Health First, a small southern Florida- based regional integrated network, has set a lofty goal of becoming one of the nat'ions  first completely paperless healthcare organizations. As if that doesn’t raise a few eyebrows, one of the departments which has nearly achieved that goal is also one of the least likely: surgery.

Health First, which operates three hospitals on Florida’s east coast, chose to excel in a department that could hardly be more demanding in documentation and charting to test its mettle. Now, Health First is well on its way. Three years ago, Health First implemented a multi-facility perioperative software system from Alpharetta, GA-based Surgical Information Systems (SIS) across its three hospitals, enabling its facilities to work both independently and as a team, combining the knowledge gathered through clinical records to streamline administrative tasks, develop clinical data and improve the way surgery is performed.

Health First is a rare case. Estimates are that fewer than 10 percent of U.S. hospitals even use computers behind the swinging double doors of surgery. But those outmoded ways may be changing, and quickly. With perioperative services encompassing half of a hospital’s costs and revenues, and operating rooms typically consuming almost half of a hospital’s supply costs, the need to closely manage every step of the surgical process is becoming increasingly critical. Hospitals stand to lose millions of dollars if they are unable to determine the cost of care or accurately bill for surgical services.

Addressing costs, nursing shortage, medical errors

Several factors are fueling the drive toward automation in the OR One is the nursing shortage, a harsh reality that’s been blamed for a wide variety of healthcare’s ills. To many, it’s a no-brainer. Software automates a countless tasks for which there are fewer and fewer people available to perform these days, including scheduling staff, equipment and suites, managing supplies, and even routine documentation.

Brian Graves, director of marketing and alliance partnerships for PICIS, an OR software provider based in Wakefield, MA, provides a telling anecdote to exemplify the stress. In his former life as a sales executive for a large supply cabinet manufacturer, Graves said on a daily basis, he would "see nurses with sticky notes all over their arms and jackets with important notes written on them. After the fact, they’d stick the note on a card and later, I’d find them scattered all over the floor in the OR." Whether software leads to improved patient care is debatable, but one undeniable fact remains: A quality OR software package can free nurses to do what they do best, and can make a surgery department more efficient.

The nursing shortage – To many, it’s a no-brainer. Software automates a great deal of tasks for which there are fewer and fewer bodies to perform these days – including scheduling staff, equipment and suites, managing supplies, and even routine documentation.

Most OR software today improves decision-making during surgical procedures, and in some cases, record patient and procedure information accurately and automatically. Cindy James-Brooks, clinical system manager and OR Manager project coordinator for 48-bed Sutter Davis Hospital, Davis, CA, has seen how software can mitigate mistakes. "There is more human error in a manual-charging system," she said. "Items that are used during a surgery may not be properly recorded. When you have nurses compiling three separate sets of charges during a procedure, some charges can easily fall between the cracks." And as Mark Constanza, enterprise vice president for surgery and anesthesiology, for Kansas City-based Cerner Corp., adds, "Today’s OR is so paper-based, and that creates a lot of undue opportunity for errors."

Bottom-line financial pressures have also propelled the OR software market. Adds Richard Howe, Ph.D., vice president of information technology consulting in VHA’s Consulting Services group, "OR throughput is a major concern in hospitals today. It’s very difficult for hospitals to analyze complex issues such as fixed costs, procedure times, and outcomes – all by any number of variables – without hard numbers." The OR generates approximately 68 percent of a typical organization’s revenues, yet is probably one of the most underutilized areas, says San Francisco-based McKesson Corp. in a 2002 report it co-authored with the Healthcare Financial Management Association.

Many of inefficiencies in the OR can be traced to poor on-time case starts (which average a dismal 27 percent) in addition to poor resource and supply management. According to Irving, TX-based Novation, supplies can consume as much as 60 percent to 80 percent of cardiac cath procedure costs. Managing the OR as a profit center instead of a cost center requires a profit-making mindset, says SIS president and CEO Richard L. Jackson. ORs that are managed as profit centers focus on the relationship between revenue and costs, something powerful OR software today makes extremely easy, Jackson said. "Few hospitals can report the profit per case three months after it occurs, much less at the moment the case is done," he said. Automation allows improved workflow management and movement management, which can improve efficiency and reduce overtime. Moreover, he said, drugs can be managed and monitored; and scheduling can be handled to prevent unnecessary cancellations, delays and overtime. Adds Richard Howe, Ph.D., vice president of information technology consulting in VHA’s Consulting Services group, "OR throughput is a major concern in hospitals today. It’s very difficult for hospitals to analyze complex issues such as fixed costs, procedure times, and outcomes – all by any number of variables – without hard numbers."

The power of information

OR software today can literally change the fortunes of a healthcare organization, from reversing poor throughput or supply utilization to changing physician behaviors.

VHA’s Howe said OR software can address critical issues such as OR utilization and supply usage. "Without this software, many ORs today are struggling with how to manage their business," Howe told HPN. Adds Bob Schlotman vice president of marketing for SIS, "ORs today are looking for information about things such as total case costs and surgeons’ cost per case. Software tools allow ORs to talk to surgeons intelligently about best practices. Surgeons will change their behavior if they are given credible and compelling information."

In its 2002 report, Engaging Physicians in Supply Cost Reduction, VHA notes that data is the lifeblood of any successful supply cost reduction effort, including the all-important area of surgery. Data can be broad in nature, such as high-level trending data or it can be customized for a target audience, such as physician-specific supply usage data. Whatever data is shared, it must motivate people to act or change their behavior, according to the VHA report. For example, Mayo Clinic used individual cost data to compare physician specific information in a huge initiative to resolve huge price inconsistencies on orthopedic implants. Because the data was customized, accurate, and current, it played a big part in convincing the physicians to participate in the initiatives. As a result, Mayo was able to save $2 million a year on implants alone.

Changing mindsets

With all of the technological sophistication of medical devices prevalent in today’s OR, it’s somewhat surprising how computer illiterate many of the people who staff it are. Many nurses today wince at having to work with computers, with all of other pressures they face. And that could neutralize many of the powerful applications today’s OR software provides.

In Florida, Health First overcame this obstacle by working closely with SIS on a comprehensive staff training program before the first software module was installed. "There was a bit of a learning curve. We had to deal with some anxiety and comfort levels among nurses who weren’t computer literate," recalls Mary Ellen Robbins, director of surgery, Cape Canaveral, a Health First hospital. "The nurses have taken great pride in the software system and it’s changed their whole outlook on the importance and value of documentation. They really went along with the program. They realized that this is the future."

While nurses may gravitate more easily toward clinical and documentation features, supply management applications may leave their heads spinning. Materials management consultant Jack Anderson said many hospital ORs have software-scheduling systems that include inventory management modules. In many cases, Anderson said, this inventory capability is not used because preference cards take too long to set up and maintain and the protocols for identifying and correcting inventory variances are not in place. "OR scheduling systems were justified as being able to control and reduce inventory," he said. "Once purchased, however, 95 percent of these hospitals don’t use the inventory module."

Successes

For those hospitals committed to making OR automation work, however, the payoffs can be significant. Consider the following examples:

Admissions data such as patient information and account numbers flow into the surgery system via a special interface, while OR schedules, resources, and other data update OR Manager directly from McKesson’s enterprise-wide scheduling system. Nurses now document patient care at the bedside in real time. The OR Manager record generates accurate and timely charges that transmit to McKesson’s accounting system daily and are posted to a patient’s bill. In addition, surgical supplies transmit to McKesson’s Materials Management System, where they are decremented from inventory and create a perpetual inventory.

This bi-directional interface also updates OR Manager whenever surgical items are added or modified or prices change. The integrated, multi-facility implementation enables Methodist Health Care System to more easily track patient care, costs, supply usage and billing from facility to facility and for the entire organization, according to Steve Ameen, director of patient management systems, Information Technology. Statistical reports from OR Manager provide a clear picture of the performance and patterns per site and provide managers with a means of implementing improvements across the enterprise to insure the efficiency and quality of patient care.

After implementing the SIS perioperative system, Duke next focused on inventory control, using SIS’ inventory module to build physician preference cards, tailor procedure case carts, capture supply charges, develop a perpetual inventory management system and integrate a carousel distribution system. As a result, case carts were redesigned to stock 90 percent of needed supplies, up from 50 percent. The Surgical Information Systems software housed the physician preference cards so when the case was booked, central sterile and receiving was notified and the cart supplies were tailored to that case and surgeon. Items not used were credited to the account, and all supply charges were captured. For Women’s Services alone, lost charges dropped from $40,000 a month to $500 a month. Duke is expanding the program to the 30 procedures beyond Women’s Services that account for most of the supply cost and itemized charges. Duke also plans to develop a perpetual inventory model in central sterile and receiving based on the supply usage data from the case cart system. The SIS system is integrated with Duke’s SAP MMIS.

Any successful surgical information system should be able to capture all clinical, financial and administrative data and cover the entire operation of the OR— from scheduling, supplies, pre-op and holding, to intra-op, post-op and discharge. It should also be accessible by all caregivers, technicians, housekeepers and physicians.

Here’s a basic shopping list of what to look for in OR software:

• A supply management function that includes supply charging capability. Once a procedure is scheduled, a pre-defined pick list of supplies is loaded and generates pick lists based on a specific procedure. Most software comes with pre-loaded equipment and supply lists applicable to a specific surgical procedure. Nurses can manage those lists by exception.

• Accessible by surgeons through a hospital network or the Internet (for procedure and test scheduling, downloading documentation and notes, etc.)

• Provides ability to crunch data so comparisons can be made by physician, supplies, outcome, case throughput, OR utilization, etc.

• Easily updated and not requiring expensive additional hardware.

• Interfaces with surgical equipment such as monitoring devices in the OR. Some sophisticated systems offer anesthesia modules that automate some of the work of the anesthesia assistants.

• Provides data sharing. Information in one module flows seamlessly into another. For example, blood test results documented in a laboratory module would automatically be available in a pre-surgery module.

• Procedure, patient and supply/equipment tracking.

• Report generation and clinician documentation capability.

• Scheduling.

• Preference card management.

• Finally – one of the most important, and critical features – is the ability of the system to fully integrate real-time with other information systems such as the materials management information system, ERP and admission/discharge. "Until recently, OR software didn’t integrate well with MMIS and ERP systems," says Richard Howe, Ph.D.; vice president of information technology consulting for Irving, TX-based VHA. "But many systems today seem to have overcome that." HPN