point to. This is just to show where such information can go.>


Related Profiles

<List profiles this one depends on, profiles that depend on this one, profiles that are synergistic with this one. Start with the name of the other profile as a link and then explain the relationship.>


Consumer Information

The Profile FAQ Template answers typical questions about what the Profile does. <Replace the link with a link to the actual FAQ page for the Profile>

The Profile Purchasing Template describes considerations when purchasing equipment to deploy this Profile. <Replace the link with a link to the actual Purchasing page for the Profile>

Implementer Information

The Profile Implementation Template provides additional information about implementing this Profile in software. <Replace the link with a link to the actual Implementation page for the Profile>

Reference Articles

<List References (good and bad) (with link if possible) to Journal Articles that mention IHE's work (and hopefully include some analysis). Go ahead, Google: IHE <Profile Name> abstract or Google: IHE <Profile Name> and under the "more" select "Scholar". You might be surprised. >

Structured Data Capture Recording

This page is based on the Profile Overview Template