Colorectal Surgery Surveillance: A Novel Method for Composing an Automated Real-time Prospective Registry.
Colonic Diseases
/ epidemiology
Colorectal Surgery
/ organization & administration
Cost-Benefit Analysis
Digestive System Surgical Procedures
/ adverse effects
Female
Humans
Israel
Male
Medical Records
Medical Records Systems, Computerized
/ organization & administration
Middle Aged
Postoperative Complications
/ epidemiology
Quality Improvement
Registries
Journal
The Israel Medical Association journal : IMAJ
ISSN: 1565-1088
Titre abrégé: Isr Med Assoc J
Pays: Israel
ID NLM: 100930740
Informations de publication
Date de publication:
Apr 2021
Apr 2021
Historique:
entrez:
26
4
2021
pubmed:
27
4
2021
medline:
8
5
2021
Statut:
ppublish
Résumé
Medical registries have been shown to be an effective way to improve patient care and reduce costs. Constructing such registries entails extraneous effort of either reviewing medical charts or creating tailored case report forms (CRF). While documentation has shifted from handwritten notes into electronic medical records (EMRs), the majority of information is logged as free text, which is difficult to extract. To construct a tool within the EMR to document patient-related data as codified variables to automatically create a prospective database for all patients undergoing colorectal surgery. The hospital's EMR was re-designed to include codified variables within the operative report and patient notes that documented pre-operative history, operative details, postoperative complications, and pathology reports. The EMR was programmed to capture all existing data of interest with manual completion of un-coded variables. During a 6-month pilot study, 130 patients underwent colorectal surgery. Of these, 104 (80%) were logged into the registry on the same day of surgery. The median time to log the rest of the 26 cases was 1 day. Forty-two patients had a postoperative complication. The most common cause for severe complications was an anastomotic leak with a cumulative rate of 12.3. Re-designing the EMR to enable prospective documentation of surgical related data is a valid method to create an on-going, real-time database that is recorded instantaneously with minimal additional effort and minimal cost.
Sections du résumé
BACKGROUND
BACKGROUND
Medical registries have been shown to be an effective way to improve patient care and reduce costs. Constructing such registries entails extraneous effort of either reviewing medical charts or creating tailored case report forms (CRF). While documentation has shifted from handwritten notes into electronic medical records (EMRs), the majority of information is logged as free text, which is difficult to extract.
OBJECTIVES
OBJECTIVE
To construct a tool within the EMR to document patient-related data as codified variables to automatically create a prospective database for all patients undergoing colorectal surgery.
METHODS
METHODS
The hospital's EMR was re-designed to include codified variables within the operative report and patient notes that documented pre-operative history, operative details, postoperative complications, and pathology reports. The EMR was programmed to capture all existing data of interest with manual completion of un-coded variables.
RESULTS
RESULTS
During a 6-month pilot study, 130 patients underwent colorectal surgery. Of these, 104 (80%) were logged into the registry on the same day of surgery. The median time to log the rest of the 26 cases was 1 day. Forty-two patients had a postoperative complication. The most common cause for severe complications was an anastomotic leak with a cumulative rate of 12.3.
CONCLUSIONS
CONCLUSIONS
Re-designing the EMR to enable prospective documentation of surgical related data is a valid method to create an on-going, real-time database that is recorded instantaneously with minimal additional effort and minimal cost.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM