Implementation of Electronic Health Record Documentation Tools to Support Compliance with New Commission on Cancer Synoptic Operative Reporting Standards for Melanoma Surgery

INTRODUCTION: The American College of Surgeons Commission on Cancer (CoC)’s new synoptic operative standards require documentation of oncologic elements for cutaneous melanoma wide local excision. Using a 3-phase approach we performed a preintervention assessment of documentation practices; designed, built, and piloted electronic health record (EHR)–based synoptic documentation tools; and performed a postintervention assessment. METHODS: Preintervention assessment of data element capture was performed via chart review. Documentation tools incorporating the CoC standard elements were built into our EHR (Epic). These were designed to satisfy CoC requirements, integrate into surgeon documentation workflows with high usability, record additional data of interest, and prospectively save data in discrete format. Pilot and usability testing were performed; usability was assessed on a 100-point System Usability Scale. RESULTS: Preintervention baseline concordance with required documentation elements was 98% (n = 98/100). To support surgeon workflows across operative dictation mode (verbal vs EHR template), we built documentation tools in 2 formats (Figure). In the 16 months since implementation, synoptic documentation has been successfully incorporated into 303 melanoma operative reports. Mean usability was 100 points on the System Usability Scale.FigureCONCLUSION: Our team successfully built and piloted EHR-based documentation tools to support synoptic operative reporting in compliance with CoC standards. Our surgeons found these tools easy to incorporate into their documentation workflows with excellent usability. Capturing data discretely will enable automated reporting for compliance, quality improvement, and research purposes. Our approach can serve as a model for future implementations at other institutions, particularly those using Epic EHRs.