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

Abstract

Background

Continuity of care in neurological surgery includes preoperative planning, technical and cognitive operative experience, and postoperative follow-up. Determining the extent of continuity of care with duty hour limits is problematic.

Objective

We used electronic health record data to track continuity of care in a neurological surgery program and to assess changes in rotation requirements.

Methods

The electronic health record was surveyed for all dictated resident–neurological surgery patient encounters (excluding progress notes), discharge summaries, and bedside procedures (July 2009–November 2011). Encounters were designated as preoperative, operative, or postoperative and were grouped by postgraduate year (PGY)–1 through PGY-6.

Results

A total of 6382 dictations were reviewed, with 5231 (82.0%) pertinent to neurological surgery. Of the 1469 operative notes, 303 (20.6%) had a record of an encounter with the operating resident in either a postoperative or preoperative setting. Preoperative encounters totaled 10.1% (148 of 1469); postoperative, 5.1% (75 of 1469); and encounters with both were 5.4% (80 of 1469). Continuity of care was as follows: PGY-1, 13.8% (4 of 29); PGY-2, 17.4% (26 of 149); PGY-3, 29.0% (36 of 124); PGY-4, 24.8% (73 of 294); PGY-5, 28.8% (109 of 379); and PGY-6, 11.1% (55 of 494). One of the highest continuity rates was observed in a rotation specifically constructed to enhance continuity of care.

Conclusions

The electronic health record can be used to track resident continuity of care in neurological surgery. The primary operating resident saw the patient in nonoperative settings, such as general admission, clinic visitation, or consultation in 20.6% (303 of 1469) of cases.

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 periods^5,19,20 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 postoperative evaluation of the patient. Resident evaluations in the preoperative holding area were not included because they did not include participating in the decision for surgery. Daily hospital progress notes during the surgical admission were not included because those notes were entered into the EHR by hand and not dictated and they could not be linked to other encounters. The EHR at UMHC was surveyed for all dictated neurological surgery patient encounters by residents between July 2009 and November 2011, with the exception of progress notes, discharge summaries, and bedside procedures. Encounters were designated as preoperative, operative, or postoperative. Data were initially sorted by resident dictation number. If a resident was involved in a preoperative clinic visit or dictated the hospital admission note and then participated in the surgery, the patient continuity was designated as “preoperative.” Similarly, if a resident saw the patient in a postoperative clinic visit after participating in the patient's operative procedure, the encounters were designated as “postoperative.” Lastly, if the resident participated in a preoperative evaluation and a postoperative clinic visit and participated in the operative procedure, the encounters were designated as “both.” Data were grouped by postgraduate year (PGY)–1 through 6, as well as by specific resident.

During core neurological surgery rotations, residents were expected to attend clinic 2 half-days per week, except the chief resident (PGY-6), who was expected to attend clinic 1 half-day per week. Rotations were similar for residents during each specific year of training, as shown in table 1. Outpatient experiences varied on each rotation. Of note, the PGY-5 rotation was designed specifically to enhance continuity of care with the resident functioning as the liaison to the Harry S. Truman Memorial Veterans' Hospital, among other responsibilities. During this rotation, residents saw all Veterans Health Administration patients in clinics specially designed for them at UMHC, participated in the patients' operative procedures, and saw them for follow-up in the UMHC Veterans Health Administration clinics.

TABLE 1.

Residency Rotations

This project was reviewed by the University of Missouri Health Sciences Institutional Review Board and approved as a Quality Improvement Project.

Results

Between July 2009 and November 2011, 6382 dictations were recorded for residents in the neurological surgery program; of those, 5231 (82.0%) were pertinent to neurological surgery patient evaluation (clinic visits, consultations, admission notes) or surgical procedures (operative notes). Of the 5231 dictations, 1469 (28.1%) were operative notes dictated by residents. Preoperative and postoperative experiences, which form the basis of the continuity of care experiences, and continuity of care by PGY level, are summarized in table 2. Continuity of care was highest for PGY-3 through PGY-5. In PGY-3, the overall operative volume was relatively low (124 of 1469 cases, 8.4%), whereas operative participation was more robust in PGY-4 (294 of 1469 cases, 20.0%) and PGY-5 (379 of 1469 cases, 25.8%). One of the highest continuity rates was observed during the year that included the rotation constructed to enhance continuity of care (PGY-5).

TABLE 2.

Continuity of Care by Postgraduate Year (PGY) Level

Continuity of care was also measured for each individual resident during the study period (table 3). Resident D, who had been in PGY-3, PGY-4, and PGY-5 during the study period, had the highest percentage of continuity of care experience (26.8%, 30 of 112).

TABLE 3.

Continuity of Care by Individual Resident

Discussion

The findings provided the proof-in-principle that the EHR could be used to track the continuity of care by neurological surgery residents. We found that the primary operating resident saw the patient in nonoperative settings, such as admission, clinic visitation, or consultation, in 20.6% (303 of 1469) of cases. Furthermore, a rotation designed with the intent to enhance continuity of care had 1 of the highest rates of continuity of care among rotations. At the same time, the percentage of patients seen preoperatively, intraoperatively, and postoperatively was a disappointing 9.8% (37 of 379). That low percentage relates, in part, to other operative and patient care responsibilities in which residents are involved.

Data such as these presented can be used to guide individual resident education to optimize available experiences or to guide rotation development to enhance continuity of care for this rotation and others. Because medical institutions are required to use EHR for patient care, residency programs have potential access to data to track resident continuity of care. The approach to be used is to retrieve and sort data for each individual resident. In our study, resident dictation number effectively assigned patient encounters to specific residents. Additional effort was needed to sort patient encounters into preoperative, postoperative, operative, and grouped experiences by PGY training. Once data on continuity of care are collected, each program can evaluate rotation structure for appropriate levels of continuity. Mechanisms suggested for improving resident continuity experiences in surgical and nonsurgical specialties have included increasing rotation length^13,22,23; mandatory ambulatory clinic¹⁹; other means of increasing clinic time¹³ without increasing panel size³; “resident-return model” of outpatient clinic, in which residents were able to see postoperative patients in clinic, even if they were on a different rotation²³; a “one-on-one mentor model,” in which each resident was assigned to a specific faculty member to see all of that faculty member's patient preoperatively, postoperatively, and intraoperatively²⁴; and variable-day clinic schedule for residents' returning patients.² Some have been more successful than others.

Interestingly, continuity of care was comparable for our PGY-3 residents (29.0%) and PGY-5 residents (28.8%). The PGY-3 residents had lower operative volumes because half of their rotations were nonclinical. In 1 rotation, the PGY-3 resident was assigned to specific faculty members and participated in those faculty members' operative procedures, similar to the one-on-one mentor model of Chung et al.²⁴ Although improvement is possible, the models we have adopted to enhance resident continuity of care include a combination of required clinic experiences and a rotation designed to enhance continuity of care as a stepping stone to independent practice. Required clinics are essentially hit-or-miss; by being in an ambulatory clinic, the resident may see some preoperative patients and then participate in their operative procedures and see some postoperative patients after participating in their operative procedures. This model is illustrated best by the data for residents in PGY-4, who had a 24.8% (73 of 294) continuity rate with a reasonable level of operative experience. Continuity of care rate was highest at 28.8% (109 of 379) for PGY-5 residents in the rotation designed to maximize continuity of care experiences. The rate is not 100% because PGY-5 residents have other operative responsibilities not associated with outpatient clinic responsibilities. To be able to participate in all operative procedures for patients in the Veterans Health Administration, the resident would not be able to attend other pediatric or adult neurological surgery clinics and would not have continuity for pediatric or on-call procedures. Our current data collection method does not permit sorting the operative procedures into those different experiences.

Our study had a number of limitations. It involved a few residents, and residents were not followed for their entire training period. At the same time, all UMHC rotations were included during the study. Another limitation was the loss of information by using unique dictation numbers. Important components of continuity of care, such as involvement in care of patient complications, daily in-hospital care, and fielding outpatient phone calls, cannot be captured by our methodology, and higher levels of continuity of care than what can be tracked may actually be present. Using unique dictation numbers can also be problematic if notes are entered into the EHR without dictation or when dictation aids, such as Dragon (Nuance Communications Inc), which does not use numerical identifiers, are used. We have no metric for what constitutes an appropriate level of continuity of care for clinical care, patient satisfaction, or resident education. In addition, we do not report any specific interventions to improve continuity of care for our residents. Finally, our study was performed at a single institution, and the results may not be generalizable to other institutions.

Conclusion

Our study showed the EHR can provide data to understand the continuity of care experience for neurological surgery residents. The primary operating residents saw patients in nonoperative settings in 20.6% (303 of 1469) of cases, with the most robust experience occurring in a rotation designed to enhance continuity of care. Information of this type can be used to optimize continuity of care experiences and to improve resident education, patient care outcome, and patient satisfaction.