Believe it or not: In some countries, doctors do not have to keep records of patients’ visits, surgical procedures or follow-up. For starters, you might think that’s great. However, most of us would accept a certain degree of accountability. We accept that we keep medical records not only to serve the patient to the best of our abilities but also to provide evidence in case someone challenges your clinical care.
Most surgeons accept that keeping medical records is absolutely necessary. Most surgeons also believe that self-auditing is an essential part of professional self-improvement and learning. However, everyone hates data entry, making it the single greatest barrier for doctors and surgeons around the world who wish to maintain their own databases.
One of the most common complaints doctors have about data entry is the fact that it takes away from the already limited and precious time we spend with patients. So we simply take notes and don’t worry about data entry until after the consultation – or surgery – is done. As you would expect, the data will pile up, and so data entry becomes a time consuming, tedious, and inconvenient chore, which is taking away time from already extremely time poor specialists.
Some doctors choose to have scribes take care of data entry; however, adding extra full-time employees to medical practices gets expensive – at least $40K per annum for a data entry clerk, or even more for a medical typist –, especially if it doesn’t improve productivity and efficiency enough to justify such an investment. Other issues with scribes include that some doctors don’t feel comfortable having someone following them around, and also the fact that some believe a scribe is yet another unnecessary person intruding on patients’ privacy.
Increasingly, surgeons are training their own staff to enter data for them and on their behalf. Nurses and midwives, for example, are required to keep records of their activities, so entering the extra data usually takes them only a couple of minutes. This allows doctors to better use their time, but they must ensure their team is trained on the programmes and software being used, to guarantee quality and consistency of data records and that patients’ identities remain unidentifiable.
SurgicalPerformance was created by a team of surgeons, who faced many challenges with record-keeping and self-audit software and registries, including the data entry issues described above, and who work to continuously improve their product to provide surgeons with the best comparative and insightful information about their performance.
The first step they took in trying to encourage consistent data entry was to maintain a low number of data fields, and only data that are associated with clinical outcomes are entered. In addition, for each of those fields, they give surgeons and data entry staff options to select from – instead of getting them to type in the data – as a means to minimise spelling mistakes and data duplication, and to ensure reports produced are of the highest quality, relevance, and insight. So, you click your way through data entry instead of typing manually.
SurgicalPerformance also offers workshops to train practice staff to enter data. Workshop participants receive a handbook for them to keep and take notes, and to refer back to whenever confused about the software. Workshops also cover the importance of protecting privacy, and how to collect data in an unidentifiable way.
SurgicalPerformance allows the option of having reception staff start entering data once patients arrive, and saving data as a draft record, only leaving very few fields for surgeons to complete. Then, with the option of entering either minimal datasets or extended datasets – depending on how deep and meaningful surgeons want their reports to be –, the data entry process is very quick and simple.
Data is entered at two tie points: The first time before or at operation, and then, 4 to 6 weeks after operation for follow up to complete a record. Typically that will take no longer than 30 seconds. Once data entry is complete, surgeons can collect professional development points.
SurgicalPerformance also offers users peace of mind; surgeons can protect their data reports and outcomes with a password, so data entry staff are able to enter data, but not access it.
To learn more about SurgicalPerformance and how to subscribe, click here.