Use of the Electronic Health Record to Track Continuity of Care in Neurological Surgery Residency

摘要

What was known Determining the extent of continuity of care in an era of duty hour limits is problematic.;What is new Study uses electronic health record data to track continuity of care in a neurological surgery program and to assess changes in rotation requirements.;Limitations Small sample and single institution study limit generalizability.;Bottom line Electronic health record data was effective in tracking continuity of care and indicated that the primary operating resident saw the patient in nonoperative settings in 21% of cases.;Introduction Continuity of care, an “informational, longitudinal, and interpersonal” relationship between patient and physician, is an important concept in medicine and medical education.1 Nonsurgical specialties provide longitudinal care experiences with a panel of patients.2–4 In surgical training programs, the components of continuity of care include participating in preoperative care by deriving diagnoses and planning operative procedures, performing operative procedures, and providing postoperative care.5,6 Resident continuity of care has a positive effect on the care of surgical patients, with research showing patients are more knowledgeable, have better satisfaction, and have improved compliance.5 Despite its importance, providing residents with appropriate continuity of care experiences is difficult. Multiple rotation sites, short rotation time, haphazard clinic scheduling, seeing new patients rather than follow-up patients,7 and work restrictions reducing outpatient clinic experiences limit continuity.8–12 These issues are complicated by other changes in medical education and clinical care, including duty hour restrictions and enhanced supervision requirements.13–16 Complex resident schedules and limited clinic time had an added negative effect on continuity.17 Resident and faculty satisfaction with continuity of care learning experiences has declined since initiation of duty hour limits.18 Clinical rotations may require adjustments to enhance continuity of care experiences to achieve resident educational and patient care benefits. Tracking continuity of care experiences is essential to ensuring that adjustments are meaningful. However, efforts to assess continuity of care may suffer from methodological flaws. Past efforts, including resident participation questionnaires for limited periods5,19,20 and retrospective medical record reviews,21 were time consuming, labor intensive, and incomplete, capturing only a glimpse of the overall experiences. With the advent (and requirement) of electronic health records (EHRs), there are new opportunities for acquisition of data on residents' educational experiences. We hypothesized that the EHR could be used to track continuity of care in residency programs and to provide data to assess changes in rotations to enhance continuity.;Methods The University of Missouri Hospital and Clinics (UMHC) uses Powerchart (Cerner) as the software for its EHR. For dictated records, providers, including residents, are identified by a unique 4-digit dictation number entered along with a 9-digit patient visit number and 3-digit type of dictation code at the beginning of dictation. In this way, each dictation can be traced to a specific provider. During rotations at UMHC, neurological surgery residents dictate all admission notes, outpatient encounters, and operative notes for procedures in which they are involved. These dictations are entered into the EHR, categorized as “clinic visits,” “admission notes,” or “operative notes.” These dictations are identified for retrieval by dictation number. For the purposes of this study, components of continuity of care were defined as preoperative notes (admission notes, consult notes, or preoperative outpatient clinic notes), operative procedure notes, and postoperative clinic notes. We defined continuity of care as the resident participating in the operative procedure and at least the preoperative evaluation or the postoperati