Leveraging electronic medical record (EMR) systems along with other health information systems (HIS) to improve data capture and reporting for a surgical quality improvement program at a tertiary care institution and integrated health system.

Many EMR systems are focused on documentation but are not designed for discrete clinical data capture for outcomes and quality measurement. This requires new clinical workflow and methods to capture patient specific data as part of usual care, without negative impact on productivity. We describe a process to harness tools within a commercially available EMR, together with other electronic data sources to improve the accuracy and efficiency and scalability of a surgical quality reporting program.