An Algorithm for Building an Electronic Database

METHODS

After institutional review board approval was obtained, we created our data fields based upon our points of interest. We included demographic and socioeconomic information, as well as intraoperative and postoperative details. Using Microsoft Access, we created drop-down menus for each data field. Drop-down menus provided standardized options that allowed easily tailored queries and were organized in a Boolean, categorical, or numerical fashion dependent on the variable. A printed form from the Microsoft Access template was given to each surgeon to be completed immediately after each case (Fig 1). The physician or the nurse practitioner then entered the case information into the database. During postoperative visits, physicians and nurse practitioners had access to the database for continued follow-up. Figure 2 outlines our algorithm.

Figure 1. Sample OR form containing preoperative and intraoperative data. OR indicates operating room; BMI, body mass index; Hgb, hemoglobin; ASA, American Society of Anesthesiologists; and IMF, inframammary fold.

Figure 2. Algorithm for building an electronic database. IRB indicates institutional review board.

RESULTS

Our database was compliant with HIPPA, as all patient identifiers (ie, name, address, phone number, etc) were removed from each data set (Table 1). Also, the database was maintained on a secure password-protected server that underwent routine backups by the information technology department. By utilizing straightforward data input fields, we permitted data collection to be easy and efficient. Data were then effortlessly transcribed to Microsoft Access. Collecting a wide variety of data allowed us the freedom to evolve our clinical interests, while the platform also permitted new categories to be added at will.

DISCUSSION

Evidence-based medicine is the most important tool physicians have to improve their practice and patient care. In 2013, the second Evidence-Based Plastic Surgery Summit recommended “that a strategic, coordinated, and sustained effort to drive an evidence-based medicine culture would accelerate adoption and advance quality of care and patient safety.”¹³ (p736) In order for physicians to truly accept evidence-based medicine, they first must understand its components. There are 5 basic elements as proposed by Swanson et al¹⁴:

   1. Converting the need for information (eg, about prevention, diagnosis, prognosis, therapy, causation) into an answerable question.

   2. Tracking down the best evidence with which to answer that question.

   3. Critically appraising that evidence for its validity (closeness to the truth), impact (size of effect), and applicability (usefulness in our clinical practice).

   4. Integrating the critical appraisal with our clinical expertise and with our patient's unique biology, values, and circumstances.

   5. Evaluating our effectiveness and efficiency in executing steps 1 to 4 and seeking ways to improve for next time.

By maintaining a database, a surgeon can incorporate the previous elements into everyday practice: it is a tool to gather data prospectively, which can then be analyzed retrospectively. A database allows surgeons to better be able to objectively and constantly analyze their outcomes, determine the best methods and treatments for patients, and evolve their practice to ensure that they are providing the best medicine to their patients.¹⁵

There are limitations of a database, however. The biggest hurdle being data entry—this can be a tedious and time-consuming endeavor that is often dependent on ancillary staff.¹⁶ Frequently, medical record reviews are necessary to gather data, which can multiply the labor. To mitigate unnecessary work, it is important to focus tracking data of immediate interest; large data sets can become overwhelming to analyze and onerous to maintain. In addition, to query a database for statistical analysis, the data must be standardized.^16,17 We achieved this goal by using preset drop-down menus instead of manual entry into our data fields. Although using Microsoft Access is intuitive to some, it can be overwhelming to others. As this article's purpose is not to be a primer for the program, if assistance is needed, we recommend your local information technologist or many of the comprehensive tutorials found on the Internet.

The majority of plastic surgery research falls within level IV or V evidence.¹⁵ The reasons for the lower grade of evidence include the need to customize reconstructions, the lack of dedicated full-time plastic surgery researchers, and the difficulty in establishing clinical trials in surgery.^1,18 We have proposed a reproducible method for institutions to create a customizable database, which allows senior and junior surgeons to analyze their outcomes objectively and also to compare them with others in an effort to improve patient care and outcomes. Concomitantly, it provides the opportunity for residents and medical students to learn how to collect, organize, and analyze data. This is a cost-efficient way to create and maintain a database without additional software.

CONCLUSION

Our algorithm provides future researchers a road map on how to set up, maintain, and use an electronic database to improve evidence-based care and future clinical outcomes.