Developing a Stone Database for Clinical Practice

Introduction

T he lifetime prevalence of stone disease is about 10% in developed countries, and this appears to be increasing. ¹ Consequently, treatment of patients with urolithiasis constitutes a significant proportion of urologic practice. In the United States, there are more than 2 million physician episodes with a primary diagnosis of stone disease per annum. ² In the United States alone, hospitalizations, surgery, and lost work time associated with kidney stones cost more than $5 billion annually. ³ Stone formers are likely to have recurrences and may need multiple episodes and/or modalities of treatment to maintain a stone-free status. Furthermore, some stone formers have metabolic conditions that necessitate regular monitoring and frequent clinic attendance. ⁴ These factors combine to result in a significant associated administrative burden.

Clinical audit is an essential requirement of clinical governance for healthcare professionals, and good data collection is a vital component of this process. Local, national, and international professional bodies are increasingly keen to evaluate new surgical techniques and audit established procedures. Clinical research relies on comprehensive data collection of defined parameters, and translational basic science research needs accurate demographic, procedure, and outcome data to link with biologic sample analysis. When clinical data are not collected in a template-based system, subsequent data mining for audit and research is laborious and often incomplete. By evaluating complete, prospectively collected datasets, decisions on best practice can be made, and patients may be stratified by phenotype to identify cohorts for targeted research projects.

Most international healthcare systems have a methods of accountability, and a physician-led system is the most accurate way to record volumes of activity and their outcomes. Collecting this prospective data will become increasingly important to meet the demands of health economics. Some centers have moved to electronic patient records to reduce administrative paperwork, and a few centers are now paper free. These systems, however, are expensive, often generic, and not yet widely adopted.

A bespoke electronic stone clinic offers the possibility both to reduce administration and provide a prospectively collected, organized dataset on stone patients for research and audit purposes. We describe how we have developed a stone database for our center that could readily be extended to other stone centers and into other areas of urologic or medical practice.

Materials and Methods

After a series of workshops and sessions between system developers and clinical users, wireframes were constructed to blueprint how the stone database would function, its processes, and appearance. A key consideration was the creation of a clinically intuitive, user-friendly "front end" for the clinician to minimize the inconvenience of moving to an electronic system. The system developers used a rapid development approach that removed the need for laborious and unnecessary documentation, instead focusing on producing a rapid prototype that could then be altered iteratively. The system was constructed with a combination of open-source content management system (Joomla) and structured query language.

Results

Security

Most electronic patient data in the United Kingdom is stored on the N3 network. ⁵ N3 is the National Health Service national broadband network linking hospitals, medical centers, and general practitioners in England and Scotland. Our database is password protected and hosted locally on an N3 virtual server. Password protected systems hosted on local intranets should offer similar levels of acceptable security (Fig. 1). Care must be taken when data are trafficked electronically to ensure identifiable and sensitive information is not accessible to a third party. Encryption of data must meet national guidelines.

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FIG. 1.

Screen shots from the database. (A) Secure password protected login; (B) patient search facility; (C) accessible list of previous procedures and clinic attendances for fictitious person; (D) example of diagram used to enter data for shockwave lithotripsy treatment.

Efficiency

The stone database offers the ability to remove the need for handwritten notes, dictation, and typing for stone procedures and outpatient clinic attendances. From the database, report files may be automatically generated for clinic letters, operation notes, and letters to family doctors (Fig. 2). These may be printed or e-mailed as needed. This generates several clear efficiency savings: The patient's stone history is immediately accessible in the clinic; no writing or dictation or typing is necessary; the patient can receive a consultation summary on departure; and reports can be communicated electronically.

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FIG. 2.

Example of database outputs. (A) First page of a blank stone clinic letter; (B) blank ureteroscopy operation note.

Data integration

Once the central stone database is created, it can be linked with other electronic resources locally, including patient demographics and clinical laboratory results (Fig. 3). This means that some data fields are populated automatically to improve efficiency and accuracy of data collection. Systems could potentially be connected to other systems, including radiology data, outpatient clinic appointment diaries, and operating lists. Other data could be incorporated from electronic patient surveys of factors such as diet and lifestyle.

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FIG. 3.

Cartoon to highlight the interactions of the stone database. Data entered in the stone clinic can be augmented from data in other hospital databases (eg, laboratory results, patient demographics) before producing formatted letters, operation notes, and procedure summaries. Data may also be linked to independent data such as a biobank of clinical samples.

Discussion

Electronic methods of data storage and communication (e-mail, electronic calendars, etc.) are ubiquitous and have been adopted by most doctors in their personal lives. Medical practice, however, generally lags behind other sectors in adopting this technology. An electronic clinical database can improve the efficiency of clinical practice, be cost effective, and provide the benefits of a custom-made solution to gather, store, and output data.

To improve patient safety, treatment, and evaluation of new technologies, representative datasets containing large numbers of patients are essential. Unfortunately, data collection for audit and research is usually an additional burden to clinical practice, yet much of the required data is collected more than once in different settings. An electronic clinical database removes the duplication of work by linking with existing systems to increase administrative efficiency and collate the data simultaneously. To encourage compliance with data collection, the system must be logical and user-friendly. This necessitates input from clinicians who are familiar with the relevant field of medicine.

Once the framework for a database is created, it forms a template for creating similar systems for other areas of urologic and medical practice. Bespoke systems designed in collaboration with clinicians promote relevant data collection via a user-friendly and intuitive interface. The system we have designed reflects practice in our institution. While it should be possible to modify the current system to meet the demands of other institutions, this has not yet been tested.

From the basic framework, there are multiple means of enhancing the system. For example, links to local/national/international guidelines, consent forms, patient information leaflets, nomograms, and risk tables could be readily incorporated.

Conclusions

Data collection remains central to medical practice, to improve patient safety, to analyze medical and surgical outcomes, and to evaluate emerging treatments. Establishing prospective data collection is crucial to this process. In the current era, we have the opportunity to embrace available technology to facilitate this process. For these systems to work, it necessitates input from clinicians to help design systems to collect appropriate information. The database template could be modified for use in other clinics. The database that we have designed helps to provide a modern and efficient clinical stone service.