Table 1.

Health Information Technology Research in Surgical Care

Author	Study Name	Year	Type of Study	Cohort Size (Study/Control)	Institution	Finding/Addition to literature/Limitations	Result
ELECTRONIC HEALTH RECORDS
Larsen et al.	Improved Perioperative Antibiotic Use and Reduced Surgical Wound Infections Through Use of Computer Decision Analysis	1989	Prospective Observational Study	1621/1830	LDS Hospital	Developed a computerized decision analysis tool to determine which patients qualified for receipt of pre-operative antibiotics. Found a decrease in surgical site infections in the patients stratified to the computerized decision analysis cohort; however, this was not statistically significant after adjusting for the larger quantity of clean cases in the cohort. Found an improvement in timing of prophylactic antibiotic administration, likely due to the impact of placing physician reminder stickers in patient charts.	Positive
Evans et al.	Reducing the Duration of Prophylactic Antibiotic Use Through Computer Monitoring of Surgical Patients	1990	Prospective Observational Study	3665/3991	LDS Hospital	The EHR was used for a clinical decision support system for identifying surgical patients who could have their antibiotics discontinued, followed by a clinical pharmacist who would place a stop-order. No decrease in the number of patients receiving antibiotics too long, but there was a decrease in the number of antibiotic doses for the patients identified as having no indication for antibiotics, from 19 to 13 days.	Positive
Durieux et al.	A Clinical Decision Support System for Prevention of Venous Thromboembolism	2000	Prospective Observational Study	1112/859	Lariboisiere Hospital	Implemented a clinical decision support system which determined based on patient characteristics the risk of a venous thromboembolism and recommendation for prophylaxis in an orthopedic surgery population. There was an improvement in compliance with guidelines from 82.8% in the control (no CDSS) to 94.9% in the intervention group.	Positive
Stengel et al.	Comparison of Handheld Computer-Assisted and Conventional Paper Chart Documentation of Medical Records	2004	Randomized Controlled Trial	36/36	Berlin Trauma Center	Compared traditional paper charting to coding software on a handheld computer for use at the bedside. The handheld device allowed automatically generated ICD codes related to complaints and clinical findings, resulting in significantly more coded diagnoses. There was a significant decrease in the time required for handheld documentation during the study period.	Positive
St. Jacques et al.	Improving Timely Surgical Antibiotic Prophylaxis Redosing Administration Using Computerized Record Prompts	2005	Retrospective Observational Study	148/139	Vanderbilt University Medical Center	Using a part of the computerized record system, the anesthesia computer charting software, computerized alerts notified providers of an approaching redose time 30 minutes prior to the specified time interval. On time antibiotic redosing increased after the implementation of the reminder system, from 20% to 57%.	Positive
O’Reilly et al.	An Anesthesia Information System Designed to Provide Physician-Specific Feedback Improves Timely Administration of Prophylactic Antibiotics.	2006	Prospective Observational Study	Unknown	University of Michigan Health System	Implemented a reminder system for antibiotic administration in an anesthesia information management system. The rate of antibiotic compliance increased from 69% to 92% during a 1-year study period.	Positive
Wax et al.	The Effect of an Interactive Visual Reminder in an Anesthesia Information Management System on Timeliness of Prophylactic Antibiotic Administration.	2007	Retrospective Observational Study	4987/9478	Mount Sinai	Retrospectively analyzed the effect of the addition of an event icon for antibiotic administration in the operating room. Compliance for administration of antibiotics increased from 82.4% to 89.1% before and after the even icon implementation.	Positive
Staes et al.	Computerized Alerts Improve Outpatient Laboratory Monitoring of Transplant Patients	2008	Prospective Observational Study	348/2123	LDS Hospital	Compared a traditional reporting system using clinic staff to track new laboratory results to a system with integrated computerized alerts in transplant patients. 34% of traditionally reported labs did not reach the office and although the results were available in the EHR, no alert notified physicians that the new result was present. 0.8% of computerized lab notifications were not reported. Nurses were able to review the results much quicker with the computerized notification (9.2 hours compared to 33.4 hours).	Positive
Haut et al.	Improved Prophylaxis and Decreased Rates of Preventable Harm with the Use of a Mandatory Computerized Clinical Decision Support Tool for Prophylaxis for Venous Thromboembolism in Trauma	2010	Retrospective Observational Study	399/1200	Johns Hopkins Hospital	Implemented a clinical decision support system (CDSS) which determined based on patient characteristics the risk of a venous thromboembolism (VTE) and recommendation for prophylaxis in adult trauma patients. The compliance rate for evidence-based VTE prophylaxis improved from 66.2% at baseline (no CDSS) to 84.4% and there was a decrease in preventable VTE rates after CDSS implementation.	Positive
Nair et al.	Feedback Mechanisms Including Real-Time Electronic Alerts to Achieve Near 100% Timely Prophylactic Antibiotic Administration in Surgical Cases	2010	Prospective Observational Study	3159/8550	University of Washington	Retrospective review of the paper anesthesia charting reports and prospective study on the implementation of an AIMS to determine antibiotic documentation rates. Real-time feedback and reminders to the anesthesia team to administer and document antibiotics made the largest improvement (9.3%).	Positive
Schwann et al.	Point-of-care Electronic Prompts: an Effective Means of Increasing Compliance, Demonstrating Quality, and Improving Outcome.	2011	Prospective Observational Study	9127/10617	Lehigh Valley Health Network	Prospectively analyzed the effect of point of care electronic prompts via an AIMS on the administration of prophylactic antibiotics and surgical-site infections. Compliance with antibiotic administration increased from 31% to 92% and the overall rate of SSI decreased from 1.1% to 0.7% for the 6-month period before and after prompts implementation.	Positive
Yang et al.	The Effect of Electronic Medical record Application on the Length of Stay in a Chinese General Hospital: a Department- and Disease-focused Interrupted Time-series Study	2013	Retrospective Observational Study	31153/56022	Xijing Hospital	Compared the length of hospital stay(LOS) for patients before and after the implementation of an EHR. Orthopedic and cardiac surgery units with patients having the specific diagnoses of intervertebral disc disorders and ventricular septal defects had decreased LOS by an average of 2.3-2.8 days. Authors note that this may be due other factors which simultaneously underwent change related to LOS.	Positive
Choi et al.	Organizational Performance and Regulatory Compliance as Measured by Clinical Pertinence Indicators Before and After Implementation of Anesthesia Information Management Systems (AIMS)	2014	Retrospective Observational Study	3997/984	Maimonides Medical Center	Compared patients who had data documented in AIMS versus the traditional paper charts. One outcome was the completeness of the documentation which significantly increased with EHR charting (p< 0.001). They also analyzed each of the separate parameters and found that although there was an improvement in documentation of medication dosages, physiological status, mental status, and pain improved, there was not a significant improvement in compliance with antibiotic administration. Of note, their system did not have an interactive prompt as a reminder for antibiotic administration.	Positive
Pinto Thirukumaran et al.	The Impact of Electronic Health Record Implementation and Use on Performance of the Surgical Care Improvement Project Measures	2015	Retrospective Observational Study	1816	Strong Memorial Hospital/Highland Hospital	Compared SCIP measures pre-EHR to post-EHR. They found a decline in odds of urinary catheter removal and blood glucose control after surgery in the months immediately following EHR deployment. After 3 months of deployment, there was a statistically insignificant improvement in scores for these measures.	Negative
Flatow et al	Quality Outcomes in the Surgical Intensive Care Unit after Electronic Health Record Implementation	2015	Retrospective Observational Study	1274/1229	Mount Sinai	Analyzed quality indicators in a surgical ICU 2 years before and after the implementation of an EHR. There was no difference in LOS, C.diff colitis, readmission rate, and case mix indexes. Found an 85% decrease in central line associated blood stream infections per 1000 catheter days and a 28% decrease in mortality within the SICU. However, the study had a significant number of cofounders including the use of daily goals sheets for central line necessity, hiring of more physician extenders, and palliative care involvement for early patient transfers.	Positive
COMPUTERIZED PROVIDER ORDER ENTRY (CPOE)
Webb et al.	Reducing Surgical Site Infections through a Multidisciplinary Computerized Process for Preoperative Prophylactic Antibiotic Administration	2006	Prospective Observational Study	unknown	Atlanta Veterans Administration Hospital	Implemented a computerized order entry option for preoperative antibiotics with practice improvement, improving appropriate and timely administration. Found a significant decrease in clean wound infection rates from 2.7% to 1.4% during the 1-year study period.	Positive
Liu et al.	Using Information Technology to Reduce the Inappropriate use of Surgical Prophylactic Antibiotic	2008	Prospective Observational Study	858	Taichun Veterans General Hospital	Implemented a physician education program and computerized reminder system to order post-operative antibiotics according to guidelines. There was no change in postoperative wound infection rates, but there was a decrease in the use of prophylactic antibiotics for clean cases and decreased duration of prophylactic antibiotics for clean contaminated cases.	Positive
Haynes et al.	Effectiveness of an Information Technology Intervention to Improve Prophylactic Antibacterial use in the Postoperative Period	2010	Prospective Observational Study	2608/2808	University of Pennsylvania	Studied the implementation of an order set preventing prophylactic antibiotics to be ordered for longer than a specified time period (20 hours or 44 hours after surgery in non-cardiac and cardiac surgery patients respectively). Timely discontinuation of antibiotics increased from 38.8% to 55.7%. This discontinuation was virtually only present in locations of the hospital where the electronic CPOE would trigger, suggesting it was not an educational improvement.	Positive
Appari et al.	Medication Administration Quality and Health Information Technology: a National Study of US Hospitals	2011	Retrospective Observational Study	Unknown	Dartmouth, The Health Information and Management Systems Society Analytics Database	Analyzed data from nationwide hospitals to determine if the use of EHR and/or CPOE had an effect on the administration of recommended medications. Found a small increase in the odds of receiving the appropriate preoperative antibiotics and VTE prophylaxis in hospitals with EHR and CPOE. Also found hospitals demonstrated better medication compliance with increased experience with EHR or CPOE.	Positive
Van Sise et al.	Improving the Selection of Recommended Prophylactic Antibiotics Using an Electronic Medical Record	2012	Retrospective Observational Study	934/938	Stony Brook Hospital	Retrospectively looked at the use of prophylactic antibiotics before and after the addition of computerized order sets for antibiotics. There was an increase in the use of recommended antibiotics from 43.4% to 58.1% after order set CPOE.	Positive
ELECTRONIC OPERATIVE NOTES
Laflamme et al.	Efficiency, Comprehensiveness and cost effectiveness when comparing dictation and electronic templates for operative reports	2005	Prospective observational study	138/198	Wishard Memorial Hospital	Compared template electronic notes to traditional dictated notes. Time to verified completed document was 0.46 hours v 374 hours for the template group compared to dictation group. Estimated an average monthly saving of 650 dollars from not having to pay for dictation services. “Key elements” were present in 97% of template electronic reports and 85% of dictated reports. Mean time to produce the report was slightly longer in the template group (6.77 minutes compared to 5.96 minutes.	Positive
Cowan et al.	Electronic Templates versus Dictation for the Completion of Mohs Micrographic Surgery Operative Notes	2007	Retrospective Observational Study	58/52	Johns Hopkins Medical Center	Compared dictated operative notes using a template to electronic template operative notes. The dictated notes required more than a minute longer to complete than those complete by templates. Editing of notes for dictations was 201 seconds compared to 41.6 seconds for electronically generated notes. Template electronic notes took 0.115 days to sign versus 20.7 days to sign dictated notes. For dictated notes, 81 % had at least one error. 5.77 % of electronic template notes had one or more errors.	Positive
Park et al.	Electronic Synoptic Operative Reporting: Assessing the Reliability and Completeness of Synoptic Reports for Pancreatic Resection	2010	Prospective/Retrospective Observational Study	112/102	MSKCC	Electronic synoptic operative reports were developed for pancreatic resections and compared to prior dictated operative notes by the same surgeon for the same procedure. The operative reports were evaluated with a checklist. Electronic notes had significantly higher completeness checklist scores compared to dictated notes (88.8% versus 59.6%) and were available in median 0.5 days compared with 5.8 days for dictated operative notes. Notes were completed in an average of 4 minutes, which was not compared to dictation.	Positive
Hoffer et al.	Structured electronic operative reporting: Comparison with dictation in kidney cancer surgery	2011	Retrospective Observational Study	158/97	Princess Margaret Hospital and the Ontario Cancer Center	Creation of an electronic, online service for electronic operative note creation for urologists. Increased completion rate from 68% to 92% with structured notes compared to dictated notes. There was no difference between attending staff and trainees, and physicians chose which method they wanted to use. 30% of dictated notes were completed in over 5 days and the median time for electronic notes was 2 days.	Positive
Ghani et al.	Smart electronic operation notes in surgery: An innovative way to improve patient care	2014	Retrospective Observational Study	50/50	Royal London Hospital	Audit of 50 operative notes before and after the implementation of electronic operative notes showed an improvement in operative note completeness. Prior to electronic note, 60% contained closure details, 69% included antibiotics at induction, and 66% had legible hand writing. After electronic operative notes, 100% included closure details, antibiotics, and were legible.	Positive
INTERNET
Melloul et al.	Donor Information for Living Donor Liver Transplantation: where can Comprehensive Information Be Found?	2012	Qualitative Research	NA	Internet	Used the EQIP (Ensuring quality information for patients) instrument to analyze living donor liver transplantation information found through the first 100 websites identified through 3 search engines, resulting in 32 unique websites. A median number of 16 out of 36 criteria were met.	NA
Bruce-Brand et al.	Assessment of the Quality and Content of Information on Anterior Cruciate Ligament Reconstruction on the Internet	2013	Qualitative Research	NA	Internet	Used the JAMA benchmark, DISCERN criteria, and HONcode certification to analyze the content returned when ACL reconstruction was queried by analyzing the first 60 returned sites on 4 search engines. Websites with HONcode certification had significantly higher mean DISCERN scores. Academic institutions had higher DISCERN scores.	NA
Fast et al.	Evaluating the quality of Internet health resources in pediatric urology	2013	Qualitative Research	NA	Internet	Used DISCERN and HONcode to analyze 60 websites identified with Google for the terms circumcision, posterior urethral valves, and vesicoureteral reflux. 25-30% of the websites were HONcode certified. Out of the maximum score of 80, the average DISCERN Plus score was 60, 40, and 45 respectively.	NA
Sullivan et al.	Can Internet Information on Vertebroplasty be a Reliable Means of Patient Self- Education?	2014	Qualitative Research	NA	Internet	Used a rating system to determine if the first 35 articles on 3 search engines contain one indication, one risk and one benefit on vertebroplasty. 43% of sites were adequate with sites lacking most in risks and contraindications to procedures, especially in academic centers.	NA
Corcelles et al.	Assessment of the quality of Internet information on sleeve gastrectomy	2015	Qualitative Research	NA	Internet	Used the JAMA benchmark, DISCERN criteria, and HONcode certification to analyze the content in 50 sites for sleeve gastrectomy. Using the mean of three separate scorers, the average score 46.3 out of 80. Academic institutions had higher DISCERN scores.	NA
Fortier et al.	Web-Based Tailored Intervention for Preparation of Parents and Children for Outpatient Surgery	2015	Randomized Controlled Trial	38/44	Children’s Hospital of Orange County and Yale Children’s	Implemented a web-based tailored pre-operative educational intervention for both parents and children. Found significantly decreased anxiety of children upon entrance to the OR and introduction of the mask as well as decreased parent anxiety in preoperative holding according to the Modified Yale Preoperative Scale and the State-Trait Anxiety Inventory, respectively.	Positive
PATIENT WEB PORTALS
Burke et al.	Transforming Patient and Family Access to Medical Information	2010	Prospective Observational Study	252	Miami Children’s Hospital	Developed a web-based patient accessible electronic health record that contained textual and image data. 252 of 270 (93%) of parents offered access became users of the system. Image data was accessed more frequently than textual data. The resource was used more frequently while patients were in the hospital (67% v 33% of total logins). No patients or families requested to see their paper charts during the study period.	Positive
Baucom et al.	Case Report: Patient Portal Versus Telephone Recruitment for a Surgical Research Study	2014	Prospective Observational Study	391/74	Vanderbilt University Medical Center	Study compares the recruitment of patients who have undergone a ventral hernia repair for a research study either through telephone call or patient web portal messaging. Patients recruited through the portal were slightly younger and more recently had undergone their operation compared to patients recruited via telephone. The portal was successful at recruiting 16% of the total study participants.	Positive
Shenson et al.	Rapid Growth in Surgeons’ Use of Secure Messaging in a Patient Portal	2015	Retrospective Observational Study	20484	Vanderbilt University Medical Center	Analyzed three years of patient-initiated portal message threads and found that secure messages accounted for 11.5% of all surgical outpatient interactions during the study period. The use of portal messaging gradually increased over the three year period (5.4 % in 2008 to 15.3% in 2010).	Neutral