The physician is able to access the patients saved report in the systems 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 facilitys 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 patients 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 patients 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 patients condition. Instead of just knowing the primary reason for surgery, they can have the entire picture of the patients 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 systems 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 systems 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 facilitys 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.
Riverview Regional Medical Center