Tuesday, November 16, 2010

EHRs in Surgical Practices

I was recently asked to offer advice about implementing EHRs in surgical practices.   Here are the lessons learned from our Massachusetts EHR rollout experts.

1)      Surgical practices are challenging in general because they frequently use dictation and the most obvious benefits of EHRs do not apply to them.  They do not have substantial amounts of structured data to enter and they do not have a high fraction of recurring patients so a large fraction of records are “new” records. The highest benefit areas for them require interoperability, which takes time to accomplish. A significant fraction of the information they need for documentation comes from hospital operative notes, referrals/consults are the biggest element of workflow, and they rely on electronic lab and imaging test results.

2)     The most successful workflow change approach requires shifting more responsibility to mid-levels so that basic structured data entry (like vitals, history, etc) and billing related entry do not fall on surgeons who can be resistant to doing that type of documentation.  Unfortunately shifting practice roles/responsibilities is not easy.

3)      Working with the practice to build structured procedure templates in advance of go-live and setting up voice-recognition to allow surgeons to continue to dictate are key workflow/adoption steps.

4)      Some EHRs such as eClinicalWorks have templates for Operative Notes as well as SOAP notes, which are key to EHR adoption.

5)      Interoperability should be implemented as quickly as possible:  diagnostic results delivery (especially imaging results) and hospital document push (operative notes, discharge summaries) should be  integrated into workflow during implementation.

6)      Voice recognition with products such as Dragon creates an immediate benefit from savings in dictation costs, enhancing EHR adoption.

An unstated source of difficulty with surgeons is that the EHR illustrates a relative light document style with less of a focus on continuity of care that is typical of most high volume ambulatory surgical practices.  EHRs require them to increase their level of documentation and attention to process generally, in addition to converting to an electronic workflow.  I've met a few surgeons who had very little documentation in their offices and the EHR implementation process put us in the awkward position of having to tell them that they needed to do more documentation generally.

With templates, division of labor among practice staff, and interoperability, surgical practice EHR implementation  can be successful, especially if incentives are aligned so that costs decrease and stimulus dollars flow.


Donald Green MD said...

Some suggestions.

Rely heavily on the history and physical exam rather than templates. Relevant sections such as Pres Hx, PH etc. can be labeled for retrieval but will be more meaningful in the user's own words. Even operative notes can have a framework(not template) that reflects studied communication tools so that any reader feels as fully informed as possible.

A dictated note can be dictated into a set up document template and then directly entered into the EMR for review and eventual storing into the patient's record. It should be easily obtained when needed. If done in the hospital it should be available from their applications. It can always be scanned into one's own EMR later or brought to the office digitally properly labeled to be entered with other documents into the EMR.

Once necessary data structured or otherwise is entered in the EMR the same mechanisms for sharing exist as for other medical specialties. As broad a solution for all practitioners should be sought and too many special cases avoided.

Todd Schnack said...

We have asked eClinicalWorks for Operative Note templates, and have only received very rudimentary templates with a few large text boxes to free-type into. Are you aware of better templates they offer?

The Neurotic Monkey said...


Jwmbosco said...

It took us three iterations of design before we arrived at our solution for surgical notes. After demonstrating OpNote to hundreds of surgeons, we have yet to have a single surgeon ask for speech recognition. This was a surprise to us. Like you point out in the article, we anticipated that it would be near impossible to pry the Dictaphone out of the surgeon’s hand. Bad assumption- surgeons have embraced the approach. We typically get one of two reactions from surgeons that usually divide along age groups. Younger surgeons see dictation as repetitive and error prone. Older surgeons state that they are resigned to having to go electronic and OpNote was obviously designed to function the way a surgeon works.

However, the reaction we get from administrators and HIM staff is “our surgeons will never use it without some form of dictation or speech recognition.” Naively we assumed that the surgeons would be the hard sell. We anticipated that hospitals and surgery centers would want to save money on transcription, to improve documentation and to capture data for quality, outcomes and performance. The opposite has proven true. Our best success has been in ambulatory surgery centers where the surgeons are not only the users but also the owners. They are enthusiastic because they appreciate the efficiency, improved coding functionality and cost savings. John Murphy, mTuitive