In June 2007, Riverview Regional Medical Center, Gadsden, Ala., first installed a system used to electronically capture surgical documentation. This system allows our physicians to vividly document the health of their patients and the procedures administered during their encounters, immediately generating a complete and accurate operative report. It has shifted our surgeon’s documentation process from an antiquated process to enhanced rich data creation. It improves efficiency within the operating room and maximizes productivity within our facility.
With this documentation system in place, our surgeons have greatly improved not only the quality of their documentation but also the timeliness of their documentation. With a system that is immediately available in the operating room, our surgeons are better able to capture a full picture of their patient’s condition and the detail of the procedure(s) performed on their patient that otherwise could have been lost with time.
User adoption growth continues. Many of our surgeons have taken to this new technology, but as is common with change, some are reluctant. Our health information management department, including the director and her coding staff, are fully behind the system’s adoption because of the immediate availability of the operative reports and the HL7 interface that instantly transmits the reports into our system.
With a documentation process shift, it’s more than just a technology installation. It’s a business process re-engineering effort.
Our surgical documentation process begins with the capture of demographic information about the patient, along with any stated diagnoses from a physician’s previous patient records. This report is saved, stored and made available for future use by the physician.
The physician is able to access the patient’s saved report in the system’s document manager inside the operating room. As the patient is being prepped for surgery, the physician can then add appropriate information, engaging properly trained nursing personnel where assistance is needed. Once the surgery is complete, the physician finalizes the details of this surgical encounter, ensuring the report contains complete, accurate and compliant documentation. Once the operative report is complete, the physician electronically signs the document. With this signature comes an automatically generated date and time stamp. The documentation is then transmitted to our system and is immediately available to the appropriate parties.
Immediately available operative reports are important for our facility’s coding and billing cycle. But much more importantly, this complete operative report gives the physician a more complete look at the health of the patient. After the procedure, when speaking with the patient’s family, the physician can have a more personable, knowledgeable, and educated conversation with those family members.
This process shift depends upon participation of several key departments: the physicians and other staff including the circulating nurse. Our director of surgical services has indicated that this system has brought dramatic improvement to documentation in the operating suite. Our physicians enjoy being able to know more about their patients with this quick, easy-to-read document.
The patient’s diagnostic information located on a single document for the physician and surgical team to review before surgery enables the entire surgical team to have a vast working knowledge of their patient’s condition. Instead of just knowing the primary reason for surgery, they can have the entire picture of the patient’s health, including important comorbid conditions. This enables our staff to better care for our patients, in a more knowledgeable, meaningful and effective way. With operative notes instantly available to the recovery room, our recovery nurses are able to better prepare for and care for each patient. The system improves their efficiency as well, allowing them to make the best use of their time in preparation for every patient that comes into recovery.
Our physicians are properly trained by the system’s specialists. It has given our physicians and our staff a refreshed focus upon accurate surgical documentation. We see the results not only inside the operating room, but also in our health information management department.
The application is Internet-based over an HTTPS connection. However, because our Internet connection is so slow, we actually house our own server. With the application available to our physicians from anywhere (with an Internet connection) our physicians are able to enjoy the accessibility of the system. With a Web-based application, the system is simple for us to manage, with little manpower required.
Our server syncs with the main system server so that all data across the board for each physician is the same, no matter where they go. All protected health information is encrypted on the main server.
Piloting the system since its installation in June 2007 has allowed us time to prove the system’s efficacy in our facility. Typically, we would have paid an upfront server cost, plus the cost of interface development.
We expect to seek funding from the American Recovery and Reinvestment Act for our system. It will be based on our facility’s efforts to improve patient care through health information technology. We have implemented a viable system that improves patient care, not only in the OR, but throughout our hospital and with its staff. Our nurses are more engaged in the health evaluation of each patient; our physicians are more knowledgeable about the health of each patient; and, our efficiency has increased since installing the software and making the process shift.
Misty Butler
Revenue-cycle manager
Riverview Regional Medical Center
Gadsden, Ala.
