Our Summary

This research paper is about creating a new tool to better document patient data for those undergoing colorectal surgery. Traditionally, medical registries (which are databases of patients’ health information) are either made by reviewing patients’ physical medical records or by using specific forms to capture the data. But with most medical records now being electronic, much of the information is written in a way that’s not easy to extract and organize.

The researchers modified the electronic medical record (EMR) system at their hospital so that it could capture the needed patient data in a more structured and searchable way. This included information about patients’ medical history before surgery, details about the surgical procedure, any complications after surgery, and pathology reports. For any data that couldn’t be captured in this structured format, doctors manually entered the information.

During a test period of six months, 130 patients had colorectal surgery at the hospital. Of these, 80% had their data entered into the new system on the same day of their surgery. The rest had their data entered by the next day. Forty-two patients had complications after surgery, most commonly a leak in the part of the intestine that was reconnected during surgery.

The study shows that redesigning the EMR to capture surgical data in a more structured way is a good strategy for creating an up-to-date, real-time database of patient information. This approach requires little extra work from doctors and is a cost-effective solution.

FAQs

  1. What was the main objective of re-designing the hospital’s EMR?
  2. How many patients were logged into the registry on the same day of their surgery during the 6-month pilot study?
  3. What was the most common cause for severe complications documented in the re-designed EMR?

Doctor’s Tip

A helpful tip a doctor might tell a patient about colorectal surgery is to follow all pre-operative instructions carefully, including any dietary restrictions and bowel preparation. This will help reduce the risk of complications during and after the surgery. Additionally, make sure to discuss any concerns or questions with your healthcare provider before the procedure.

Suitable For

Patients who are typically recommended colorectal surgery include those with colorectal cancer, inflammatory bowel disease (such as Crohn’s disease or ulcerative colitis), colorectal polyps, diverticulitis, and other benign or malignant conditions affecting the colon and rectum. Additionally, patients with hereditary colorectal cancer syndromes, such as Lynch syndrome or familial adenomatous polyposis, may also be recommended for colorectal surgery.

Timeline

  • Before surgery:
  1. Patient undergoes pre-operative evaluation and testing
  2. Patient meets with surgeon to discuss procedure and potential risks
  3. Patient may need to prepare for surgery by following specific diet and medication instructions
  • Day of surgery:
  1. Patient is admitted to the hospital
  2. Patient undergoes surgery
  3. Surgeon documents pre-operative history, operative details, and postoperative complications in the EMR
  • After surgery:
  1. Patient is monitored in the recovery room
  2. Patient is transferred to a hospital room for further monitoring
  3. Surgeon continues to document postoperative progress and complications in the EMR
  4. Patient may experience pain, discomfort, and limited mobility
  5. Patient begins a recovery process that may involve physical therapy and follow-up appointments with the surgeon

Overall, the use of the EMR to document patient-related data as codified variables allows for the creation of a comprehensive database that can improve patient care and outcomes in colorectal surgery.

What to Ask Your Doctor

Some questions a patient should ask their doctor about colorectal surgery include:

  1. What specific type of colorectal surgery do I need and why?
  2. What are the potential risks and complications associated with this surgery?
  3. What is the expected recovery time and what should I expect during the recovery process?
  4. Will I need any special dietary or lifestyle changes before or after the surgery?
  5. How many of these surgeries have you performed and what is your success rate?
  6. Will I need any additional treatments or follow-up care after the surgery?
  7. What is the long-term outlook for someone who undergoes this type of surgery?
  8. Are there any alternative treatment options that I should consider?
  9. What should I do if I experience any unexpected symptoms or complications after the surgery?
  10. How will my information be documented and shared with other healthcare providers involved in my care?

Reference

Authors: Rayman S, Benvenisti H, Westrich G, Schtrechman G, Nissan A, Segev L. Journal: Isr Med Assoc J. 2021 Apr;23(4):239-244. PMID: 33899357