Capturing Postoperative Structured Data May Save Lives

Looking for the needle

Tomorrow's health care decisions are based on today's medical data. It's a statement that I've repeated often in these blog posts, but it simply cannot be overstated. Putting aside the question of structured data, even unstructured narrative text is the raw data that is being extracted and used to inform future practices in medicine. Those long sentences of transcription contain within them the keys to unlocking better care for patients by noticing trends in outcomes, efficacy of treatments, and best practices for combating certain ailments or injuries.

Recently, there was an excellent piece written by Dr. Michael Goldfarb, MD FACS for General Surgery News entitled "The Elephant in the OR." In it, Dr. Goldfarb outlines the various ways that multiple cancer surgeries are prone to risks of infection and the best way to anticipate, identify, and manage these factors in order to promote better outcomes for patients. It's a fascinating read, especially as Dr. Goldfarb had to strenuously search for information found in other journal entries to access the data he needed to test his theories and arrive at his potentially life-saving conclusions. But what if there were a better way?

Electronic structured data is that better way. By documenting health information in a standardized manner, using the same verbiage and location in charts, and preventing incomplete reporting, electronic structured data enables physicians to properly record the accounts of their work and their findings in such a way that easily accessible and viable for future physicians to then use for such research. Electronic structured data allows logic branching and intelligent decision tree questions—that means that physicians won't have to answer irrelevant questions, but their answers may bring up further questioning about key areas. For example, if physician answers "Yes" to something, she or he may then get some follow up questions that they easily fill out to better explain the behavior or the finding. If they answer "No," those questions never appear because it is not applicable to the case. Meanwhile, all physicians using the structured data form would be using the same format and language, making it easier to find the information and to understand it without bogging down each other with follow up questions to explain what was meant by this phrase or that word. Standardization wouldn't just benefit communication between physicians, it also means that each field is a searchable field. Now reports can be run on any field (or multiple fields) in order to see trends in population health, demographic behaviors, or how effective the treatments and protocols are in dealing with the various problems patients present. Furthermore, each itemized piece of data can now be automatically submitted to a database—whether that's a disease registry, a compliance organization, or simply the EHR. The data is now working for the physician in a way that is easier to understand and far more cost effective.

There is an elephant in this blog post, of course. mTuitive is the synoptic reporting company and we traffic in structured data. So this could all be seen as an extended sales pitch for one of our products. And that may be true, though there are other solutions out there for those interested. But more importantly is the question of Why mTuitive began. Our co-founder, Dr. William O'Toole, was a former chief pathologist at a hospital who noticed the laborious nature of communicating results to physicians. He also noticed that redundant processes were occurring where information in a transcribed, unstructured report had to be entered into another form in order to meet requirements of American College of Surgeons and the College of American Pathologists certifications. Information could easily be lost in that translation or, worse yet, there was no assurance that the information was being entered in the first place. While we are private company who still makes sales, our focus has always been on empowering physicians by streamlining workflows and improving data entry. And in the decade or so since we've started, we've only seen reality confirm our reasons for why structured data is important. It seems every year there is a new disease registry that requires data be submitted by physicians, or compliance agencies that require specific information be documented, or quality assurance initiatives that require certain elements of the case be entered into the record. CAP, VQI, cancer registries, CPAC, CCO, ACS are all such agencies or initiatives that now require improved reporting and itemized data. This is why we at mTuitive have expanded beyond pathology and into areas such as radiology, surgery, and vascular procedures. Not simply because they are possible markets but because the need for capturing data in this way is becoming more important and recognized as such by many organizations across the world. But it still comes down to the Why - to improve patient care by capturing the most important information and communicating it as effectively and efficiently as possible. We believe that structured data is the key to this, and the increase in reporting initiatives and requirements is slowly bearing that belief out to be true.

Tomorrow's health care decisions are based on today's medical data. Whenever physicians or researchers are looking to see if there's room for improvement, they must first ask "what is being done presently?" They become explorers combing through reams of text to find the salient points and try to connect the dots. Why make this process more laborious than it already is? Imagine a world where a simple search could return itemized results with the necessary information—the ailment, the procedure, the patient demographic, whatever is in the scope of interest. Structured data is the key to making this a more efficient and precise process. Instead of Dr. Goldfarb poring over medical journals hoping to find some article that matches his interest, he could see the results himself, chart and graph them to notice the trends, and better understand what changes need to be implemented to improve patient care. Instead of this incredibly valuable information being lost to the differences in parlance, location, or simply lack of inclusion, electronic structured data standardizes these elements and eliminates complications when searching for key, helpful information. Instead of simply having vital health information lie dormant until someone decides to look into it, structured data empowers those elements and puts them to work for physicians. Tomorrow's health care decisions are based on today's medical data—so why not ensure that the process of capturing today's data is as effective, efficient, and proactive as the physicians entering it?

photo credit: Perry McKenna via photopin cc