title: An automatic female pelvic medicine and reconstructive surgery registry and complications manager developed in an electronic medical record.
abstract: OBJECTIVE
  The aim of this study is to incorporate a structured clinical documentation system (SCDS) into the electronic medical record (EMR), allowing for automatic flow of clinical data into an enterprise data warehouse (EDW) and clinical registry.
  
  
  METHODS
  The SCDS programming was developed within inpatient and ambulatory EMR domains, allowing routine documentation in these settings to trigger data flow into an EDW. An extensive set of clinical outcomes was included, focusing on data points likely to exist in the forthcoming American Urogynecologic Society Pelvic Floor Disorders Registry. An electronic complications manager was developed to link immediate and/or delayed complications to the index surgery, allowing for accurate morbidity tracking.
  
  
  RESULTS
  All aspects of EMR documentation were successfully reconfigured for charting in both inpatient and office settings. Clinicians transitioned to clinical documentation such that no additional data entry beyond routine charting was required, and this resulted in data flow into the EDW. Physician feedback led to the refinement of SCDS entry fields.
  
  
  CONCLUSIONS
  This SCDS system allows for automatic flow of a comprehensive data set from our EMR into an EDW and registry. It also provides the ability to systematically track complications and longitudinal clinical outcomes. Integrated systems may eliminate barriers associated with free-standing registries including those relating to cost, maintenance, data integrity, and consistent clinician participation. In addition, it should improve ascertainment of a complete patient population in comparison to voluntary registries.
authors.affiliation: From the *Division of Female Pelvic Medicine and Reconstructive Surgery, †Department of Obstetrics and Gynecology, and ‡Center for Biomedical Research Informatics, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, IL.
authors.forename: Roger P
authors.initials: RP
authors.lastname: Goldberg
authors.forename: Adam
authors.initials: A
authors.lastname: Gafni-Kane
authors.forename: Kelly
authors.initials: K
authors.lastname: Jirschele
authors.forename: Richard
authors.initials: R
authors.lastname: Silver
authors.forename: Darryck
authors.initials: D
authors.lastname: Maurer
authors.forename: Tony
authors.initials: T
authors.lastname: Solomonides
authors.forename: Alan
authors.initials: A
authors.lastname: Simmons
authors.forename: Jonathan
authors.initials: J
authors.lastname: Silverstein
mesh_terms: D001331:Automation; D004282:Documentation; D057286:Electronic Health Records / Q000458:organization & administration*; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000706:statistics & numerical data*; D006801:Humans; D011183:Postoperative Complications; D012042:Registries