The purported value of the electronic health record (EHR) is built from promises of increased clinical efficiencies, enhanced quality and safety, research capabilities and improved patient centered care. However, despite the ubiquity of the EHR in pediatric urology practices (93% of surveyed pediatric urologists reported using an EHR in their practices according to data from the 2017 AUA Census), these promises have yet to be fulfilled. Pediatric urologists like many specialists are experiencing unsustainable rates of burnout that often stem from EHR use (38% reported EHR use as their top job dissatisfier compared to 27% of nonpediatric urologists; p=0.002 examining the same data).

Part of this EHR-related burnout stems from overall time spent on EHRs, as physicians spend an average of 1 to 2 hours on the EHR per hour spent in direct contact with patients in addition to evening and weekend EHR time. Contributors to EHR fatigue include clerical burden from documentation requirements and poor EHR usability. Interestingly, not all physician groups feel the same about the EHR, with higher rates of acceptability in groups with better workflow and physician engagement in EHR design. Given the reported high levels of EHR-related job dissatisfaction in our specialty, it is incumbent on us to find ways of making the EHR help us work faster and smarter and to improve the care we provide to our patients.

Hypospadias is a defining condition for pediatric urologists with potential for significant quality improvement. With dozens of surgical techniques used across the world and complication rates ranging from less than 5% to more than 50% in some recent reports, there is a demonstrated need for technical standardization to improve these outcomes. Furthermore, a lack of descriptive diagnostic criteria poses challenges to accurate comparison between studies. For example, publications on distal hypospadias classifying patients simply by meatal location (or diagnostic codes for distal hypospadias) may inappropriately group patients with significantly different risks due to anatomic differences (such as patients in the figure).

Figure. Photos of patients referred with “distal” hypospadias based on meatal location in glans or distal shaft showing clear differences in anatomy.

As part of our work with the Pediatric Urology Epic EHR Specialty Steering Board, member pediatric urologists recommend and codesign new Epic Foundation content, propose modifications that facilitate workflow for our specialty and promote multihospital research collaborations. In a recent workflow review, we found that many pediatric urology centers utilize different documentation formats (semi-structured, free text/dictated, structured). Given the variability in documentation at participating sites, our group elected to develop a structured data capture note type (Epic SmartForm) with the ability to capture granular data at point of care that can then be mapped with high accuracy to a data dictionary. This EHR-based SmartForm can rapidly produce a customizable surgeon-designed operative note that can meet both billing and state documentation requirements. Content for the SmartForm was aligned with the recommendations of the Society of Pediatric Urology Taskforce on Hypospadias. The taskforce identified essential intraoperative and postoperative followup details to be included in prospective data collection.

Following the release of the forms (Epic Nov 2019 Upgrade) our group evaluated individual center usability and recently approved some modifications to facilitate incorporation at hospitals using Epic. As of February 2020 (Special Update E9210728) users can type .hypospadiasrepair to automatically insert the form into their operative notes and .hypospadiasrepairfollowup for postoperative visit notes. These notes can report directly into customized dashboards to allow for outcomes assessment based on surgeon defined parameters and reporting preferences.

While a single EHR-based template is an important step forward for our group, it does not provide an adequate solution for pediatric urologists using EHRs aside from EPIC. The most recent census data available on EHR use by pediatric urologists according to the 2014 Annual census found that the most commonly used EHRs were EPIC (28.6%), Allscripts (14.4%) and Cerner (13.5%)²; in 2021 there likely has been a shift in this distribution with increased EHR adoption and market consolidation favoring EPIC in academic centers. In discussions with the AQUA Registry leadership, we have explored the potential use of AQUA to facilitate a more inclusive approach for streamlined, HIPAA-compliant data aggregation, analysis, and reporting of hypospadias outcomes. As participating centers join AQUA, the registry’s automated extraction of EHR data, supplemented by natural language processing technologies, can further our ability for meaningful benchmarking while accounting for variations in patient characteristics (penile curvature, urethral assessments), use of testosterone therapy, technical aspects (urethroplasty techniques/suture types) and other areas of research interest. Finally, the AQUA registry is equipped to assess patient reported outcomes, which will be the final frontier for our specialty to inform evidence-based guidelines for this well-deserving field.

Acknowledgements: A sincere thank you to Raymond Fang from the AUA for assistance in obtaining AUA census data, review of statistical analyses and article review.