Opening the black box of cancer surgery quality: WebSMR and the Alberta experience

A comparison of synoptic reports and dictated reports to enhance and standardize surgical documentation and quality of care in epithelial ovarian cancer

OBJECTIVE

The purpose of this study is to assess the degree to which synoptic reports (SRs) and dictated reports (DRs) document elements of the Ovarian Cancer Pan-Canadian Standards Data Elements (OCPCDE) checklist, and to compare their completeness. Analysis of dictated versus synoptic reporting has never been performed for suspected epithelial ovarian cancer (EOC) based on literature review at the time of data collection (1-12).

METHODS

A retrospective chart review was performed including 254 charts of women 18 years or older, from 2012 to 2017, undergoing surgery for suspected EOC. Charts from five gynecologic oncologists, at a single tertiary care centre were used. The OCPCDE checklist was used to evaluate their completeness. Comparison of completeness between SRs and DRs was done using linear regression with a fixed effect of surgeon to account for intraclass correlation.

RESULTS

The data showed that SRs included 20.1% more data elements than DRs. Data elements that may be perceived as being more critical were more likely to be documented in SRs. Residual disease data was documented in 51.7% DR versus 99.1% of SR. Descriptive data upon entering the abdomen was more frequently documented in DRs.

CONCLUSION

This study shows that synoptic reporting includes more data elements deemed important by the OCPCDE checklist authors for suspected epithelial ovarian cancer surgery in our centre. We would recommend continuation of SRs in our department, and implementation of synoptic reporting in other gynecologic oncology centres where surgery for suspected epithelial ovarian cancer is performed.

Synoptic operative reporting in cancer surgery: A scoping review

BACKGROUND

Narrative operative reports (NOR) are important for cancer management but often lack key information. This review investigated the efficacy of synoptic operative reports (SORs) for cancer operations compared to NORs.

METHODS

A database search included published studies up to October 31, 2021. Overall report completeness and reporting frequencies of cancer elements were descriptively compared between NORs and SORs.

RESULTS

Among 4353 studies, 32 were included. 47% of studies compared NORs to SORs. Overall completeness favored SORs (80 ± 19%) over NORs (47 ± 18%, p < 0.001). Essential cancer operative report elements including tumor location (NOR: 51 ± 28%, SOR: 89 ± 11%, p < 0.001), presence of metastases (NOR: 36 ± 33%, SOR: 96 ± 5%, p < 0.001), and final resection margins (NOR: 39 ± 30%, SOR: 87 ± 17%, p < 0.001) demonstrated higher mean reporting frequencies in SORs.

CONCLUSION

Overall completeness and reporting of cancer elements were superior in SORs. Although standardization of SORs requires further research, transition from NORs to SORs may improve the quality of postoperative cancer care.

Synoptic Operative Reporting: Documentation of Quality of Care Data for Rectal Cancer Surgery

Operative reports can be used to evaluate quality of care indicators in surgical patients. This study evaluated documentation of preoperative and intraoperative quality of care indicators for rectal cancer surgery in synoptic reports and traditional dictated reports. Two surgeons independently reviewed 40 prospectively collected synoptic operative reports from rectal cancer cases and a case-matched historical cohort of 40 dictated reports. Rectal cancer–specific quality measures were scored in both report groups using two separate, previously validated checklists. Synoptic reports had significantly higher overall scores on both checklists 1 (mean adjusted score ± SD 76 ± 4 vs 41 ± 19, P < 0.01) and 2 (54 ± 3 vs 24 ± 11, P < 0.01; maximum score of 100 for both checklists). Synoptic reports scored significantly higher in reporting preoperative and intraoperative care indicators. Data were extracted quickly from synoptic reports (mean 3:46 vs 6:21, minutes:seconds to complete checklists, P < 0.05). Synoptic reports are associated with accurate documentation of quality of care data for rectal cancer surgery. Refining the synoptic templates used will further enhance the collection of quality indicators and reporting in complex oncologic procedures.

Synoptic operative reporting for laparoscopic cholecystectomy and pancreaticoduodenectomy: A multi institutional pilot study evaluating completeness and surgeon perceptions

BACKGROUND

Synoptic operative reports (SOR) are more accurate than dictated operative reports (DOR) in a few single institution experiences. We sought to examine the completeness of SOR for laparoscopic cholecystectomy (LC) and pancreaticoduodenectomy (PD) in a multi institutional pilot study.

METHODS

Six institutions participated in SOR submission via a web-based survey. One institution collected DOR and case matched historical dictated operative reports (HOR) for subset analysis. A checklist evaluated completeness of all reports. A post-survey assessed participant opinions.

RESULTS

40 PD SORs were 98.5% complete and 35 LC SORs were 99.7% complete. Single institution subset analysis respective percent complete were: 11 PD SORs 99%, DORs 70% and HORs 74% and 14 LC SORs 99.7%, DORs 76%, and HORs 75%. Post-survey results yielded 10 PD and 24 LC responses. An overwhelming majority agreed that SOR were easy to use and would prefer to use SOR compared to DOR.

CONCLUSION

SOR are more complete than both study associated DOR and HOR. The majority of surgeons indicated their preference for SOR and their willingness to use them.

Completeness of breast cancer operative reports in a community care setting

OBJECTIVES

The narrative operative report represents the traditional means by which breast cancer surgery has been documented. Previous work has established that omissions occur in narrative operative reports produced in an academic setting. The goal of this study was to determine the completeness of breast cancer narrative operative reports produced in a community care setting and to explore the effect of a surgeon's case volume and years in practice on the completeness of these reports.

MATERIALS AND METHODS

A standardized retrospective review of operative reports produced over a consecutive 2 year period was performed using a set of procedure-specific elements identified through a review of the relevant literature and work done locally.

RESULTS

772 operative reports were reviewed. 45% of all elements were completely documented. A small positive trend was observed between case volume and completeness while a small negative trend was observed between years in practice and completeness.

CONCLUSION

The dictated narrative report inadequately documents breast cancer surgery irrespective of the recording surgeon's volume or experience. An intervention, such as the implementation of synoptic reporting, should be considered in an effort to maximize the utility of the breast cancer operative report.

Quality Improvement: An Assessment of Participation and Attitudes of Medical Oncologists

Canadian medical oncologists face limitations to participating in QI initiatives as a result of lack of time, publication resources, and knowledge about ongoing initiatives. Improving networking opportunities and prioritizing QI at the institutional level can address this need.

Influence of data quality on computed Dutch hospital quality indicators: a case study in colorectal cancer surgery

BACKGROUND

Our study aims to assess the influence of data quality on computed Dutch hospital quality indicators, and whether colorectal cancer surgery indicators can be computed reliably based on routinely recorded data from an electronic medical record (EMR).

METHODS

Cross-sectional study in a department of gastrointestinal oncology in a university hospital, in which a set of 10 indicators is computed (1) based on data abstracted manually for the national quality register Dutch Surgical Colorectal Audit (DSCA) as reference standard and (2) based on routinely collected data from an EMR. All 75 patients for whom data has been submitted to the DSCA for the reporting year 2011 and all 79 patients who underwent a resection of a primary colorectal carcinoma in 2011 according to structured data in the EMR were included. Comparison of results, investigating the causes for any differences based on data quality analysis. Main outcome measures are the computability of quality indicators, absolute percentages of indicator results, data quality in terms of availability in a structured format, completeness and correctness.

RESULTS

All indicators were fully computable based on the DSCA dataset, but only three based on EMR data, two of which were percentages. For both percentages, the difference in proportions computed based on the two datasets was significant.All required data items were available in a structured format in the DSCA dataset. Their average completeness was 86%, while the average completeness of these items in the EMR was 50%. Their average correctness was 87%.

CONCLUSIONS

Our study showed that data quality can significantly influence indicator results, and that our EMR data was not suitable to reliably compute quality indicators. EMRs should be designed in a way so that the data required for audits can be entered directly in a structured and coded format.

Evaluating population-based breast cancer surgical practice in real time with a web-based synoptic operative reporting system

BACKGROUND

A Web-based synoptic operative reporting system (WebSMR) incorporates implicit guidelines and real-time feedback of a surgeon's practice compared with provincial data. This study compares rates of total mastectomy (TM) between the overall provincial and WebSMR patients and examines decision-making factors in WebSMR patients.

METHODS

Patients treated for invasive breast cancer (2007 to 2011) were identified from WebSMR and the Alberta Cancer Registry. Reports include surgery type and reasons for TM.

RESULTS

Among 5,787 patients in WebSMR (2007 to 2011), TM rate decreased from 48% to 42% (P < .001). In 2011, the provincial cancer registry recorded a 56% TM rate compared to 42% in WebSMR patients. Patient preference accounted for 36% in the latter group.

CONCLUSIONS

In WebSMR patients, TM rates were lower than the overall provincial rate and decreased significantly during the study period. Reasons are unclear, but guidelines and real-time feedback likely plays a role.

Quality of inguinal hernia operative reports: room for improvement

BACKGROUND

Operative reports (ORs) serve as the official documentation of surgical procedures. They are essential for optimal patient care, physician accountability and billing, and direction for clinical research and auditing. Nonstandardized narrative reports are often of poor quality and lacking in detail. We sought to audit the completeness of narrative inguinal hernia ORs.

METHODS

A standardized checklist for inguinal hernia repair (IHR) comprising 33 variables was developed by consensus of 4 surgeons. Five high-volume IHR surgeons categorized items as essential, preferable or nonessential. We audited ORs for open IHR at 6 academic hospitals.

RESULTS

We audited 213 ORs, and we excluded 7 femoral hernia ORs. Tension-free repairs were the most common (82.5%), and the plug-and-patch technique was the most frequent (52.9%). Residents dictated 59% of ORs. Of 33 variables, 15 were considered essential and, on average, 10.8 ± 1.3 were included. Poorly reported elements included first occurrence versus recurrent repair (8.3%), small bowel viability in incarcerated hernias (10.7%) and occurrence of intraoperative complications (32.5%). Of 18 nonessential elements, deep vein thrombosis prophylaxis, preoperative antibiotics and urgency were reported in 1.9%, 11.7% and 24.3% of ORs, respectively. Repair-specific details were reported in 0 to 97.1% of ORs, including patch sutured to tubercle (55.1%) and location of plug (67.0%).

CONCLUSION

Completeness of IHR ORs varied with regards to essential and nonessential items but were generally incomplete, suggesting there is opportunity for improvement, including implementation of a standardized synoptic OR.

Pan-Canadian REspiratory STandards INitiative for Electronic Health Records (PRESTINE): 2011 national forum proceedings

In a novel knowledge translation initiative, the Government of Ontario's Asthma Plan of Action funded the development of an Asthma Care Map to enable adherence with the Canadian Asthma Consensus Guidelines developed under the auspices of the Canadian Thoracic Society (CTS). Following its successful evaluation within the Primary Care Asthma Pilot Project, respiratory clinicians from the Asthma Research Unit, Queen's University (Kingston, Ontario) are leading an initiative to incorporate standardized Asthma Care Map data elements into electronic health records in primary care in Ontario. Acknowledging that the issue of data standards affects all respiratory conditions, and all provinces and territories, the Government of Ontario approached the CTS Respiratory Guidelines Committee. At its meeting in September 2010, the CTS Respiratory Guidelines Committee agreed that developing and standardizing respiratory data elements for electronic health records are strategically important. In follow-up to that commitment, representatives from the CTS, the Lung Association, the Government of Ontario, the National Lung Health Framework and Canada Health Infoway came together to form a planning committee. The planning committee proposed a phased approach to inform stakeholders about the issue, and engage them in the development, implementation and evaluation of a standardized dataset. An environmental scan was completed in July 2011, which identified data definitions and standards currently available for clinical variables that are likely to be included in electronic medical records in primary care for diagnosis, management and patient education related to asthma and COPD. The scan, sponsored by the Government of Ontario, includes compliance with clinical nomenclatures such as SNOMED-CT® and LOINC®. To help launch and create momentum for this initiative, a national forum was convened on October 2 and 3, 2011, in Toronto, Ontario. The forum was designed to bring together key stakeholders across the spectrum of respiratory care, including clinicians, researchers, health informaticists and administrators to explore and recommend a potential scope, approach and governance structure for this important project. The Pan-Canadian REspiratory STandards INitiative for Electronic Health Records (PRESTINE) goal is to recommend respiratory data elements and standards for use in electronic medical records across Canada that meet the needs of providers, administrators, researchers and policy makers to facilitate evidence-based clinical care, monitoring, surveillance, benchmarking and policy development. The focus initially is expected to include asthma, chronic obstructive pulmonary disease and pulmonary function standards elements that are applicable to many respiratory conditions. The present article summarizes the process and findings of the forum deliberations.

Point-of-care clinical documentation: assessment of a bladder cancer informatics tool (eCancerCareBladder): a randomized controlled study of efficacy, efficiency and user friendliness compared with standard electronic medical records

OBJECTIVE

To compare the use of structured reporting software and the standard electronic medical records (EMR) in the management of patients with bladder cancer. The use of a human factors laboratory to study management of disease using simulated clinical scenarios was also assessed.

DESIGN

eCancerCare(Bladder) and the EMR were used to retrieve data and produce clinical reports. Twelve participants (four attending staff, four fellows, and four residents) used either eCancerCare(Bladder) or the EMR in two clinical scenarios simulating cystoscopy surveillance visits for bladder cancer follow-up.

MEASUREMENTS

Time to retrieve and quality of review of the patient history; time to produce and completeness of a cystoscopy report. Finally, participants provided a global assessment of their computer literacy, familiarity with the two systems, and system preference.

RESULTS

eCancerCare(Bladder) was faster for data retrieval (scenario 1: 146 s vs 245 s, p=0.019; scenario 2: 306 vs 415 s, NS), but non-significantly slower to generate a clinical report. The quality of the report was better in the eCancerCare(Bladder) system (scenario 1: p<0.001; scenario 2: p=0.11). User satisfaction was higher with the eCancerCare(Bladder) system, and 11/12 participants preferred to use this system.

LIMITATIONS

The small sample size affected the power of our study to detect differences.

CONCLUSIONS

Use of a specific data management tool does not appear to significantly reduce user time, but the results suggest improvement in the level of care and documentation and preference by users. Also, the use of simulated scenarios in a laboratory setting appears to be a valid method for comparing the usability of clinical software.

Electronic synoptic operative reporting: assessing the reliability and completeness of synoptic reports for pancreatic resection

BACKGROUND

Electronic synoptic operative reports (E-SORs) have replaced dictated reports at many institutions, but whether E-SORs adequately document the components and findings of an operation has received limited study. This study assessed the reliability and completeness of E-SORs for pancreatic surgery developed at our institution.

STUDY DESIGN

An attending surgeon and surgical fellow prospectively and independently completed an E-SOR after each of 112 major pancreatic resections (78 proximal, 29 distal, and 5 central) over a 10-month period (September 2008 to June 2009). Reliability was assessed by calculating the interobserver agreement between attending physician and fellow reports. Completeness was assessed by comparing E-SORs to a case-matched (surgeon and procedure) historical control of dictated reports, using a 39-item checklist developed through an internal and external query of 13 high-volume pancreatic surgeons.

RESULTS

Interobserver agreement between attending and fellow was moderate to very good for individual categorical E-SOR items (kappa = 0.65 to 1.00, p < 0.001 for all items). Compared with dictated reports, E-SORs had significantly higher completeness checklist scores (mean 88.8 +/- 5.4 vs 59.6 +/- 9.2 [maximum possible score, 100], p < 0.01) and were available in patients' electronic records in a significantly shorter interval of time (median 0.5 vs 5.8 days from case end, p < 0.01). The mean time taken to complete E-SORs was 4.0 +/- 1.6 minutes per case.

CONCLUSIONS

E-SORs for pancreatic surgery are reliable, complete in data collected, and rapidly available, all of which support their clinical implementation. The inherent strengths of E-SORs offer real promise of a new standard for operative reporting and health communication.

Synoptic operative record for point of care outcomes: a leap forward in knowledge translation

INTRODUCTION

Modern information technology coupled with synoptic methodology allows point of care, real time outcomes generation. Our objective was to review province-wide breast cancer surgery outcomes from a prospective synoptic operative record to demonstrate its value in knowledge translation.

METHODS

All synoptic reports for breast cancer procedures from 2006 until March 2010 were reviewed and descriptively analyzed. Key outcomes included frequency of breast cancer procedures captured over time, methods of breast cancer detection, clinical staging, method of axillary staging, breast conservation and reconstruction rates. Further analysis involved important decision-making for mastectomy and resource allocation for surgery.

RESULTS

Four thousand nine hundred fifty-five breast cancer procedures were recorded synoptically; greater than 80% of cases provincially. Method of breast cancer detection was 49%, 45% and 4% by screening radiology, patient or family, and physician, respectively. Pathologic diagnoses were via core or mammotome biopsy in 94%; nearly half of all patients were clinical Stage I at time of operation. Overall rate of breast conservation was 48%. Of the 65% who had no contra-indication to breast conservation surgery, 76% had breast conservation and 4% had primary reconstruction. Of those having mastectomy, one third were due to patient choice. Seventy-nine percent had sentinel node staging, 18% had full axillary dissection and 3% had no axillary staging.

CONCLUSION

A new paradigm of creating medical records using synoptic electronic templates allows prospective outcomes generation at point of care by the surgeon which is unparalleled in its depth of surgical detail capturing surgical decision-making.