RE: EHRs in Surgical Practices

November 17, 2010 at 4:25 pm Leave a comment

Recently, on his blog “Life as a Healthcare CIO,” Dr. John Halamka gave advice on how to implement EHRs for surgical practices. Dr. Halamka points out many of the issues we’ve found when meeting with surgical practices and ambulatory surgery centers (ASCs). Surgical practices offer a unique set of problems as they have a very specific purpose, are less likely to have many returning patients, and capture a limited amount of information (the rest being captured by referring general practitioners/primary care physicians and their respective facilities). So where is the incentive for these practices to adopt an electronic solution? How can EHRs address these particular needs without being too disruptive to the surgeons’ workflows? Dr. Halamka has some ideas – based on his own experiences – but I think there’s more to add to this discussion.

Please go read Dr. Halamka’s email post, but I will be reprinting parts of it below in italics so I can directly comment on each point:

1) Surgical practices are challenging in general because they frequently use dictation and the most obvious benefits of EHRs do not apply to them.

Many surgeons are attached to (or at least very comfortable with) their current workflows; they’re used to dictating their reports and it’s hard to envision another way. Especially when you couple in the fact that dictation can be very quick (moreso with the use of dictated templates), it’s a painless easy process that is just accepted as “the way things are done.” That means that when approaching surgeons with a different method, you’re already at a conversational disadvantage. However – that doesn’t mean they are not willing to change. Many surgeons now use various mobile apps to code their procedures to initiate billing and reimbursement faster. Additionally, the mentality of “the way things are done” tends to be a bit of a straw man argument; if you can prove something is more convenient while empowering the user, people tend to go with it. For example – how many people use ATMs versus tellers at a bank? Certainly there are some transactions where the teller is better – but for your most common uses and needs, why not use the ATM?

3) Working with the practice to build structured procedure templates in advance of go-live and setting up voice-recognition to allow surgeons to continue to dictate are key workflow/adoption steps.

This is an important point that we at OpNote have had to stress with our prospective users. It’s a hard sell when convincing people that an initial time investment will result in tremendous time savings later on. Modern society/culture is not conducive to delayed gratification, but through careful explanation hopefully we can illustrate how much time is actually being saved. One way to do that is to really work on your arguments and shape them as precisely as possible. For example, the time it takes to complete a report isn’t just how long it takes to dictate that report. There’s time to transcribe, time to revise and time to resubmit. The real measure of time is between finishing the surgery and signing out the report – which is generally anywhere between a few hours and a few weeks. By repositioning surgeons so they can see a larger view, hopefully they’ll be able to recognize the validity of our perspective.

  • Some EHRs such as eClinicalWorks have templates for Operative Notes as well as SOAP notes, which are key to EHR adoption.
  • Voice recognition with products such as Dragon creates an immediate benefit from savings in dictation costs, enhancing EHR adoption.

Templates are key to promoting adoption of electronic solutions amongst surgeons – but not the way that eClinicalWorks or other EHRs use them. In the comments section of this post, some users have talked about the problem with these canned text/unstructured templates. Which is something we at OpNote agree with – unstructured templates are essentially useless and more cumbersome than helpful. Even for surgeons that use templates, they still have to go through the awkward phrasing of what to change in their template, and then need to make sure that the correct changes were made before signing out. Digital reports should allow for the most common aspects of the procedures to be defaulted in by surgeons, but still be dynamic enough for users to make changes based on the unique aspects of each surgery. When possible, these reports need to be broken up into structured elements with a finite number of responses. For example, anesthesia used, position of patient, blood loss, discharge, etc. are all areas where a specific answer can be culled from a limited list of possibilities. This approach encourages comprehensive and complete reporting and a standardized electronic report will be much easier to integrate into the patient’s (and other facilities’) EHRs.

With templates, division of labor among practice staff, and interoperability, surgical practice EHR implementation can be successful, especially if incentives are aligned so that costs decrease and stimulus dollars flow.

In addition to the compensation from stimulus incentive programs, electronic reports can help increase payment as well, and not in a dubious manner. As Dr. Atul Gawande has discussed in his pieces on “The Checklist Manifesto,” seeing items in a checklist format helps tremendously with the practice of medicine. Even if the item that the physician recalls isn’t on the list, the list helps the physician remember to even mention that item. In fact, a recent study out of the Netherlands reveals how incorporating various checklists throughout the surgical process (pre-, peri- and postoperatively) helps improve patient care and outcomes.

But, more to the point of compensation, seeing the possible answers (or just those that are related) laid out spurs memory and encourages these surgeons to include more information in their reports. And, with the report having a synoptic and clear structure, it’s much easier for those in billing & coding to see what occurred, and how much they should be compensated. Eliminating dictation and transcription, boosting inclusion of more information to be properly coded while capturing valuable pieces of data for various initiatives all result in an a very persuasive financial argument for such adoption.

So much of what is done in these practices and facilities is already electronic; the scheduling programs that book the operating rooms and coordinates with the appropriate staff; the mail merge/carbon copied referral letters that are generated with reports and faxed to the appropriate PCPs; the intake of a new patient. Why not include one of the most important – and information rich – elements of a patient’s care into this workflow? Not only does it make sense for safety reasons, but it also can lead to improved patient care and financial benefits for the surgeons who recognize this and adopt to it.

As physicist William G. Pollard once said, “Without change there is no innovation, creativity, or incentive for improvement. Those who initiate change will have a better opportunity to manage the change that is inevitable.”

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SourceMedical Partners with mTuitive to Improve Postoperative Reporting for ASCs and Surgeons Dr. John Mattson – Streamlining Postoperative Reporting

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