Structured electronic operative reporting: Comparison with dictation in kidney cancer surgery
ABSTRACT The purpose of this study was to evaluate the functionality of eKidney as a structured reporting tool in operative note generation. To do this, we compared completeness and timeliness of eKidney template-generated nephrectomy OR notes with standard narrative dictation.
A group of academic uro-oncologists and medical informaticians at the University Health Network designed and adopted an electronic online, point-of-care clinical documentation tool, eCancerCare(Kidney) (eKidney) for kidney cancer patient care. The optimal components of clinic and operative note templates, including those for nephrectomy, were agreed upon by expert consensus of the uro-oncologists. Clinician nephrectomy OR reports were analyzed for completeness, comparing those generated in eKidney with conventionally dictated notes. Patterns of missing information from both dictated and eKidney-generated reports were analyzed. The procedure, note completion and transcription dates were recorded which generated time intervals between these events. The records of 189 procedures were included in the analysis.
Comparison of clinicians who used both note generation modalities, revealed a mean completion rate of 92% for eKidney/structured notes and 68% for dictated notes (p<0.0001). There was no significant difference in completion rates between attending staff and trainees (residents and fellows) (p=0.131). Most notes were dictated/entered on the day of surgery. Dictated notes were transcribed to EPR a median of 2 days after dictation, however roughly 30% of dictated notes took 5 days or more to get transcribed. All notes generated using eKidney were uploaded to the EPR immediately.
Our study has three significant limitations. Firstly, our study was not randomized: physicians could elect to dictate or use eKidney. Secondly, we did not identify data from dictated notes that were not captured by eKidney. Third, we did not compare the time it took physicians to complete the fields in eKidney with the time it takes to dictate a note.
We have demonstrated that the use of structured reporting improves the completeness and timeliness of documentation in kidney cancer surgery. eKidney is an example of the power of templates in ensuring that important details of a procedure are recorded. Future studies looking at user satisfaction, and research and educational potential of eKidney would be valuable.
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ABSTRACT: Although operative report documentation (ORD) is an essential skill for surgeons and is evolving with electronic health records (EHRs), little is known about current ORD teaching in surgical training. An electronic survey was sent out in January 2012 to all 1,096 ACGME surgical program directors that assessed characteristics of training programs, EHR adoption, ORD education, synoptic or templated report usage for ORD, and attitudes and opinions about ORD education and electronic tools for ORD. Content thematic analysis of qualitative responses was performed iteratively until reaching saturation. Overall, 441 program directors (40%; 17.9 ± 8.8 years in practice) responded from university-affiliated (383 [87%]), community/private (44 [10%]), and military (14 [3%]) programs. Although most (n = 295 [67%]) consider ORD teaching a priority, only 76 (17%) programs provide ORD instruction. Program directors formally trained in ORD were more likely to offer ORD instruction (61% vs 11%; p < 0.0001), as were obstetrics/gynecology programs (obstetrics/gynecology 35% vs surgery 18%, neurosurgery 16%, ophthalmology 14%, orthopaedics 14%; p < 0.05 each). Although EHR adoption and electronically available operative reports were common (91%), besides ophthalmology (31%) and obstetrics/gynecology (30%) programs, ORD with synoptic reporting was used in only 18% of programs overall. Program directors perceived major barriers to ORD instruction and synoptic reporting for ORD. Although most program directors consider ORD teaching an educational priority, incongruence exists between its perceived value and its adoption into surgical training. Operative report documentation with synoptic reporting is currently not common in most surgical subspecialties.Journal of the American College of Surgeons 11/2013; DOI:10.1016/j.jamcollsurg.2013.09.004 · 4.45 Impact Factor
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ABSTRACT: BACKGROUND: The current trend in surgery toward further trauma reduction inevitably leads to increased technological complexity. It must be assumed that this situation will not stay under the sole control of surgeons; mechanical systems will assist them. Certain segments of the work flow will likely have to be taken over by a machine in an automatized or autonomous mode. METHODS: In addition to the analysis of our own surgical practice, a literature search of the Medline database was performed to identify important aspects, methods, and technologies for increased operating room (OR) autonomy. RESULTS: Robotic surgical systems can help to increase OR autonomy by camera control, application of intelligent instruments, and even accomplishment of automated surgical procedures. However, the important step from simple task execution to autonomous decision making is difficult to realize. Another important aspect is the adaption of the general technical OR environment. This includes adaptive OR setting and context-adaptive interfaces, automated tool arrangement, and optimal visualization. Finally, integration of peri- and intraoperative data consisting of electronic patient record, OR documentation and logistics, medical imaging, and patient surveillance data could increase autonomy. CONCLUSIONS: To gain autonomy in the OR, a variety of assistance systems and methodologies need to be incorporated that endorse the surgeon autonomously as a first step toward the vision of cognitive surgery. Thus, we require establishment of model-based surgery and integration of procedural tasks. Structured knowledge is therefore indispensable.Surgical Endoscopy 12/2012; 27(5). DOI:10.1007/s00464-012-2656-y · 3.31 Impact Factor