Challenge: OR scheduling requests

At the time of implementation the vendor for the OR scheduling and clinical documentation system that MedStar purchased had not completed development of its Web-based self-scheduling module. However, MedStar says it still selected the application because they were assured that the module was in development at the time of purchase. This forced MedStar to find an interim solution, a traditional fax-based system, in order to reduce the time and staff required to manually process OR scheduling requests.

Using the fax-based system, an OR scheduling request is submitted by a clinical practice to schedule an OR room in the hospital. The scheduling request form, which is faxed to the OR scheduling office, contains information about the surgical procedure to be scheduled; necessary equipment and medication required; demographic, insurance, and brief medical information about the patient; and requested surgical dates.

The OR scheduling office reviews the form and either approves the request and faxes the form back with the OR date/time, or returns the form to the practice with a request for additional information.

Though the traditional fax-based system worked, it was inefficient. Problems included lost faxes, the lack of easily traceable records, and frequent phone calls to clarify information between the requesting practice and the OR scheduling office. The inefficient workflow resulted in prolonged scheduling time and a decreased ability to proactively plan cases. In addition, patient safety was potentially compromised because of illegible faxes, a large majority of which were handwritten.

With the new computer-based OR system, the process would be further complicated because the hospital scheduling representatives would now have to toggle between the new software and the old faxing method. Why not just stop accepting faxes? Is that not practical? Is there a point at which you can insist on electronic scheduling? The challenge was how to make the process less onerous for the clinicians, their practice, and MedStar Health.

Complex solution: Web-based form

The MedStar e-Health team, created by the MedStar Board to provide its clinicians with information on available e-health applications and emerging technology, was contacted to devise an interim solution to quickly and inexpensively ease the effort of OR scheduling. The first idea considered was to create a Web form to submit scheduling requests. The clinician practice would complete a multi-page schedule request form that would be securely transmitted to the OR scheduling office via the MedStar Clinician Portal Application (a MedStar developed application reported in January 2007 Healthcare Informatics).

At first, the idea of a Web-based form seemed like the ideal solution as it would leverage existing systems, and most MedStar clinicians already had accounts on the Clinician Portal. A more detailed analysis quickly proved that this workflow solution was not viable. The first flaw was the real-world clinical office workflow and the Clinician Portal's idle timed automatic logout. In a modern clinical practice, the staff is often simultaneously working on multiple tasks and the OR scheduling request form is frequently completed over a period of time. However, when the staff member stops working on the scheduling form in order to complete another task, the Clinician Portal would force a logout put in place for security reasons, and all the previous work on the form would be lost. The only way to prevent this loss would be to devise a mechanism to auto-save the form as it progressed, which would add significant development time before delivery of the solution.

The second flaw in the Web form idea was the need for interactions between the OR scheduling office and the clinical practice. A scheduling request often changes as a result of refinements to the request, as well as the requirement to provide the final form to the clinical practice. A document management system to track the Web-form would need to be created or purchased — either way adding significant time and/or cost to the solution.

Simple solution: clinical messaging

Since the use of a Web form could not meet the project requirements, an alternative solution was selected that utilized multiple projects and resources already established and in operation at MedStar. The MedStar Clinician Portal has an integrated clinical messaging system based on the SMX system by DrFirst (Bethesda, Md.). The clinical messaging feature enables clinicians to email messages and files to colleagues, securely and efficiently, using existing Internet e-mail addresses. Due to HIPAA privacy considerations, the clinical messaging system does not actually send the secure message or any file attachments over the Internet. Instead, the system sends the recipient an email notifying them that they have a secure message waiting with instructions on how to retrieve the message (see Figure 1).

Figure 1: Overview of clinical messaging functionality

The solution was to create a PDF-based scheduling form and use clinical messaging to securely send the form between the clinical practice and the MedStar hospital OR scheduling office. The clinical practice completes the form using the free Adobe Reader, saves it to their local drive, logs into the Clinician Portal, and uploads the completed PDF form via the OR scheduling request screen in the Clinician Portal.

The system automatically attaches the form to a new clinical message, allows the user to add comments to the request message, and inserts the appropriate email address for the MedStar hospital scheduling office.

For the clinical practice, the PDF form has several benefits over the Web-form:

• Ability to save the form for permanent records

• Potential reuse of completed forms to save time with new scheduling requests

• Enables multi-tasking staff to be "interrupted" in their work

• Ability to store and track OR scheduling requests.

The benefits for MedStar include:

• Increased patient safety by eliminating legibility issues

• Increased workflow efficiency in the scheduling office

• Ability to electronically organize the requests for easier filing and record keeping

• Electronic audit for tracking the requests.

Future: expanding solution

Currently, there are six physician offices using this scheduling request process. They are pleased with the following process improvements: a decrease in phone calls received from the OR scheduling office to clarify requests, improved turn around time for scheduling requests, and improved efficiency in filing and locating scheduling requests by the scheduling office. In addition to the improved filing efficiency, the scheduling office's main benefit includes a legible request form leading to a safer patient scheduling process. A second OR scheduling office is in the process of adopting this. Future plans include roll-out of this process to all interested MedStar Health sites which include six hospitals and two surgicenters.

Subsequent to the start of this project, the original OR scheduling vendor has added the capability for self-scheduling by the requestor. Because the system is a traditional client-server application, a complicated and expensive VPN would be required to provide remote access to clinician practices until the Web solution is available, which, at this point, is not an option.

As a result, MedStar is in the process of expanding the clinical messaging scheduling process to all interested sites. While the solution is not "cutting-edge" healthcare technology, it is an example of how even a simple and low-cost system can have a positive impact on healthcare administrative tasks.