Urodynamic studies (UDS), with their complexity in terms of obtaining, recording and interpreting data, are ideally suited for innovative methods to take advantage of the electronic health record (EHR) for data aggregation and analytics. EHR platforms allow users to design and implement structured data entry systems (SDES), which allow data to be entered in real time based on predefined categories and conditions. SDES can also be tailored to specific procedures and allow for uniformity and standardization of data entry and collection, which is a must when multiple providers are performing a complex procedure such as UDS. Use of SDES has been shown to decrease research costs, increase patient-oriented research and facilitate medical advancements. ¹ With this in mind, we aimed to develop a SDES for UDS that would allow us to better serve our patients by standardizing the study, provide a safety function to allow us to quickly aggregate data from all UDS and analyze data to find the most hostile bladder, and allow for efficient hypothesis generated research.

Figure 1. UDS structured data entry system utilized in our department. SDES are easy to use flowsheets that can be opened up in patient EHR and allow for prompted entry of data in real time. UTI, urinary tract infection. DESD, detrusor-external sphincter dyssynergia.

A working group of pediatric urologists, advanced practice providers and members of our hospital informatics team designed and implemented a template SDES in a flowsheet within Epic (Epic Systems Corporation, Madison, Wisconsin). Over a 3-month trial period, the template was used in the office and additional parameters were added as determined by a consensus of the working group. The final SDES included dropdown and fill-in questions on clinical history, UDS technique, UDS findings and subjective assessments including safe bladder capacity and if the study led to change in management (fig. 1). ² The SDES also included equations that automatically calculated estimated bladder capacity (EBC) and 25%, 50% and 75% of EBC to assist with timing of pressure measurements and fluoroscopic imaging. Since the SDES flowsheet is filled out in real time, all data are easily incorporated into a prepopulated area of the clinical note, thus fulfilling billing requirements and improving efficacy for the provider who does not need to repeat or retype the information. The template for the clinical note also has space for the provider to enter a history and summary impression in prose, which allows the clinician to provide a record of their thinking behind their decision making based on the urodynamic data. Another benefit of SDES is that they help standardize how UDS are performed with multiple providers, in effect serving as a checklist.

Figure 2. Example of using SDES data to quickly assess patients above safe end storage bladder pressure. Graph shows end storage detrusor pressure for all UDS obtained at our institution in last 6 months. Red line set at 25 cm H ₂O as cutoff for safe end storage bladder pressure (this value can be set to whatever level is appropriate for patient population and determined by provider). All patients above this threshold can be reviewed and checked for adherence to followup plan. Patients with missed appointments can be called and rescheduled.

The real benefit of using an SDES flowsheet for UDS in the office come from the fact that the information obtained and data recorded are searchable. Each week our hospital information systems team aggregates data from all urodynamic studies performed that week and sends the data to us via email in a CSV delimited format for easy use in common data analysis programs such as Excel®, Stata® and R (R Project for Statistical Computing, Vienna, Austria). Weekly data can be added to previously collected studies to form a prospective database, which can be used for monitoring patients for safety, quality improvement initiatives and for research projects. Data can also be entered and uploaded into REDCaP (Research Electronic Data Capture, Vanderbilt University, Nashville, Tennessee) for sharing across multiple institutions if needed for a multicenter study or trial.

Since implementing the UDS SDES flowsheet in June 2015, we have now aggregated data from 2,210 UDS at our institution. Overall, review of data consistently shows that less than 5% of all cells or data entry points are missing. This high data accrual rate is achieved by the physician performing the UDS without the need for research assistants or any manual copying of the data, which could lead to errors.

Quality improvement is one way to harness the power of SDES in the care of complex patients and can be implemented via the “plan-do-study-act” (PDSA) approach. ³ An example of the ease with which collected data can be used for patient safety review or quality improvement is illustrated in figure 2, which shows the end storage pressures obtained from each study over the last 6 months. By organizing the studies in this way, a cutoff can be determined above which all patient charts can be reviewed to see if followup has been consistent and management changes implemented. Patients with missed followup visits can be reached out to and called so that these high risk patients are not lost for months or years.

While our pilot use of SDES in the EHR focused on UDS, SDES flowsheets can also be implemented for other office or operating room procedures. Our colleagues have designed flowsheets and are using them in our division for hypospadias diagnoses both in clinic notes to standardize measurements and preoperative and postoperative findings. Additionally, SDES flowsheets can be used within operative notes to standardize data collection and facilitate recording of information for patient safety and research purposes. The near universal use of the EHR allows for the possibility of multi-institutional sharing of SDES flowsheets and aggregation of data across centers for quality improvement and research purposes. While SDES flowsheets take buy-in from providers, minimization of provider resistance can be accomplished by creating SDES that are easy to use without increasing time burden or interrupting clinical workflow.