Colorectal Surgery Surveillance: A Novel Method for Composing an Automated Real-time Prospective Registry.

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: 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: 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: 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: 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.

An Experience of Electronic Health Records Implementation in a Mexican Region.

Employing software engineering to build an integrated, standardized, and scalable solution is closely associated with the healthcare domain. Furthermore, new diagnostic techniques have been developed to obtain better results in less time, saving costs, and bringing services closer to the most unprotected areas. This paper presents the integration of a top-notch component, such as hardware, software, telecommunications, and medical equipment, to produce a complete system of Electronic Health Record (EHR). The EHR implementation aims to contribute to the expansion of the health services offer concerning people who live in locations where typically have difficult access to medical care. The methodology throughout the work is a Strategic Planning to set priorities, focus energy and resources, strengthen operations, ensure that directors, managers, employees, and other stakeholders are working toward common goals, establish agreement around intended outcomes/results. A medical and technical team is incorporated to complete the tasks of process and requirements analysis, software coding and design, technical support, training, and coaching for EHR system users throughout the implementation process. The adoption of those tools reflect notably some expected results and benefits on patient care. The EHR implementation ensures that information collection does not duplicate already existing information or duplicate effort and maximize the practical use of the data collected. Moreover, the EHR reduces mistakes in hospital readmissions, improves paperwork, promotes the progress of the state's health care system providing emergency, specialty, and primary health care in a rural area of Campeche. The EHR implementation is critical to support decision making and to promote public health. The total number of consults increased markedly from 2012 (14021) to 2019 (34751). The most commonly treated diseases in this region of Mexico are hypertension (17632) and diabetes (13156). The best results are obtained in the Nutrition (20,61%) and clinical psychology services (16,67%), and the worst levels are registered in pediatric and surgical oncology services where only 1,59% and 1,97% of the patients are admitted in less than 30 min, respectively.

Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial.

Importance: Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation. Objective: To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records opened concurrently. Design, Setting, and Participants: This randomized clinical trial included 3356 clinicians at a large health system in New York and was conducted from October 2015 to April 2017 in emergency department, inpatient, and outpatient settings. Interventions: Clinicians were randomly assigned in a 1:1 ratio to an EHR configuration limiting to 1 patient record open at a time (restricted; n = 1669) or allowing up to 4 records open concurrently (unrestricted; n = 1687). Main Outcomes and Measures: The unit of analysis was the order session, a series of orders placed by a clinician for a single patient. The primary outcome was order sessions that included 1 or more wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder measure (an electronic query that identifies orders placed for a patient, retracted, and then reordered shortly thereafter by the same clinician for a different patient). Results: Among the 3356 clinicians who were randomized (mean [SD] age, 43.1 [12.5] years; mean [SD] experience at study site, 6.5 [6.0] years; 1894 females [56.4%]), all provided order data and were included in the analysis. The study included 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 in the restricted vs unrestricted group, respectively, overall (90.7 vs 88.0; odds ratio [OR], 1.03 [95% CI, 0.90-1.20]; P = .60) or in any setting (ED: 157.8 vs 161.3, OR, 1.00 [95% CI, 0.83-1.20], P = .96; inpatient: 185.6 vs 185.1, OR, 0.99 [95% CI, 0.89-1.11]; P = .86; or outpatient: 7.9 vs 8.2, OR, 0.94 [95% CI, 0.70-1.28], P = .71). The effect did not differ among settings (P for interaction = .99). In the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, including 34.5% of ED, 53.7% of inpatient, and 83.4% of outpatient order sessions. Conclusions and Relevance: A strategy that limited clinicians to 1 EHR patient record open compared with a strategy that allowed up to 4 records open concurrently did not reduce the proportion of wrong-patient order errors. However, clinicians in the unrestricted group placed most orders with a single record open, limiting the power of the study to determine whether reducing the number of records open when placing orders reduces the risk of wrong-patient order errors. Trial Registration: clinicaltrials.gov Identifier: NCT02876588.

Implementation of a virtual vascular clinic with point-of-care ultrasound in an integrated health care system.

OBJECTIVE: Using secured videoconferencing technologies, telemedicine may replace traditional clinic visits, save patients' time and travel, and improve use of limited surgeon and facility resources. We report our initial experience of the remote clinical encounter (RCE) by evaluating vascular surgery patients. METHODS: In this proof-of-concept pilot study, we conducted telemedicine evaluations of vascular patients at a tertiary care institution from October 2015 to August 2016. Patients were offered synchronous virtual visits from a surgical provider in lieu of an in-person visit. We used Skype for Business (Microsoft, Redmond, Wash) over secured networks for patient-provider interaction, clinical data entry in the Epic electronic medical record (Epic Systems Corporation, Verona, Wisc) for documentation, and established satellite facilities with existing vascular laboratories for imaging and laboratory testing. We evaluated feasibility, demographics, encounter type, and satisfaction of the patient through web-based questionnaires. RESULTS: During a 10-month period, 41 women and 14 men with an average age of 57 years (range, 29-79 years) underwent 82 RCEs. There were 43 white (78.1%), 9 black (16.3%), 1 Asian (1.8%), and 2 Middle Eastern (3.6%) patients. Diagnoses included both arterial (aneurysm, carotid, and occlusive disease) and venous (deep venous thrombosis and varicose vein) disease. Among the 82 RCEs, visit types included 15 new patients, 30 postoperative visits, and 37 follow-up visits. Ultrasound imaging was performed in conjunction with the RCE in 74 patients (90.2%). Most patients (57%) had multiple RCEs during the study period. All 55 patients responded to the satisfaction questionnaire; 91% stated that they would highly recommend a virtual physician encounter to a friend or colleague, and all of the respondents found their encounter more convenient than having a traditional office visit. All patients thought that they were able to communicate clearly with the provider, and overall quality responses were overwhelmingly positive. CONCLUSIONS: Secured virtual visits can be conducted using commercially available hardware and software solutions. Synchronous telemedicine with point-of-care ultrasound is effective in evaluating common vascular conditions. Virtual care may be used for management of patients with chronic vascular disease.

[The REDSIAM network]. / Le réseau REDSIAM (Réseau données Sniiram) ­ Spécial REDSIAM.

The French national health database (SNIIRAM) proved to be very useful for epidemiology, health economics, evaluation, surveillance or public health. However, it is a complex database requiring important resources and expertise for being used. The REDSIAM network has been set up for promoting the collaboration of teams working on the Sniiram. The main aim of REDSIAM is to develop and validate methods for analyzing the Sniiram database for research, surveillance, evaluation and public health purposes by sharing the knowledge and experience of specialized teams in the fields of diseases identification from the Sniiram data. The work conducted within the network is devoted to the development and the validation of algorithms using Sniiram data for identifying specific diseases. The REDSIAM governance includes the Steering Committee composed of the main organizations in charge of producing and using the Sniiram data, the Bureau and the Technical Committee. The network is organized in thematic working groups focused on specific pathological domains, and a charter defines the rules for participation in the network, the functioning of the thematic working groups, the rules for publishing and making available algorithms. The articles in this special issue of the journal present the first results of some of the thematic working groups.

Value of a national administrative database to guide public decisions: From the système national d'information interrégimes de l'Assurance Maladie (SNIIRAM) to the système national des données de santé (SNDS) in France.

In 1999, French legislators asked health insurance funds to develop a système national d'information interrégimes de l'Assurance Maladie (SNIIRAM) [national health insurance information system] in order to more precisely determine and evaluate health care utilization and health care expenditure of beneficiaries. These data, based on almost 66 million inhabitants in 2015, have already been the subject of numerous international publications on various topics: prevalence and incidence of diseases, patient care pathways, health status and health care utilization of specific populations, real-life use of drugs, assessment of adverse effects of drugs or other health care procedures, monitoring of national health insurance expenditure, etc. SNIIRAM comprises individual information on the sociodemographic and medical characteristics of beneficiaries and all hospital care and office medicine reimbursements, coded according to various systems. Access to data is controlled by permissions dependent on the type of data requested or used, their temporality and the researcher's status. In general, data can be analyzed by accredited agencies over a period covering the last three years plus the current year, and specific requests can be submitted to extract data over longer periods. A 1/97th random sample of SNIIRAM, the échantillon généraliste des bénéficiaires (EGB), representative of the national population of health insurance beneficiaries, was composed in 2005 to allow 20-year follow-up with facilitated access for medical research. The EGB is an open cohort, which includes new beneficiaries and newborn infants. SNIIRAM has continued to grow and extend to become, in 2016, the cornerstone of the future système national des données de santé (SNDS) [national health data system], which will gradually integrate new information (causes of death, social and medical data and complementary health insurance). In parallel, the modalities of data access and protection systems have also evolved. This article describes the SNIIRAM data warehouse and its transformation into SNDS, the data collected, the tools developed in order to facilitate data analysis, the limitations encountered, and changing access permissions.

Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy.

In this report, we describe 2 instances in which expert use of an electronic health record (EHR) system interfaced to an external clinical laboratory information system led to unintended consequences wherein 2 patients failed to have laboratory tests drawn in a timely manner. In both events, user actions combined with the lack of an acknowledgment message describing the order cancellation from the external clinical system were the root causes. In 1 case, rapid, near-simultaneous order entry was the culprit; in the second, astute order management by a clinician, unaware of the lack of proper 2-way interface messaging from the external clinical system, led to the confusion. Although testing had shown that the laboratory system would cancel duplicate laboratory orders, it was thought that duplicate alerting in the new order entry system would prevent such events.

Base de datos sistematizada de historias clínicas pertenecientes al I. I. HEMA: informe preliminar / Systematized database of medical records belonging to I. I. HEMA: preliminary report

Se procedió a confeccionar una base de datos de los casos atendidos en Clínica Hematológica del Instituto de Investigaciones Hematológicas. Se registró información sobre: a) Datos demográficos; b) Enfermedad actual; c) Métodos diagnósticos y d) Clasificación de las enfermedades según CIE 10. Sobre un total de 3573 casos registrados entre junio de 2002 y noviembre 2015 se analizaron 1300 (42%) casos. Los principales resultados muestran un predominio de las anemias, y entre ellas las ferropénicas. El mielograma y el frotis de sangre periférica predominaron entre los procedimientos diagnósticos. El tiempo entre primera consulta y diagnóstico muestra que en la mayoría (79,24%) de los casos este fue menor a 3 meses. En un 55,9 % de los casos se inició tratamiento antes del mes. (AU)

A data base was made from cases treated in the Hematological Clinic service. The following information was recorded: a) Demographics; b) Current disease; c) Diagnostic methods and d) Disease classification according to CIE 10. There were analyzed 1300 (42%) out of 3573 cases between June 2002 and November 2015. The main results show predominance of anemia and among them iron deficiency. The myelogram and peripheral blood smear predominated among the diagnostic procedures. Time between first consultation and diagnosis shows that in the majority (79.24%) of cases was less than 3 months. In 55.9% of cases it started treatment before the month. (AU)

[Introduction of the Screening Tool OncoFunction for Functional Follow-up of Head and Neck Patients]. / Vorstellung des Screeningsystems (OncoFunction) für Funktionsstörungen im Kopf-Hals-Tumor-Follow-up.

INTRODUCTION: The follow-up for head and neck cancer (HNC) focussed on therapy control. Accessory long term functionality is important. Impairment of function is observed, but a comparable documentation is not established. Additional we frequently see psychooncological comorbidities, what complicates the assessment. This was the reason why Tschiesner et al. developed on the base of the "ICF Core set for head and neck cancer" a guideline for the Assessment of Function in HNC. In consequence of good results in other tumour entities we developed an electronic version (OncoFunction). METHODS: In a proof of concept study all patients of our follow up consultation from 07/13 to 03/14 were included. OncoFunction was given to patients in a digital form using tablet computers. The results were visible to the physician in a concentrated form before consultation and were supplemented by a physician questionnaire. Furthermore we evaluated the usability in 202 patients. RESULTS: We had 682 patient contacts. 530 patient contacts (77, 7%) used the questionnaire. The physician questionnaire was answered in 470 times. Finally there are from 69.8% of the patient contacts full datasets available. Between users and non-users of the questionnaire we see no difference. CONCLUSION: The use of a computer-based screening and feedback system (OncoFunction) in clinical use is feasible and excellent assessed by patients. The patient data are visible in a compact form for the physician and problems can clear addressed to the patient. One more benefit is the standardized follow up documentation and the use of comparable data in research.

Implementing an Electronic Event-Reporting System in a Radiation Oncology Department: The Effect on Safety Culture and Near-Miss Prevention.

PURPOSE: We implemented an electronic event-reporting system to investigate its effect on quality improvement in our department. METHODS: We developed an event-reporting program that launched in October 2012; data analysis was performed in January 2014. Events were logged by the radiation oncology staff and reviewed by our quality and safety committee on a biweekly basis. To measure the efficacy of the new program, and change in safety culture, a Likert-scale survey was administered before, and three months after, implementation of the event-reporting system. RESULTS: A total of 194 events were logged into the new system during a 15-month period (approximately 13 events per month), compared with 93 events in an 18-month period (approximately five events per month) before the program was launched. The average number of events reported by radiation therapists increased from 0.9 per month to 8.6 per month. The survey results showed a shift toward stronger agreement by staff members, in postimplementation versus preimplementation responses, when they were asked if they knew how to report an event in the department (P = .042), and if the current event-reporting system would reduce the incidence of future events (P = .032). Results showed a trend toward stronger agreement by staff members when they were asked if they felt more comfortable reporting events that they had observed (P = .093). Multiple safety action plans were implemented as a result of analysis of these events. CONCLUSIONS: An electronic event-reporting system streamlines quality and safety in a radiation oncology department by increasing reported events and promoting a safety culture. A program that is widely accessible, easy to use, and can analyze data meaningfully will be the most successful.

Scale-up of networked HIV treatment in Nigeria: creation of an integrated electronic medical records system.

OBJECTIVES: The implementation of PEPFAR programs in resource-limited settings was accompanied by the need to document patient care on a scale unprecedented in environments where paper-based records were the norm. We describe the development of an electronic medical records system (EMRS) put in place at the beginning of a large HIV/AIDS care and treatment program in Nigeria. METHODS: Databases were created to record laboratory results, medications prescribed and dispensed, and clinical assessments, using a relational database program. A collection of stand-alone files recorded different elements of patient care, linked together by utilities that aggregated data on national standard indicators and assessed patient care for quality improvement, tracked patients requiring follow-up, generated counts of ART regimens dispensed, and provided 'snapshots' of a patient's response to treatment. A secure server was used to store patient files for backup and transfer. RESULTS: By February 2012, when the program transitioned to local in-country management by APIN, the EMRS was used in 33 hospitals across the country, with 4,947,433 adult, pediatric and PMTCT records that had been created and continued to be available for use in patient care. Ongoing trainings for data managers, along with an iterative process of implementing changes to the databases and forms based on user feedback, were needed. As the program scaled up and the volume of laboratory tests increased, results were produced in a digital format, wherever possible, that could be automatically transferred to the EMRS. Many larger clinics began to link some or all of the databases to local area networks, making them available to a larger group of staff members, or providing the ability to enter information simultaneously where needed. CONCLUSIONS: The EMRS improved patient care, enabled efficient reporting to the Government of Nigeria and to U.S. funding agencies, and allowed program managers and staff to conduct quality control audits.

Uses of cancer registries for public health and clinical research in Europe: Results of the European Network of Cancer Registries survey among 161 population-based cancer registries during 2010-2012.

AIM: To provide insight into cancer registration coverage, data access and use in Europe. This contributes to data and infrastructure harmonisation and will foster a more prominent role of cancer registries (CRs) within public health, clinical policy and cancer research, whether within or outside the European Research Area. METHODS: During 2010-12 an extensive survey of cancer registration practices and data use was conducted among 161 population-based CRs across Europe. Responding registries (66%) operated in 33 countries, including 23 with national coverage. RESULTS: Population-based oncological surveillance started during the 1940-50s in the northwest of Europe and from the 1970s to 1990s in other regions. The European Union (EU) protection regulations affected data access, especially in Germany and France, but less in the Netherlands or Belgium. Regular reports were produced by CRs on incidence rates (95%), survival (60%) and stage for selected tumours (80%). Evaluation of cancer control and quality of care remained modest except in a few dedicated CRs. Variables evaluated were support of clinical audits, monitoring adherence to clinical guidelines, improvement of cancer care and evaluation of mass cancer screening. Evaluation of diagnostic imaging tools was only occasional. CONCLUSION: Most population-based CRs are well equipped for strengthening cancer surveillance across Europe. Data quality and intensity of use depend on the role the cancer registry plays in the politico, oncomedical and public health setting within the country. Standard registration methodology could therefore not be translated to equivalent advances in cancer prevention and mass screening, quality of care, translational research of prognosis and survivorship across Europe. Further European collaboration remains essential to ensure access to data and comparability of the results.

Supporting patient screening to identify suitable clinical trials.

To support the efficient execution of post-genomic multi-centric clinical trials in breast cancer we propose a solution that streamlines the assessment of the eligibility of patients for available trials. The assessment of the eligibility of a patient for a trial requires evaluating whether each eligibility criterion is satisfied and is often a time consuming and manual task. The main focus in the literature has been on proposing different methods for modelling and formalizing the eligibility criteria. However the current adoption of these approaches in clinical care is limited. Less effort has been dedicated to the automatic matching of criteria to the patient data managed in clinical care. We address both aspects and propose a scalable, efficient and pragmatic patient screening solution enabling automatic evaluation of eligibility of patients for a relevant set of trials. This covers the flexible formalization of criteria and of other relevant trial metadata and the efficient management of these representations.

Lessons learned from the American College of Surgeons National Surgical Quality Improvement Program Database: has centralized data collection improved immediate breast reconstruction outcomes and safety?

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program database was implemented to longitudinally track surgical 30-day surgical outcomes and complications. The authors analyze the program-reported outcomes for immediate breast reconstruction from 2007 to 2011, to assess whether longitudinal data collection has improved national outcomes and to highlight areas in need of continued improvement. METHODS: The authors reviewed the database from 2007 to 2011 and identified encounters for immediate breast reconstruction using Current Procedural Terminology codes for prosthetic and autologous reconstruction. Demographics and comorbidities were tabulated for all patients. Postoperative complications analyzed included surgical-site infection, wound dehiscence, implant or flap loss, pulmonary embolism, and respiratory infections. RESULTS: A total of 15,978 patients underwent mastectomy and immediate reconstruction. Fewer smokers underwent immediate reconstruction over time (p=0.126), whereas more obese patients (p=0.001) and American Society of Anesthesiologists class 3 and 4 patients (p<0.001) underwent surgery. An overall increase in superficial surgical-site infection was noted, from 1.7 percent to 2.3 percent (p=0.214). Wound dehiscence (p=0.036) increased over time, whereas implant loss (p=0.015) and flap loss (p=0.012) decreased over time. Mean operative times increased over the analyzed years, as did all complications for prosthetic and autologous reconstruction. CONCLUSIONS: The American College of Surgeons National Surgical Quality Improvement Program data set has shown an increase in complications for immediate breast reconstruction over time, because of a longitudinally higher number of comorbid patients and longer operative times. This knowledge allows plastic surgeons the unique opportunity to improve patient selection criteria and efficiency. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Development, implementation, and evaluation of a hybrid electronic medical record system specifically designed for a developing world surgical service.

BACKGROUND: The Pietermaritzburg Metropolitan Trauma Service previously successfully constructed and implemented an electronic surgical registry (ESR). This study reports on our attempts to expand and develop this concept into a multi-functional hybrid electronic medical record (HEMR) system for use in a tertiary level surgical service. This HEMR system was designed to incorporate the function and benefits of an ESR, an electronic medical record (EMR) system, and a clinical decision support system (CDSS). METHODS: Formal ethical approval to maintain the HEMR system was obtained. Appropriate software was sourced to develop the project. The data model was designed as a relational database. Following the design and construction process, the HEMR file was launched on a secure server. This provided the benefits of access security and automated backups. A systematic training program was implemented for client training. The exercise of data capture was integrated into the process of clinical workflow, taking place at multiple points in time. Data were captured at the times of admission, operative intervention, endoscopic intervention, adverse events (morbidity), and the end of patient care (discharge, transfer, or death). RESULTS: A quarterly audit was performed 3 months after implementation of the HEMR system. The data were extracted and audited to assess their quality. A total of 1,114 patient entries were captured in the system. Compliance rates were in the order of 87-100 %, and client satisfaction rates were high. CONCLUSIONS: It is possible to construct and implement a unique, simple, cost-effective HEMR system in a developing world surgical service. This information system is unique in that it combines the discrete functions of an EMR system with an ESR and a CDSS. We identified a number of potential limitations and developed interventions to ameliorate them. This HEMR system provides the necessary platform for ongoing quality improvement programs and clinical research.