Structured electronic operative reporting: Comparison with dictation in kidney cancer surgery

PURPOSE 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. METHODS 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. RESULTS 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. LIMITATIONS 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. CONCLUSIONS 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.

[1]  M. Apkon,et al.  Impact of an electronic information system on physician workflow and data collection in the intensive care unit , 2001, Intensive Care Medicine.

[2]  K. Marill,et al.  Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department. , 1999, Annals of emergency medicine.

[3]  Charlene R. Weir,et al.  Direct Text Entry in Electronic Progress Notes , 2003, Methods of Information in Medicine.

[4]  M. Murari,et al.  A synoptic reporting system for bone marrow aspiration and core biopsy specimens. , 2006, Archives of pathology & laboratory medicine.

[5]  Kaija Saranto,et al.  Definition, structure, content, use and impacts of electronic health records: A review of the research literature , 2008, Int. J. Medical Informatics.

[6]  Blackford Middleton,et al.  Measuring the quality of medical records: a method for comparing completeness and correctness of clinical encounter data , 2001, AMIA.

[7]  I. Edhemovic,et al.  The Computer Synoptic Operative Report—A Leap Forward in the Science of Surgery , 2004 .

[8]  J. Srigley,et al.  Standardized synoptic cancer pathology reporting: A population‐based approach , 2009, Journal of surgical oncology.

[9]  E A Rose,et al.  Use of a template to improve documentation and coding. , 2001, Family medicine.

[10]  T. Massaro.  Introducing physician order entry at a major academic medical center: I. Impact on organizational culture and behavior. , 1993 .

[11]  Carolyn Ford,et al.  Electronic Templates versus Dictation for the Completion of Mohs Micrographic Surgery Operative Notes , 2007, Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.].

[12]  J F Hurdle,et al.  Direct text entry in electronic progress notes. An evaluation of input errors. , 2003, Methods of information in medicine.

[13]  L. M. Ho,et al.  The application of a computerized problem-oriented medical record system and its impact on patient care , 1999, Int. J. Medical Informatics.

[14]  F. Elevitch.  SNOMED CT: electronic health record enhances anesthesia patient safety. , 2005, AANA journal.

[15]  Randolph A. Miller,et al.  Review Paper: Interface Terminologies: Facilitating Direct Entry of Clinical Data into Electronic Health Record Systems , 2006, J. Am. Medical Informatics Assoc..

[16]  Zhenhong Qu,et al.  Synoptic reporting in tumor pathology: advantages of a web-based system. , 2007, American journal of clinical pathology.

[17]  Jeremy C. Wyatt,et al.  Reviewing the integration of patient data: how systems are evolving in practice to meet patient needs , 2007, BMC Medical Informatics Decis. Mak..

[18]  R. Hellesø.  Information handling in the nursing discharge note. , 2006, Journal of clinical nursing.

[19]  Edward H. Wagner,et al.  Strengthening primary care with better transfer of information , 2008, Canadian Medical Association Journal.

[20]  K. Leslie,et al.  Standardization of the surgical pathology report: formats, templates, and synoptic reports. , 1994, Seminars in diagnostic pathology.

[21]  P. Shekelle,et al.  Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care , 2006, Annals of Internal Medicine.

[22]  D. Bates,et al.  How can information technology improve patient safety and reduce medication errors in children's health care? , 2001, Archives of pediatrics & adolescent medicine.

[23]  Estela O'Meara.  The effects of electronic documentation in the ambulatory surgery setting. , 2007, AORN journal.

[24]  P. C. Tang,et al.  Research Paper: Use of Computer-based Records, Completeness of Documentation, and Appropriateness of Documented Clinical Decisions , 1999, J. Am. Medical Informatics Assoc..

[25]  Nancy Knight,et al.  Radiology reporting, past, present, and future: the radiologist's perspective. , 2007, Journal of the American College of Radiology : JACR.

[26]  Yuri W. Novitsky,et al.  Prospective, Blinded Evaluation of Accuracy of Operative Reports Dictated by Surgical Residents , 2005, The American surgeon.

[27]  N. T. Cheung,et al.  Structured Data Entry of Clinical Information for Documentation and Data Collection , 2001, MedInfo.

[28]  H. Prokosch,et al.  Perspectives for Medical Informatics , 2009, Methods of Information in Medicine.

[29]  Steven H. Brown,et al.  The Effect of Standardized, Computer-Guided Templates on Quality of VA Disability Exams , 2006, AMIA.

[30]  Hagop S. Mekhjian,et al.  Implementation Brief: Key Attributes of a Successful Physician Order Entry System Implementation in a Multi-hospital Environment , 2002, J. Am. Medical Informatics Assoc..

[31]  Jane C Atkinson,et al.  Electronic patient records for dental school clinics: more than paperless systems. , 2002, Journal of dental education.

[32]  Anil V Parwani,et al.  Synoptic tool for reporting of hematological and lymphoid neoplasms based on World Health Organization classification and College of American Pathologists checklist , 2007, BMC Cancer.

[33]  J D M Nicopoullos,et al.  Significant improvement in quality of caesarean section documentation with dedicated operative proforma--completion of the audit cycle , 2003, Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology.

[34]  W J Temple,et al.  Opening the black box of cancer surgery quality: WebSMR and the Alberta experience , 2009, Journal of surgical oncology.

[35]  S. Rivard,et al.  Getting physicians to accept new information technology: insights from case studies , 2006, Canadian Medical Association Journal.

[36]  T. Massaro,et al.  Introducing Physician Order Entry at a Major Academic Medical Center: II. Impact on Medical Education , 1993, Academic medicine : journal of the Association of American Medical Colleges.