Case Report | Published:

Electronic medical record: data collection and reporting for spinal cord injury

Spinal Cord Series and Casesvolume 4, Article number: 70 (2018) | Download Citation

Abstract

Study design

Presentation of implementation of International Spinal Cord Injury (SCI) Data Sets, International Standards for Neurological Classification of SCI (ISNCSCI), and other structured SCI tools in to the Electronic Medical Record (EMR) Epic.

Objectives

To describe the implementation of SCI tools in Epic at Rigshospitalet, University of Hospital, Capital Region of Denmark, and the ambitions for the future development of SCI related structured data and their reporting in the Epic EMR to be able to standardize data collection to facilitate research within institutions and collaboratively with other institutions locally and globally.

Setting

Denmark and United States of America.

Methods

The general content of the EMR Epic and the SCI-specific structured data implemented are described as well as the tools for reporting.

Results

The ISNCSCI is made available via access to http://isncscialgorithm.azurewebsites.net/. After filling in the test data on the website, one can save the completed form as an image within the patient’s chart. The International SCI Core Data Set and 13 International SCI Basic Data Sets (Table 1) are nearly completely implemented in the Danish version of Epic as SmartForms. In addition, 14 functional measures, including the Spinal Cord Independence Measure III, are implemented as flowsheets (Table 2).

Conclusions

The possibility of entering international recognized structured data into the EMR gives better possibility for data sharing across SCI centers worldwide.

Sponsorship

Gianna Maria Rodriguez, Stacey Cohen, and Fin Biering-Sørensen are users of Epic, but have no economic relationship with Epic. Kelly Tausk and Josh Martin are employees of Epic.

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Author information

Affiliations

  1. Clinic for Spinal Cord Injuries, Neuroscience Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark

    • Fin Biering-Sørensen
  2. Clinical Informatics, Mount Sinai Health System, New York, NY, USA

    • Stacey Cohen
  3. Physical Medicine and Rehabilitation, University of Michigan Hospital System, Ann Arbor, MI, USA

    • Gianna Maria Rodriguez
  4. Epic Systems Corporation, Verona, WI, USA

    • Kelly Tausk
    •  & Josh Martin

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Conflict of interest

Gianna Maria Rodriguez, Stacey Cohen, and Fin Biering-Sørensen are users of Epic, but have no economic relationship with Epic. Kelly Tausk and Josh Martin are employees of Epic.

Corresponding author

Correspondence to Fin Biering-Sørensen.

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DOI

https://doi.org/10.1038/s41394-018-0106-3