Improving quality of oncology (onc) documentation and enhancing structured data collection using a standardized onc note template.

• DOI: 10.1200/jco.2024.42.16_suppl.11128
• Publication Date: 2024-06-03T20:28:50Z
• Authors: Matthew Folstad; Arun Augustine; Fauzia Hollnagel; Cibele Carroll; Ashleigh Saner; Jeff Pier; Michael Lavitschke; Peter Kleinschmidt; Heidi Twedt; Amye Juliet Tevaa...; Hamid Emamekhoo
• Keywords: 03 medical and health sciences; 0302 clinical medicine

11128 Background: To improve documentation quality in Medical Onc outpatient clinics, a standardized template was created. In this we embedded: 1. An Epic SmartForm to collect structured data (SD) about patient, disease, and response status at each encounter. Minimal Common Oncology Data Elements (mCODE) compatible SD elements were used enhance interoperability. 2. Several clinically impactful metrics (QM) selected based on the Quality Practice Initiative (QOPI) guidelines. analysis, aim assess how use impacted quality. Methods: 113,376 encounters occurred between 01/2018 – 12/2022 (41 providers: 35 physicians, 6 APPs). The go live 3/19/2019. 2,520 randomly manually reviewed. Distinct of 8 items served as QMs (Table). Of note, using voluntary entry embedded form is not mandated. Documentation QM compared notes authored with/without template. For completeness score calculated total number present/note. Categorical comparisons made chi-squared or Fisher’s exact tests. Numerical/continuous values summarized means standard deviations. A “user” defined provider >10% after live. This QI project exempted by IRB. Results: 154/2520 excluded manual review (visits for solid tumor malignancy). 38.7% (917/2366) reviewed notes. Cancer diagnosis documented >99.8% regardless use. Template associated with increased 7 overall improved from 62% 90% very large effect size positively correlated female gender fewer years since last training (p<0.001). subgroup written “users” (21 4 APPs), individual scores Conclusions: profoundly (statistically significant meaningful) clinic providers. strategy enhances mCODE collection semantic interoperability systems, strengthening available real-world (RWD) EHR. [Table: see text]