Structured vs Unstructures Data Entry

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The flood of clinical data a physician receives on a daily basis may exceed the human capacity to process information. A computerized patient record (CPR) employing structured data entry by clinicians at the point of care can organize this information in useful ways. EpicCare(R), the CPR developed by Epic Systems, Inc, will be deployed at the Children's Hospital of Philadelphia in 2001. The attitudes of pediatricians toward structured data entry, and the optimal mechanism of note entry in the unique environment of the pediatric exam room are unknown. In this pilot study physician attitudes will be measured by survey, and a structured data entry modality using templates will be compared to unstructured data entry using voice. Outcomes will include time spent on documentation, completeness of documentation, and quality of patient experience. Data from this pilot will be used to design a subsequent definitive study with the ultimate goal of refining the mechanisms of data entry at the point of care.