Identification of Local Problem
Difficulty finding an efficient way to identify Emergency General Surgery (EGS) patients and collecting data elements from the electronic medical record (EMR) for the EGS program registry.
Context of the QI Activity
Need for an accurate and timely data collection. EGS specific EMR notes, and operative notes were developed to help address the issue of program data collection.
What were the interventions?
Development of a Smart Phrase EGS Consult and Operative Notes to include Smart Lists of dropdowns to add to the ease and more complete data collection with the providers’ documentation. With these dropdowns embedded into the EGS provider’s note, providers could select categories and gradings which best fit the patient at the time of assessment.
Cost and Funding Sources
No cost as we utilized a function in our electronic EMR, Epic. Dr. Grant utilized her own time to develop this process, and she was valuable in helping to get her partners set up with the same notes for continuity.
Overall Results and Analysis
Development of an EGS program and registry begins with accurate identification of this patient population in the EMR. Developing EMR reports, through the EGS H&P/Consult Note, proved difficult but necessary. In addition, our standardized EGS notes have made data collection for EGS National Surgical Quality Improvement Program (NSQIP) more efficient for the Surgical Case Reviewer.
Limitations
Challenges in identifying EGS patients in the EMR can precipitate an increase of manual labor, and that can be challenging with a new program and limited resources. Development of reports to identify the EGS Consult note proved challenging, as we were looking to find a way to rapidly sort through the patients who were seen for EGS and cohort them onto the EGS registry.
Lessons Learned
Collaboration with EGS Program leadership enhanced the transition/adoption of our new notes. Working with our IT department and our EGS providers, development of EMR reports and note templates improved the identification of EGS patients and efficacy of collecting data within the EGS registry. Consistent utilization of EGS Consult/Operative Notes has proved beneficial in identifying EGS patients and has allowed for highly reliable data abstraction.
