ABSTRACT
Maintenance of Certification (MOC) was designed to assess physician competencies including operative case volume and outcomes. This information, if collected consistently and systematically, can be used to facilitate quality improvement. Information automatically extracted from the electronic medical record (EMR) can be used as a prompt to compile these data. We developed an EMR-based program called MyPOD (My Personal Outcomes Data) to track surgical outcomes at our institution. We compared occurrences reported in the first 18 months to those captured in the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-P) over the same time period. During the first 18 months of using MyPOD, 691 cases were captured in both MyPOD and NSQIP-P. There were 48 cases with occurrences in NSQIP-P (6.9% occurrence rate). MyPOD captured 33% of the occurrences and 83% of the deaths reported in NSQIP-P. Use of the MyPOD program helped to identify series of complications and facilitated systematic change to improve outcomes. MyPOD provides comparative data that is essential in performance evaluation and facilitates quality improvement in surgery. This program and similar EMR-driven tools are becoming essential components of the MOC process. Our initial review has revealed opportunities for improvement in self-reporting which we can continue to measure by comparison to NSQIP-P. In addition, it has identified systems issues that have led to hospital-wide improvements.
