Automating Clinical Score Calculation within the Electronic Health RecordA Feasibility Assessment Funding This publication was made possible by CTSA Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH.
01 September 2016
accepted: 07 February 2017
21 December 2017 (online)
Objectives: Evidence-based clinical scores are used frequently in clinical practice, but data collection and data entry can be time consuming and hinder their use. We investigated the programmability of 168 common clinical calculators for automation within electronic health records.
Methods: We manually reviewed and categorized variables from 168 clinical calculators as being extractable from structured data, unstructured data, or both. Advanced data retrieval methods from unstructured data sources were tabulated for diagnoses, non-laboratory test results, clinical history, and examination findings.
Results: We identified 534 unique variables, of which 203/534 (37.8%) were extractable from structured data and 269/534 (50.4.7%) were potentially extractable using advanced techniques. Nearly half (265/534, 49.6%) of all variables were not retrievable. Only 26/168 (15.5%) of scores were completely programmable using only structured data and 43/168 (25.6%) could potentially be programmable using widely available advanced information retrieval techniques. Scores relying on clinical examination findings or clinical judgments were most often not completely programmable.
Conclusion: Complete automation is not possible for most clinical scores because of the high prevalence of clinical examination findings or clinical judgments – partial automation is the most that can be achieved. The effect of fully or partially automated score calculation on clinical efficiency and clinical guideline adherence requires further study.
Citation: Aakre C, Dziadzko M, Keegan MT, Herasevich V. Automating clinical score calculation within the electronic health record: A feasibility assessment. Appl Clin Inform 2017; 8: 369–380 https://doi.org/10.4338/ACI-2016-09-RA-0149
KeywordsAutomation - decision support algorithm - clinical score - knowledge translation - workflow - clinical practice guideline
Clinical Relevance Statement
Automated calculation of commonly used clinical scores within the EHR could reduce the cognitive-workload, improve practice efficiency, and facilitate clinical guideline adherence.
Human Subjects Protects
Humans subjects were not included in the project.
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