Decision-making in five key areas can improve clinical and economic performance.
The rate of adoption of perioperative information technology has increased dramatically over the last few years. These systems have become an integral part of the business process of hospitals, providing valuable data that the institution can use to improve the clinical and economic performance of the perioperative service. For institutions considering such technology, some key aspects in decision-making should include system integration, fault tolerance, accessibility, workflow support and measurable results.
Decision-making in five key areas can improve clinical and economic performance.
The rate of adoption of perioperative information technology has increased dramatically over the last few years. These systems have become an integral part of the business process of hospitals, providing valuable data that the institution can use to improve the clinical and economic performance of the perioperative service. For institutions considering such technology, some key aspects in decision-making should include system integration, fault tolerance, accessibility, workflow support and measurable results.
As in other clinical areas of the hospital, perioperative IT offers a choice between two polarized paths; i.e., a departmental extension of an existing enterprise solution (hospital information system, or HIS) into the OR, or the integration of multiple applications for the OR and other individual departments.
There is enough evidence to show that the worst thing that the hospital can do in the face of this decision is nothing. According to a 2004 study by Towers Perrin, perioperative services account for 55 percent to 65 percent of a hospital’s margin, and the OR accounts for up to 50 percent of the overall cost of an operated patient. Small increases in OR utilization, efficiency, cost capture and reimbursement accuracy can all provide for a rapid ROI from the implementation of perioperative IT.
System Integration in Support of the EHR
President Bush has set an ambitious goal to have the majority of Americans served by an interoperable electronic health record (EHR). The EHR is not a single system, but rather a collection of interlocking systems tied to a series of complex care delivery workflows, including clinical, administrative, financial, and technological processes in various care settings. Under this model, “island” solutions are not acceptable; not integrating means missing an opportunity to access data at all levels, one of the first steps in achieving an EHR.
A clear EHR strategy will help define the requirements for the components of a hospital’s perioperative IT system. Ultimately, all of the components, whether purchased as an integrated suite from one vendor or as best-of-breed individual solutions, must be able to interface and feed into the master EHR and functional systems, such as billing.
The selection of best-of-breed components generally provides a higher level of customization and flexibility. With lack of user adoption/acceptance as the leading cause of IT implementation failures, the additional infrastructure required to customize and manage multiple interfaces will likely prove a worthwhile investment. Users in the perioperative area range from surgeons to anesthesiologists to administrative personnel. Each of them has different needs, and training is critical for the periop end-user to see the benefits of IT (e.g., improving the uniformity of anesthesiologists’ preoperative evaluations, or helping nurses to spend more time caring for patients rather than completing documentation).
Establishing the link from the OR to the EHR also requires the use of industry standard languages and protocols. The Health Level 7 (HL7) version 2 messaging language has become a standard framework for the exchange, integration, sharing and retrieval of electronic health information that supports the management, delivery and evaluation of health services. However, although HL7 version 2 has provided the robust connectivity required within a hospital’s HIS system, it has not proved the most effective choice for interfacing to external systems and medical devices. Here the use of XML (extensible markup language) promises to greatly extend the capability of the planned HL7 version 3 messaging standard.
National initiatives are spurring the overall shift to XML. The short-term challenge will be to maintain multiple interfacing technologies to allow connectivity to legacy HIS and departmental systems until these can be upgraded to take advantage of the greater flexibility and performance that a combination of HL7 v3 and XML can offer.
Fault Tolerance at the Acute POC
In the EHR model, loss of data or loss of access is a critical business issue. The costs of acquiring patient data or missing access to pertinent data become much more transparent once paper systems are eliminated. This is especially true in the OR, where the density of data capture is very high. Typically, the manual anesthesia record will record data every three or five minutes, and incomplete or missing anesthesia records or surgical notes represent a potential litigation liability in the event of a negative outcome. Automated anesthesia documentation capabilities are necessary to assure comprehensive real-time data gathering (including data fields, time stamps and electronic signatures) for reimbursement, scheduling and delivery of care.
A high reliability system is one of the key environmental considerations for IT systems deployed at the acute point of care. Hardware, software and the network itself are all potential points of weakness in the perioperative setting. The use of reinforced medical grade hardware can minimize the risk of damage due to fluid spills or shock; however, often the weakest link is the simple network connection to the outlet on the wall.
In ORs, where the computer terminals are mobile, the use of a distributed architecture can help maintain access to the application in the event of a network interruption. A robust solution, with redundancy and backup, can help an institution avoid losing all data from a single fault condition. For example, during a recent server shutdown at a hospital in Rockford, Ill., a distributed data management system prevented the loss of anesthesia data, which could have taken the hospital months to recover. Because the anesthesia workstations were thick clients and could function without connection to the server, they were able to continue running while all of the hospital’s other software systems (including remote and Web-based applications) were down.
Accessibility Aids Reviews and Scheduling
Mobile and wireless computing technology has now developed to a point that makes paperless systems a reality, and perioperative departments are reaping the rewards.
The ability to conduct preoperative assessments at the patient bedside or remotely at a physician’s office dramatically reduces the risk of surgical schedule delays or errors due to missing information. In a study conducted over a three-year period at The Cleveland Clinic Foundation, the use of a preoperative assessment computer program led to a 49 percent decrease in the average monthly preoperative surgical delay rate and significant monetary savings (i.e., cost per patient) due to decreased unnecessary laboratory testing.
Additionally, the option for peer review of a patient’s history (including DICOM images, demographic and lab data) at any time or location, with secure Web access in support of HIPAA guidelines, provides another opportunity for improved patient care. This also decreases the need for backup office support in record distribution, archiving and billing. The OR schedule can also be made accessible from any location—saving time and facilitating workflow.
Workflow Support to Re-engineer Care Processes
Clinical IT systems frequently are implemented without first conducting an analysis of the staff, patient and equipment workflows. Information technology does not change workflow, but acts as an enabler, providing workflow support to allow hospitals to reengineer their perioperative care processes.
Perioperative information systems need to do more than simply replace legacy paper systems or become a repository for data. IT can be used to drive key performance metrics, cost reductions, and improvements in quality. The workflow can be redesigned to make periop more efficient, streamlining how the service is provided and coordinating the efforts of multiple players: anesthesia, surgery, nursing, scheduling, etc.
For example, a preoperative assessment tool that automatically routes patient information to the relevant parties can shorten the time from consultation to scheduled surgery, as well as reduce cancellation and complication rates. As a result, the surgery department can maximize its value as a revenue generator, for bottom-line impact to the hospital.
In Pursuit of Measurable Results
Departmental IT solutions such as perioperative applications must demonstrate their value, and IT must be part of a business decision to become more efficient. The market wants to see ROI on such specific projects, as well as tools for ongoing measurement. In the first year after implementation, it’s best to focus on one to two measures; e.g.:
- Reducing reimbursement time (from weeks down to days) for better cash flow;
- Improving cost capture (recording close to 100 percent of costs incurred);
- Demonstrating quality assurance (e.g., conducting automated reviews of hundreds of anesthesia records to improve performance, or identifying causes of hospital-acquired infections); or
- Streamlining scheduling (maximizing the use of the OR).
Incremental increases in these areas can make perioperative IT a valuable investment, but the data must be capable of being captured and available for reporting in such a way as to easily facilitate best practices and benchmarking. For example, through a computerized anesthesia information management system (AIMS), the Department of Anesthesiology at Duke University Medical Center saved several hundred thousand dollars in one year by simply reducing the vial size of a particular anesthetic. (They had been throwing the unused portion away.)
The AIMS also played an integral role in promoting more appropriate use of costly anesthetics: The institution of automated practice guidelines allowed for an annualized savings of close to $1 million in drug costs. These cost savings were achieved without any substantial changes in clinical outcomes, and perioperative patient flow was minimally affected.
The use of an automated anesthesia relational database allows for the historical measurement and analysis of demographic variables, anesthetic and airway management techniques, material resource utilization, vital signs, and drugs and fluids administered. The ability of client-server database technology to facilitate data exchange and produce exception reporting in near real-time (as well as standardized reporting to support the requirements of regulatory bodies), will greatly enhance the quality of perioperative care processes while reducing the cost of care, minimizing human error and enhancing patient safety.
For more information about Dräger Medical’s perioperative solutions, www.rsleads.com/607ht-201
