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ENDOSCOPIC REPORTINGMikael Ragbar1, Erika Rodrigues2, Mary Lam3, Dr. Peter Rossos11. University of Toronto 2. TECHNA 3. University Health Network
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CURRENT STATEFor upper gastrointestinal (GI) endoscopy and colonoscopy, unstructured documentation including dictation and hand-written records remain prevalent
Unstructured documentation results in:- Poor and variable documentation quality- Delayed reporting and communication- Inefficient data collection
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PROBLEMDesigning clinical interfaces with complex documentation requirements
Address and identify usability challenges
Recommendations for tackling these issues in the future
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Based on International best practice guidelines, a pan-Canadian National Data model was developed
The National Data model was built to support clinical best practice and optimal procedural documentation
Supported through Canada Health Infoway, The Canadian Association of Gastroenterology and The Canadian Partnership Against Cancer
technainstitute.com/snare
DEVELOPMENT
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StructuredNotes Auditing and Reporting in Endoscopy is a method of collecting data from an endoscopic exam in a uniform way, where important factors are laid out in a list of options rather than described by a physician’s narrative.
Important clinical features from the procedure go into specific areas of the report.
SNARE
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Designed as part of an iterative design approach
Clinicians and clinical experts were actively involved in all stages in the development of the eNote application
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eNOTE