Structured data system for a breast cancer medical record.

Abstract We have developed software for an Electronic Medical Record (EMR) to be used by oncologists and researchers. It has rapid, structured data entry, visualization of clinical information and a searchable data base. Interactive, rules-based forms were designed for structured data entry. The web-based forms have been customized for the clinical staff who enter the data. The forms have been tested by oncologists and their office assistants. Modules have been added to upload images and add legends, metadata, and code classifications such as ICD and CPT. Other features include a search interface and a permission system that controls user access. Oncologists enter detailed information during a patient's visit to the clinic. The electronic forms capture diagnoses, stage and history, which includes social, family, and medical history. A time map provides a graphical summary of a patient's record. Visualization of complex clinical information with intuitive navigation increases clarity while retaining the detail necessary for clinical information. Customized data entry forms and automatic coding speed the workflow. The system can potentially interface with multi-institutional data-sharing systems such as Cancer Bioinformatics Grid (CaBig).