How I use Data to improve myself
How I got interested in keeping data
In 1988 after passing the part 1 of the MRCOG examination and while waiting for a registrar’s post in Obstetrics and Gynaecology, I was posted to the Chest Clinic of The Sultanah Aminah Hospital in Johor Bahru. Instead of wasting my time, I decided to write my ‘’long case’, which is a requirement for the Part 2 of the MRCOG examination. As I was working in the chest clinic, I decided to write on “Tuberculosis and Pregnancy”. The aim of the study was to look at all the Tuberculosis cases over the previous 5 years and select cases where the patients were already pregnant when diagnosed with tuberculosis as well as those who conceived while on tuberculosis treatment, to see how they fared during their pregnancy. I also examined the children born to these mothers who were treated for tuberculosis while pregnant.
The Chest Clinic kept meticulous records of all their patients who had undergone tuberculosis treatment. This was because of the National Tuberculosis Registry. However, this was not reflected in the outpatient department of the hospital where many of the patients underwent antenatal follow-ups. I had a great deal of difficulty retrieving medical records of these patients. They were kept in storerooms, which were in terrible state. However, somehow I managed to retrieve most of the data and wrote the paper, which was ultimately accepted by the Royal College of Obstetricians and Gynaecologists as my gynaecology long case report.
In the beginning of private practice
In 1994, when I moved to private practice in Mahkota Medical Centre, I was determined to keep good data. We did not have any electronic medical records. Everything was written down. We all know that we learn the most from our patients. I was keen to know who my patients were and what procedure I had performed on them. I wanted to know how they were after the procedures. I wanted to learn from every patient. Keeping good data was the best way to learn from my patients. Memory is short-term and only by revisiting my patients’ notes, especially the interesting and most definitely, the patients I messed up, that I could learn the most.
The problem was how to keep good data in an era prior to digital record keeping? Current doctors have the benefit of an Electronic medical system as the hospital keeps all the records electronically. It is easy to retrieve data. In the 1990s and 2000s I had to make my own effort in keeping patients’ data electronically. I first started by keeping data in Microsoft Excel and Microsoft Access. However, the amount of data I could keep in these files was limited.
In 1999, the hospital management changed and we were asked to rent or buy our own suites in the hospital. With my own clinic, I was able to revamp my outpatient data collection. The first data I wanted to keep was my outpatient records. I computerised my clinic so that I have a complete record of all my outpatient clinic notes. I had difficulty finding a clinic software which was reasonably priced. I found a clinic software created by a doctor, which I bought and used for almost 10 years. Unfortunately, his company went bust and he stopped supporting the software. I was forced to discontinue using it. I then bought another programme from a software engineer and migrated my earlier data to this software. I am still using this software till today.
Besides outpatient records, I wanted to keep more data. My operation procedure, intrauterine insemination and invitrofertilization data were still on Microsoft Access, Microsoft Excel and Word documents. I was keeping my operation records in Word documents. I did not write my operation findings. Everything was typed into Word document and I printed a copy and placed it into the patients’ medical files. These are important data for me as there is a lot to learn from them. Microsoft Access was cumbersome and not optimal. A friend suggested that I try Bento a simple database for Mac users. I managed to source someone from Hong Kong to migrate my data from the Access to Bento. We then manually migrated the Word documents of operation records to Bento. I used Bento for almost 15 years. Unfortunately, Bento was also discontinued a few years ago. I had to look for another programme, which would allow me to migrate my data from Bento. I found TAP Forms. This programme allowed me to migrate all my data and I am using TAP Forms till today.
Another dataset I wanted to keep is ultrasound photographs. I consulted a friend to find a way to keep this data. Even though it is kept in the ultrasound machine, it was inconvenient for me to retrieve it. Morever, the hard disk in the ultrasound machine gets full and old pictures have to be deleted. I needed the photographs to be kept on my computer. A friend suggested OSIRIX. This is a software programme with DICOM whereby photographs taken on the ultrasound machine can immediately be migrated to my computer. I started storing ultrasound photographs in 2009. Since then all ultrasound images are stored in my computer and the data is at my fingertips. In this way I can look at someone’s ultrasound picture taken 10 years ago, to one that has been taken recently. I can show the patient the difference immediately. What an impact it gives to the patient. This is also a good learning resource for me as well.
My own server
As more and more data is collected the digital storage space in my clinic became insufficient. I had to invest in my own server. All my surgeries are recorded. For laparoscopic surgeries this process is easy but for open surgeries I had to invest in a good video camera so that someone can record part of the surgery for me. Since it is impossible to store all the videos in my server, every case is edited down to 10 minutes and kept in the server. The original videos of an operation are saved in a DVD or blue ray disc and stored. The edited videos can be retrieved at any time. This is very convenient because when a patient comes for a follow-up besides looking at my operation notes, I can also look at the edited video reminding me about the surgery. These edited videos are also useful for teaching and research. I have learnt so much by simply looking at the videos of operations done many years before, especially those where complications occur.
This reminds me of a patient who underwent a laparoscopic hysterectomy. 5 years later she presented with right loin pain. CT scan showed a right hydronephrosis and a sac like structure next to the right ureter. Urethroscopy showed the sac like structure was a collection of urine from a fistula in the right ureter. I could not explain how this fistula occurred. I reviewed the recording of my surgery. In this patient, I dissected out the right ureter. At the end of the surgery the right ureter looked good. I did not cause the fistula. So we concluded that a ureteric stone, which she probably passed out, must have caused the fistula.. She had to undergo a reimplantation of the ureter to the bladder. If I did not have a recording, I would have been blamed for the fistula formation even though I performed the surgery 5 years earlier. It was a learning experience for me because now I refrain from routine dissection of all ureters prior to a hysterectomy and only do so if indicated. When dissecting a ureter, I have to ensure that the blood supply to the ureter is not compromised, to avoid any stricture formation in the future. The advantage of the computerization is that all the data is at my fingertips. I can retrieve data easily and this becomes very convenient.
Another data set that I keep is office hysteroscopy. This procedure is always recorded and kept in my server. If the patient develops a problem the video can easily be reviewed. I can also show her previous recording and compare it with the current findings.
Recently, I started HIFU for fibroids and adenomyosis. I am following the same steps. All the HIFU procedures are recorded and stored in my server. I will be able to go back and watch what I did to see how well or badly, I performed. Having a feedback loop of revisiting recordings of the procedure allows me to learn faster and more efficiently.
Keeping data can be painfully difficult. It requires careful planning and organisation. The good news is that many of the tasks can be delegated to your staff.
As more and more hospitals are moving towards the Electronic Medical System, I realise that many of the things I have done by myself over the years, is being done by hospitals now. Even then hospitals will never be able to keep as much data as I do myself.
So what advise can I give young doctors going into private practice?
- In the era of digitalization you cannot afford to say that you are not computer literate. Have a good knowledge and habit of using computers.
- It is well known that we need feedback loops to tell us that what we are doing is outstanding. Having data of different sorts helps in giving us a good feedback loop.
- Look at how data is kept in the hospital you work. Go beyond what your hospital provides and keep your own data.
- Periodically, look at your data to see what you can learn from your patients.
- Keep a book and write down all the interesting cases you have seen or done and review these cases periodically with the data you have, to improve yourself.
- Invest in a good and robust software that is reliable and last years. Information technology progresses rapidly and software systems must last and be able to migrate if necessary
- Have a reliable copy of data in case of accidents, fires or natural disasters. Preferably have a cloud based data system
- Data works to help in litigation. At the same time resist the temptation to delete/erase data as it can be detected forensically
- Be open to share data. This way you can pull all the data from colleageus or centre and use it for a more robust study.
I would like to thank
My wife Sarojini for editing this article
Dr. Gunasegaran for reading through this article and giving good suggestions for its improvement.