Streamlining Postoperative Reporting

Last year John Mattson, M.D., who practices at the 6-physician Berkeley Orthopaedic Medical Group was doing an anterior cruciate ligament reconstruction on young woman from San Francisco. It just so happened that her fiancé was the marketing director for the Centerville, Mass.-based synoptic reporting and structured data provider mTuitive. After the surgery, the patient’s fiancé asked Dr. Mattson to consult on mTuitive’s OpNote Web-based postoperative report tool. In January of this year Mattson started developing default surgical pages for OpNote, and in June he started using the product in his surgical practice. Since then he has been proselytizing the value of a surgical information system at local surgery centers and the hospital he is affiliated with, the Alta Bates Summit Medical Center in Berkeley. Mattson spoke with HCI Associate Editor Jennifer Prestigiacomo about the quality gains and cost savings he’s realized through using a surgical information system.

Healthcare Informatics: Why does surgery lend itself so well for templatized postoperative notes?

John Mattson, M.D.: OpNote is based on default pages, which are the most common operations which individual surgeons do. Ninety percent of surgical notes have identical information, and there are only a few discrete bits of information that differ to make each case individual. I help create the common orthopedic default pages, for example, arthroscopic meniscectomy, anterior cruciate ligament reconstruction, and some forms of shoulder surgery.

HCI: What are the benefits of surgical information systems?

Mattson: By eliminating transcription it cuts the cost in half of producing an operative report. For those surgeons who are co-owners in a surgery center, that means more money in their pocket. Also, for surgeons who work in hospitals, to be able to save the institution money, it gives them more room in the capital budget the next year. That’s one reason.

The other issue I discovered in my career—I review medical legal cases for our county medical association, primarily for defense purposes—in reviewing cases, I have found that the content of reports in dictation are extremely variable in terms of how much information they contain. In narrative dictation there is very little structure involved. Hospitals have imposed some elements of the structure such as the date, the surgeon, what was removed/done, but as far as the description of the operative report, it’s very sparse. I think of [a surgical information system] as sort of a checklist, which is becoming more and more involved in operating rooms to prevent errors in wrong site surgery and that kind of thing. And OpNote comes in a structured form, so the surgeon must answer a certain number of questions that they wouldn’t normally deal with in a narrated report, and we call that synoptic reporting. That kind of report is much more complete than a dictated report and much more helpful in coding, in RAC [recovery audit contractor] review later. The other part is that it contains the codes, which dictation reporting does not. So, by the time the report goes to the billing or coder, it is pre-coded, which will save time and money as far as processing the operative report because it can be billed the same day as the surgery.

HCI: Are the notes saved as discrete data that can be easily data-mined?

Mattson: That is another major advantage that will be really invaluable I think for research and data mining because it’s in synoptic form, those words can be identified. So, I can go through and see all the ACLs I’ve done using a donor graft, and I can easily pick out those files.

HCI: How has having a surgical information system improved the quality in your postoperative reports?

Mattson: Let’s take an institution like a surgery center—if all the physicians were using a [surgical information system], the content of their operative reports would be uniform and complete and the economic benefits would be substantial and the audit of issues would be eliminated. During an operation, there are three different people who use codes: the surgeon, the circulating nurse, and the anesthesiologist, and those codes are frequently confused, mixed up, and changed. And during the recovery audit process those are picked up, and when the circulating nurse and the anesthesiologist use a [surgical information system], that discrepancy is eliminated. It goes immediately into the electronic health record, pre-coded for compliance issues. I think that will make a really big difference, as far as compliance, providing information, data mining, and also [provide a] financial advantage.

A few years ago, I was using a new type of bio-absorbable screw for my anterior cruciate ligament reconstruction, and they were consistently breaking apart early, requiring second procedures. I think I had eight or nine cases, and it took quite a long time to find those cases by going back into the records. With a [surgical information system], we could have found those in minute. So, that is an advantage of it, although I have not used it as thus so far. It’s still a little early.

HCI: What has it been like getting physicians and Alta Bates Summit Medical Center onboard to use surgical information systems?

Mattson: I’ve had to be very careful in my approach in trying to get Alta Bates to use it prior to the [its] adoption of Epic [the Verona, Wis.-based Epic Systems Corp.], and perhaps make it a value-added proposition for the Epic software. But I’m meeting considerable resistance because Epic is so much bigger, and they’re not interested in having outside vendors complicate their software.

HCI: Can you tell me about the challenges getting physicians in your practice onboard?

Mattson: We have a rather unique practice in that all of our physicians are older, and two of them don’t do surgery. I’ve been concentrating more on the department of surgery [at Alta Bates Summit Medical Center] where there are general and plastic surgeons, who take an interest in using [technology]. The chairman of the department of surgery is a general surgeon, and she has been very supportive of it. So, I have been focusing on the younger physicians, who are more likely to adopt it.

HCI: What are some lessons learned about surgeon culture in adopting new technology?

Mattson: Surgeons are notorious for being difficult, arrogant, and unchangeable, and of course that is changing to a large degree with the younger surgeons. The first thing I noticed immediately was that the financial issue does touch physicians, and they become interested. The second thing is they like to see the immediate feedback of their operative report. They like to have it immediately available, so they do not have to spend time later reviewing it, changing the codes, and electronically signing it. Until recently, surgeons had to go to medical records to sign the operative reports. Now we can do it online, but we have to be reminded to do it. With OpNote you can do it immediately.

I think the other thing that interests physicians, particularly those interested in electronic health records, is the fact that the report is so structured that it contains all the information that is needed for data mining and compliance purposes. I’ve had a fair amount of enthusiasm especially with the younger physicians who are interested in getting into it.