Summary

Background: Medical registries have been shown to be an effective way to improve patient care and reduce costs. Constructing such registries entails extraneous effort of either reviewing medical charts or creating tailored case report forms (CRF). While documentation has shifted from handwritten notes into electronic medical records (EMRs), the majority of information is logged as free text, which is difficult to extract.

Objectives: To construct a tool within the EMR to document patient-related data as codified variables to automatically create a prospective database for all patients undergoing colorectal surgery.

Methods: The hospital's EMR was re-designed to include codified variables within the operative report and patient notes that documented pre-operative history, operative details, postoperative complications, and pathology reports. The EMR was programmed to capture all existing data of interest with manual completion of un-coded variables.

Results: During a 6-month pilot study, 130 patients underwent colorectal surgery. Of these, 104 (80%) were logged into the registry on the same day of surgery. The median time to log the rest of the 26 cases was 1 day. Forty-two patients had a postoperative complication. The most common cause for severe complications was an anastomotic leak with a cumulative rate of 12.3%.

Conclusions: Re-designing the EMR to enable prospective documentation of surgical related data is a valid method to create an on-going, real-time database that is recorded instantaneously with minimal additional effort and minimal cost