Utility of Synoptic Reporting to Improve Operative Reports for Spinal Cord Injury Patients
The author did his internship in the Division of Neurosurgery of Capital District Health Authority (CDHA) in Halifax. This organization is one of the acute care and rehabilitation hospitals across the country, which is responsible for management, collection and analysis of important data from Canadians with spinal cord injuries through the Rick Hansen Spinal Cord Injury Registry (RHSCIR). During his internship, he worked as Health Informatics research support staff in “Improving Neurosurgery Operative Reports through an Electronic Template for Patients with Spinal Cord Injury” project. While attempting to improve the quality of reporting of operative procedures on spinal injury patients, some of the operative reports of spinal injury patients, who were treated in the past in that organization, were evaluated to detect the drawbacks with the current reporting system and also to find out the possible ways to improve the quality of reporting. A survey of the literature was also done and it was found that the use of template for synoptic operative reporting was one of the possible ways to improve the completeness, accuracy and conciseness of operative reporting on spinal injury patients. An electronic template was created using Microsoft Office InfoPath 2007 which may be published in a SharePoint environment (as discussed in Appendix C). The template is web enabled and browser compatible. It may be filled out in the SharePoint environment even without having InfoPath software on the user’s computer. While composing the content of the synoptic operative report (SOR) template, the author further surveyed the literature, consulted with domain experts and reviewed organizational policies for selection of different data fields so that the SOR would be a good repository for secondary analysis of health data to improve the quality of health care for spinal injury patients (as discussed in Appendix B). Secondary analysis of health data is the use of personal health information for purposes other than direct health care delivery. Tools have also been developed in order to assess the completeness, accuracy and conciseness of the synoptic operative report template (as discussed in Appendix D). The literature survey revealed the importance of standard medical terminology in operative procedure reporting to support interoperability and promote sharing of medical information among different organizations. The author did an “Evaluation of SNOMED CT to represent Spinal Cord Injury Registry” which was reported in the form of an article in Appendix A. In that article the author tried to show the importance of Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) as a standard medical terminology that can improve the quality of reporting for spinal injury patients. A study was conducted to explore the potential for SNOMED CT in the 15 forms with well designed data fields by RHSCIR to track the experiences and outcomes of people with traumatic forms of spinal cord injury (SCI) during their journey through acute care, rehabilitation and community reintegration.