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HIS-based electronic documentation can significantly reduce the time from biopsy to final report for prostate tumours and supports quality management as well as clinical research.

Breil B, Semjonow A, Dugas M - BMC Med Inform Decis Mak (2009)

Bottom Line: We compared 87 paper-based with 86 electronic cases.The possibility to use these routine data for quality management and research purposes is an additional important advantage of the electronic system.Electronic documentation can significantly reduce the time from biopsy to final report of prostate biopsy results and generates a reliable basis for quality management and research purposes.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Medical Informatics and Biomathematics, University of Münster, Domagkstrasse 9, 48149 Münster, Germany. bernhard.breil@ukmuenster.de

ABSTRACT

Background: Timely and accurate information is important to guide the medical treatment process. We developed, implemented and assessed an order-entry system to support documentation of prostate histologies involving urologists, pathologists and physicians in private practice.

Methods: We designed electronic forms for histological prostate biopsy reports in our hospital information system (HIS). These forms are created by urologists and sent electronically to pathologists. Pathological findings are entered into the system and sent back to the urologists. We assessed time from biopsy to final report (TBF) and compared pre-implementation phase (paper-based forms) and post-implementation phase. In addition we analysed completeness of the electronic data.

Results: We compared 87 paper-based with 86 electronic cases. Using electronic forms within the HIS decreases time span from biopsy to final report by more than one day per patient (p < 0.0001). Beyond the optimized workflow we observed a good acceptance because physicians were already familiar with the HIS. The possibility to use these routine data for quality management and research purposes is an additional important advantage of the electronic system.

Conclusion: Electronic documentation can significantly reduce the time from biopsy to final report of prostate biopsy results and generates a reliable basis for quality management and research purposes.

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Related in: MedlinePlus

Prostate biopsy form. In the upper part fax date ("Fax gesendet am"), the time of biopsy ("Biopsie Datum"), PSA and prostate volume ("Prostatavolumen") are recorded. Up to 12 specimens can be documented with length of the biopsy core ("Länge gesamt"), percentage tumour in biopsy core, and Gleason score ("Gleason Summe"). The yellow part is provided by urologists, the rest is documented by pathologists.
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Figure 4: Prostate biopsy form. In the upper part fax date ("Fax gesendet am"), the time of biopsy ("Biopsie Datum"), PSA and prostate volume ("Prostatavolumen") are recorded. Up to 12 specimens can be documented with length of the biopsy core ("Länge gesamt"), percentage tumour in biopsy core, and Gleason score ("Gleason Summe"). The yellow part is provided by urologists, the rest is documented by pathologists.

Mentions: These forms are used for documentation of biopsies and are similar to the previously used paper forms. The main form is shown in figure 4. The urologist (upper yellow part) provides clinical findings like prostate volume, PSA, ultrasound findings and International Prostate Symptom Score (IPSS). Pathological grading systems (Gleason score [28], Helpap-Grading) are filled in by pathologists. After the final assessment of the urologist in the lower part (yellow) of this document it is being sent to the referring physician.


HIS-based electronic documentation can significantly reduce the time from biopsy to final report for prostate tumours and supports quality management as well as clinical research.

Breil B, Semjonow A, Dugas M - BMC Med Inform Decis Mak (2009)

Prostate biopsy form. In the upper part fax date ("Fax gesendet am"), the time of biopsy ("Biopsie Datum"), PSA and prostate volume ("Prostatavolumen") are recorded. Up to 12 specimens can be documented with length of the biopsy core ("Länge gesamt"), percentage tumour in biopsy core, and Gleason score ("Gleason Summe"). The yellow part is provided by urologists, the rest is documented by pathologists.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2651130&req=5

Figure 4: Prostate biopsy form. In the upper part fax date ("Fax gesendet am"), the time of biopsy ("Biopsie Datum"), PSA and prostate volume ("Prostatavolumen") are recorded. Up to 12 specimens can be documented with length of the biopsy core ("Länge gesamt"), percentage tumour in biopsy core, and Gleason score ("Gleason Summe"). The yellow part is provided by urologists, the rest is documented by pathologists.
Mentions: These forms are used for documentation of biopsies and are similar to the previously used paper forms. The main form is shown in figure 4. The urologist (upper yellow part) provides clinical findings like prostate volume, PSA, ultrasound findings and International Prostate Symptom Score (IPSS). Pathological grading systems (Gleason score [28], Helpap-Grading) are filled in by pathologists. After the final assessment of the urologist in the lower part (yellow) of this document it is being sent to the referring physician.

Bottom Line: We compared 87 paper-based with 86 electronic cases.The possibility to use these routine data for quality management and research purposes is an additional important advantage of the electronic system.Electronic documentation can significantly reduce the time from biopsy to final report of prostate biopsy results and generates a reliable basis for quality management and research purposes.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Medical Informatics and Biomathematics, University of Münster, Domagkstrasse 9, 48149 Münster, Germany. bernhard.breil@ukmuenster.de

ABSTRACT

Background: Timely and accurate information is important to guide the medical treatment process. We developed, implemented and assessed an order-entry system to support documentation of prostate histologies involving urologists, pathologists and physicians in private practice.

Methods: We designed electronic forms for histological prostate biopsy reports in our hospital information system (HIS). These forms are created by urologists and sent electronically to pathologists. Pathological findings are entered into the system and sent back to the urologists. We assessed time from biopsy to final report (TBF) and compared pre-implementation phase (paper-based forms) and post-implementation phase. In addition we analysed completeness of the electronic data.

Results: We compared 87 paper-based with 86 electronic cases. Using electronic forms within the HIS decreases time span from biopsy to final report by more than one day per patient (p < 0.0001). Beyond the optimized workflow we observed a good acceptance because physicians were already familiar with the HIS. The possibility to use these routine data for quality management and research purposes is an additional important advantage of the electronic system.

Conclusion: Electronic documentation can significantly reduce the time from biopsy to final report of prostate biopsy results and generates a reliable basis for quality management and research purposes.

Show MeSH
Related in: MedlinePlus