The Use of Electronic Synoptic Operative Reporting to Improve Operative Reports for Spinal Cord Injury Patients
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Improving the quality of care for patients requires assuring accurate diagnosis and timely, accessible information that enables treatment planning and makes patient care decisions more informed and evidence-based. Traditionally, in the surgical domain, physicians and surgeons document surgical information in a narrative reports. These traditional operative reports collect information in non-standardized format which depends mainly on the surgeon‘s ability to remember and collect the details of the surgical procedures. The narrative (dictated) operative report can contain redundant, nonessential information and can lack critical information for enhancing the continuing of care for patients. Also, narrative reports limit the use of operative data for secondary purposes such as research or evaluation projects. One solution that has been discussed widely to improve the data quality of operative reporting is the use of the electronic synoptic operative report template. Synoptic reporting allows the use of a structured format when collecting data and enables the capture of discrete data items. Consequently, allocation and reuse of these data can be done quickly and more efficiently. The synoptic template can also represent a potent educational tool, since it reminds clinicians of important steps and details of the occurrence. The Neurosurgery Division of Dalhousie University, in which the author is performing her internship project, is considered a leader in Canadian surgery and contains many academic programs promoting clinical and research activities. The Spin program is one of the active programs which is provided to promote the care delivery of patients with diseases of the spine. At present, spinal surgeons and residents of the Neurosurgery division use the traditional narrative reporting to gather information about spinal cord injury operations on patients. Consequently, important details can be missed and redundant information can be collected. In this way, operative reports are likely to be incomplete, and unable to efficiently support the continuity of care for patients and to support research studies and administrative purposes. The author of the report is participating in a research study that is being conducted in the Neurosurgery department to test if implementing an electronic synoptic operative report for spinal cord injury patients improves the quality of data captured for primary and secondary use. In this research study, participants (Surgical residents) will be recruited to generate operative reports by using the two methods (dictated and Synoptic reporting). Consequently, the narrative (dictated) and synoptic reports will be compared. This study will measure accuracy, conciseness,completeness and reuse. The electronic template that will be used in this research study will be developed to enable the capture of data elements that are considered important to the collection of data based on consensus between investigators. Moreover, the electronic synoptic operative report template will be built based on Health Level Seven (HL7) clinical statement to enable the collection of discrete data items which is a specific method to construct electronic templates. Also, a medical vocabulary system called SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms statement) will be used as a medical terminology standard to enable the exchange of medical data items between different computer systems. The author worked in this research project as a research assistant and she completed the following tasks: 1- In the electronic synoptic template there 402 clinical data items that should be encoded to SNOMED CT code values. From these, the author completed the SNOMED CT code values for 396 clinical data items. The remaining six data items were considered uncodable by the research team. The author confirmed that the SNOMED CT code values developed for the clinical data items fit the HL7 clinical statements that are used in developing the sections of the electronic template. 2- A confirmation methodology was developed to confirm some of the SNOMED CT code values with the research team. From the 396 clinical data items that were encoded to SNOMEDCT expressions, 43 were considered as needed to be confirmed with the clinician (Dr. Sean Christie). Consequently, the SNOMED CT expressions for 38 data items were confirmed and five were considered as uncodable. As a result, out of the 402 clinical data items provided in the electronic template there are 391 clinical data items that were encoded to SNOMED CT expressions representing 97.26% of the all clinical data items provided in the electronic synoptic template, while 11 data items were considered as uncodable, representing 2.75 % of all clinical data items of the electronic template. 3- The author developed lookup tables containing the SNOMEDCT code values and their descriptions for all clinical data items of the electronic Synoptic template 4- The author conducted a pilot test of the electronic template to test the completeness and usability of the electronic template before providing it to the participant. Results were presented and discussed with the research team and it was found that there is no need to add additional clinical data items to the electronic synoptic operative report template. Also, some issues that were discovered when entering data items were considered when developing the user manual to support participants to efficiently use the electronic template. 5- The author developed a user manual and quick start guide to support participants when using the electronic template. 6- the author could not participate in analyzing the data on accuracy, completeness and reusability of the dictated and synoptic operative reports since there was insufficient time to recruit participants in the study and have them complete the both reports (synoptic and narrative), so the author worked at the modification of the data analysis instruments which will be used in the study to assess the usefulness of the operative reports, (dictated & synoptic). These instruments are; ?Completeness and Accuracy Assessments forms? and ?Recruitment Questionnaire form? Knowledge and experiences, that the author obtained from completing courses of the Health Informatics program have supported the author to effectively complete and perform tasks that have been assigned to her in the internship project. In this paper the author discusses how some Academic courses from the Master of Health Informatics Program enabled her to work in the internship project. These courses are ?Health Information Flow And Standards (HINF 6102)?, ?Research Method (HINF 6020)?, ?Information Systems and Issues (HINF 6110)? and ?Nursing Administration and Leadership (NURS 6000)?, which is an elective course, While the Author was encoding the clinical data items of the electronic template, reviewing the code values with the supervisor (Dr. Grace Paterson), and confirming SNOMED CT code values provided by another previous work, she recognized that there is a tendency for individual users to encode clinical data items differently when using the SNOMED CT system. Therefore, the author searched the literature to explore the issue of the variability of SNOMED CT coding and explored some approaches discussed to enhance the consistency of coding. As a result of this search, the author provides in this paper some approaches recommended in the literature to reduce or overcome the problem of variability of SNOMED CT coding. For example, it is recognized that if it is not feasible to assure the consistency of coding among different coders, it is important to find a method that can algorithmically determine similarities and differences among divergent codes and enable the reconciliations of these differences. Also, it is important to enhance the usability of a complex terminology system like SNOMED CT by developing a logical model that fits users‘ needs. Moreover, the importance of standardized guidelines and training sessions was recognized widely in the literature to reduce variability of coding. Also, binding a terminology standard like SNOMED CT with an information reference model like HL7 Reference Information Model (RIM) was recognized as a way to provide coders with a structured way to restrict their coding performance. The use of more than one terminology standard was also recommended as an approach to increase the coverage of coded data and accordingly reducing the need to use post-coordination SNOMED CT expressions, which is a considerable source of variation when encoding data. In fact, all the approaches discussed in the literature were recommended to promote the reliability of SNOMED CT coding. There is no solution that can avoid variations among different coders since the language is inherently complex in its use and control. Individuals have different interests and ways of understanding things as well. Also the author provides in the report some recommendations derived from her experience in the internship project and these recommendations are presented below: ? The variability of SNOMED CT coding among different coders seems unavoidable, so a crucial task is to enhance the development of a method that algorithmically can detect the similarities and differences among discordant codes. ? A standardized and structured work environment can enhance the reliability of coding. Under controlled circumstances, when coders use the same coding instructions and are exposed to the same training sessions, there will be less coding discrepancy than in more informal situations. ? It is important to promote and encourage the use of more than one terminology standard when encoding data items of a clinical domain. A comprehensive, controlled vocabulary system can support coders to utilize the existence of different terminology standards to allocate the most appropriate code and increase the quality of the coding process ? Guidelines that are released by the International Health Terminology Standards Development Organization (IHTSDO) can effectively help coders learn and understand the concept model of SNOMED CT system, which will support them in the coding process. However, using guidelines or attending train sessions might not be sufficient to promote the quality of the coding process, therefore, exploring examples of real life situations, which describe the coding process that have been taken by other projects from other clinical domains can be very useful in enhancing the quality of coding. ? Changing the traditional way that surgeons use to document operative information can be difficult, therefore it is very important to consider the issue of user satisfaction and adopt methods or approaches to increase the acceptance and avoid resistance of users. At the end of the report, there are some lessons learned that the author obtained from participating in this project for example: ? The author increased her knowledge about the use of SNOMED CT, an important medical terminology standard that is used to enable the collection, retrieval and exchange of medical data items between different computer systems. ? Also, she learned how to use the SNOMED CT compositional grammar in order to build the post-coordination expressions to represent the required meaning of the intended clinical concepts ? Also, in this project the author increased her knowledge about very important component of the HL7 Clinical Document Architecture; which is the HL7 clinical statement.