- Email: [email protected]
The Effects of Electronic Documentation in the Ambulatory Surgery Setting
The Effects of Electronic Documentation in the Ambulatory Surgery Setting ESTELA O’MEARA, RN, MSN, CNOR
D
espite efforts to shorten the length of hospital stays and the use of managed care services to contain hospital costs, the price of hospitalization continues to rise. The Centers for Medicare & Medicaid Services (CMS) reported that in 2003, the United States spent $1.7 trillion for health care services.1 Concerns about rising health care costs have caused a major shift in the location of health care delivery from traditional health care settings to the outpatient or short-stay setting. The health care industry has recognized outpatient surgery as an economically acceptable substitute for inpatient surgery. As of 2005, there were more than 4,000 ambulatory surgery centers (ASCs) in the United States.2 The health care system continues to evolve with new processes to improve
ABSTRACT ELECTRONIC DOCUMENTATION can improve organizational processes in health care settings and may be of particular benefit to ambulatory surgery centers. A DECISION SUPPORT SYSTEM (DSS) can be integrated with an electronic documentation system. A DSS can identify potential errors and deviations from best practices and provide electronic alerts for health care clinicians to support patient screening and care. BARRIERS TO IMPLEMENTATION of a DSS include practitioner noncompliance with alerts and limitations in system design. NURSES CAN BE INSTRUMENTAL in overcoming the barriers that prevent some clinicians from adopting these useful information systems. AORN J 86 (December 2007) 970-979. © AORN, Inc, 2007.
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patient safety and quality of care. Newer techniques have been developed that have shortened surgical procedures and improved anesthesia delivery. Research has shown, however, that 44,000 to 98,000 preventable deaths per year are the result either of unnecessary actions taken or of practitioners not using evidence-based therapies.3 This discrepancy in delivering quality care has resulted in the creation of several nationwide initiatives to improve patient safety and to investigate mechanisms that would improve the delivery of care. The goal of these efforts is to provide structured interventions that will reduce the margin of error in patient safety. One of these is the implementation of information technology (IT), including electronic health records systems that replace paper-based documentation systems. An additional application of technology in the health care industry is the development of decision support systems (DSS). In a DSS, raw data from an electronic health record can be converted into useful information for making important patient-care decisions. A DSS offers health care providers decision-making tools and identifies potential medical errors and deviations from best practices.4 In an effort to support the development of IT systems in health care settings, President George W. Bush proposed that the fiscal year 2005 budget include $100 million for projects to test the effectiveness of using electronic health records in DSS. These funds also were earmarked to establish best practices standards for the integration of this technology in the health care industry. The President expressed his commitment to ensuring that most
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Americans will have electronic health records by the year 2014.5 Federal agencies and private organizations have similar interests in supporting IT research. The Agency for Healthcare Research and Quality (AHRQ) has funded several research projects on informatics to assist in the development and standardization of electronic DSS.6 Crucial to the success of a DSS, however, is the creativity of key players, RNs, and other providers in performing the cognitive thinking required to make logical choices.7
BENEFITS
OF A
DSS
Before the advent of electronic health records systems, all providers relied on paper documentation systems. Duplication of data was a predominant issue because of redundant requests for similar information. Illegible handwriting resulted in fatal medical errors, and this became a legal and ethical issue that increased concerns about the effective delivery of care. Longer hospital stays were attributed to missing patient records and the inaccurate or inadequate documentation of patient progress. Massive amounts of paper documentation created a medical records nightmare. The transfer of records to other facilities for storage purposes made the retrieval of information a challenge to health care providers.8 Building reports with aggregated data for research purposes was an arduous task made even more difficult by the absence of standardized documentation. Information technology systems are not just alternative methods for documentation. They can capture and store important information in a “data warehouse” that can support management decision making in administrative and financial transactions.9 There are clinical performance benefits associated with IT systems as well. These include improving outcomes in patient care by assisting in the development of working diagnoses and implementing the proper courses of treatment.10 The more advanced forms of information systems can be designed with clinical alerts that serve as tools for changing behavior and improving quality of care (eg, alerts for patient allergies or an adverse reaction in the form of a
An electronic information system is more than just an alternative method of documenting patient information. A well-designed system can capture important data that can be used to support administrative and financial decisions.
flashing red light or audible alarm). These alerts can be an effective tool for improving adherence to preventive care and screening guidelines. Decision support systems can be created with many capabilities designed to improve processes in the OR. Among these functionalities are • surgery scheduling, • management of preference cards, • case cart and pick list management, • charge services, • reports available for managers, • case reporting, • inventory of supplies and their specific locations, • standardized documentation of patient records, • equipment conflict management, • preoperative testing documentation, • preoperative nursing documentation, and • intraoperative and postoperative nursing documentation.
HUMAN
FACTORS
Human factors play an integral part in the success of electronic documentation. For eight years, Bates et al11 implemented and studied the impact of electronic documentation in the clinical setting and discovered several factors important to its success. The goal of these researchers was to share lessons learned and to maximize providers’ output through the use of the DSS. Users’ expectations of an ideal system included speed and the ability to anticipate AORN JOURNAL •
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clinician needs in real time. Other expectations included user-friendly functionalities that fit well with the users’ workflow and accurate displays of physiologic values (ie, normal versus abnormal) with little time required to navigate to the desired screen or information. An ideal DSS should follow evidence-based guidelines, and it should provide suggestions that require simple interventions. It also should use an accurate database and quality assurance tools to monitor health care provider compliance with alerts and reminders.11
LITERATURE REVIEW A review of the literature was conducted to identify evidence of the relevance and use of IT systems in ASCs. This review focused on the benefits, barriers, and possible outcomes of IT solutions in patient care. The keywords used in the search were “decision support,” “information technology,” and “ambulatory surgery.” FACTORS AFFECTING PATIENT SAFETY. In a 2006 article, Carayon et al12 reported on physicians’ and nurses’ perceptions of patient safety in outpatient surgery. The goal of the study was to identify factors in the workflow affecting patient safety. Five outpatient centers in Madison, Wisconsin, participated in this study, yielding a total of 79 responses. The study focused on health care providers who could give information on the quality and safety of patient care. The area that elicited the most concern was the cancellation of procedures because of inadequate preoperative preparation of the patient. The authors strongly recommended further research in outpatient surgery centers. This study highlighted several areas where ASCs could benefit from the information captured and stored by electronic documentation. These areas include the preoperative preparation of the patient and the workflow that influences the quality of patient safety. Through data captured by electronic documentation, it is possible to identify the causes of these cancellations and patient safety issues, thereby providing immediate decision-making strategies to address the issues. PRACTITIONER’S PERFORMANCE. Garg et al13 performed a systematic review of 100 studies to identify how practitioners’ performance as a
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result of using electronic documentation to support clinical decisions affected patient outcomes. Ninety-seven studies assessed clinical outcomes, and of these, 62 (ie, 64%) showed improvement in practitioners’ performance as a result of using electronic documentation. In 52 trials out of 100 identified randomized and nonrandomized trials that assessed patient outcomes, only seven (13%) using computerized DSS reported positive outcomes. The authors concluded that there is insufficient information about the effect of using a DSS on patient outcomes. They suggested that further research should be focused in this area.13 HEALTH CARE CHALLENGES. Articles from 2005 and 2006 provided a review of the challenges facing health care providers in the twenty-first century. In 2005, Donley14 focused on the nursing shortage and the aging population of nurses. This article also discussed how nurses should start “thinking out of the box” to create a new perspective in nursing and adjust to the fast transformation in the delivery of care.14 In 2006, Kennedy and Pronovost3 focused on patient safety and the stakeholders who could make significant safety contributions. Regulators such as the CMS and organizations such as the Leapfrog Group15 and the AHRQ are working to make patient safety a priority. The performance of health care providers is becoming increasingly visible as hospitals comply with requirements to report their staffing patterns and morbidity and mortality rates. This is one of the provisions specified in the Illinois Hospital Report Card Act (ie, SB59).16 This law allows the public access to information about hospital staffing and patient outcomes, and hospitals are required to submit quarterly reports of these metrics. As consumers become more educated and have ready access to webbased medical information, the demand for quality care heightens. Both Donley14 and Kennedy and Pronovost2 also addressed the systematic obstacles prohibiting institutions from adopting IT systems. They suggested that national legislation is required to reduce structural barriers and to speed up the process of standardizing IT systems, system formats, and functionalities. This would eliminate competing products in
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the industry and may lower the cost of these systems. They believe a public policy should be in place to regulate the cost of adopting electronic information systems and to approve government funding to help absorb the high costs of implementation of this technology. Additionally, people have to be educated in the areas of health care IT systems to reengineer workflows and to improve methods of delivering safe patient care. Training is another aspect of adopting technology in health care settings that some believe has not been addressed in the literature.6
To support facilities in their decision-making processes, more information needs to be made available regarding the costs of information technology systems in health care settings.
IMPACT ON QUALITY, EFFICIENCY, AND COSTS. Chaudhry et al17 performed a systematic review to identify the impact of health IT systems on the quality, efficiency, and costs of medical care. They reviewed 257 studies dating from 1995 to January 2004. In their review, 25% of the studies were from four institutions with internally developed IT systems; only nine studies reported on commercially developed systems.17 The authors were asked by the AHRQ to review evidence on the costs and benefits of using IT systems. Another objective of the review was to identify gaps in the literature and to present current evidence. The systematic review showed that health IT systems have had a positive effect on improving quality of care by assisting health care professionals in adhering to protocols, improving disease management, and reducing medical errors. On
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the downside, very little data were obtained on • the effects of multifunctional, commercially developed systems; • system costs; • interoperability (ie, easy access to the system with better coordination of health care information, regardless of the patient’s location in the system); and • consumer health information technology (ie, public access to medical information to facilitate decision making). The length of time required for documentation and provider-patient contact was a negative effect of new IT systems during the initial phase of implementation. This negative effect improved over time as providers became more familiar with the systems. No published evidence was found on critical decision-making processes in selecting and implementing a desirable information system. The necessary redesigning of workflow during implementation of IT also was not addressed in the literature.17 This systematic review suggested some areas that could be addressed to add to the body of literature regarding the use of IT systems in health care settings. Contributions in the form of quantitative and qualitative descriptions of implementation processes for the information systems would greatly enhance the decision making of stakeholders (eg, administrators, health care providers) who are interested in using this technology in the future. Secondly, more information on the costs of the systems, including additional fees such as maintenance and licensing fees, should be published to educate organizations that are considering the pros and cons of implementing an IT system.17 Without this type of information, both hospitals and ASCs will find it difficult to perform a cost/benefit analysis of implementing a DSS.18 ADHERENCE TO CLINICAL REMINDERS. Three studies conducted by the Veterans Health System identified several barriers to health care providers’ adherence to clinical reminders. The Veterans Health Administration (VHA) is the largest integrated health care delivery system in the United States and has invested heavily in IT systems. To identify barriers to the effective use of clinical reminders, Patterson et al19 conducted a
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longitudinal study in a VHA system, making ethnographic observations of providers specialized in treating HIV at six VHA sites from October 2001 to October 2002. They also conducted semi-structured interviews of available personnel. Six barriers to the effective use of HIV clinical reminders were identified at two of eight outpatient clinics. Among these were • busy workloads, which led to the inability to use reminders; • lack of time to document; • inappropriate reminders at some care points; • inadequate training to use clinical reminders; • reduced eye contact with patients; and • inconsistent use of paper forms.19 The first four findings from this study were identical to those identified in a separate survey by Fung et al,20 in which 261 primary care providers (eg, physicians, nurses, physician assistants, advanced practice nurses [APNs]) participated. In this cross-sectional study, questionnaires were given to volunteers from 104 VHA facilities at a national electronic health care meeting. The strength of this study lies in its national scope involving VHA facilities nationwide.20 Most respondents blamed inadequate training and inapplicability of reminders for not adopting a DSS. The results of the study suggested the importance of adequate training of users to ensure compliance in adoption of a DSS. These authors also recommended evaluating the specificity and ease of using reminders to assess their relevance and applicability to the workflow.20 Agrawal and Mayo-Smith21 conducted a descriptive, longitudinal study, collecting data during a 30-day period in 2003. The data contained standardized reporting of adherence rates, which were determined by calculating the total number of “applicable reminders” (eg, protocols, options to maintain normal physiologic state, warnings of sound-alike medications) and “due reminders” (eg, reminders of medications or laboratory tests that require immediate attention) that clinicians responded to during a given period. A total of 451 clinicians were evaluated in this study. Physicians, nurse practitioners, and physician assistants in 49 VHA clinics were tested for adherence to 15 clinical reminders. The data demonstrated a wide range in adher-
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ence rates.21 Researchers suggested that without the full participation of all health care professionals, the success of implementing electronic documentation would be jeopardized.
DISCUSSION The literature review revealed evidence about the benefits of and barriers to using electronic documentation to support decision making. There was no discussion, however, of system costs, training styles for effective implementation, or positive patient outcomes related to use of electronic medical records. It also is unclear how the push to implement electronic health records by the year 20145 is going to affect the growing number of ASCs. The directive may create a financial burden for these facilities, which likely would result in higher fees for the patient. If this happens, it would defeat the intention of using ASCs to lower the cost of health care. Small ASCs also may be unable to compete with large organizations that have more financial resources available. Clearly, one consideration in adopting an IT system will be the initial costs involved, but equally important is whether the long-term financial benefit of increased efficiency will justify the initial investment. Stakeholders should consider the positive impact of electronic documentation and its potential effects in the long run. Ideally, the costs of acquiring and implementing this technology would be recouped through increased efficiency. ELECTRONIC REPORTS. With the aid of electronic documentation, reports can be created easily, in less time, and without the hassle of manually going through medical records. Reports on idle time, turnover time, the number and type of procedures performed, and unusual scheduling patterns can be created readily. Charges also can be entered and tracked more easily. Computerized reports allow clinicians and providers the opportunity to carefully examine the workflow and to design strategies for improving processes. For example, idle time in the OR can cost a health care facility many thousands of dollars each year. If the average cost of an OR is $10 per minute, 10 minutes of delay per day would translate to a AORN JOURNAL •
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cost of $100 per day. This figure, multiplied by 260 working days a year, amounts to a loss of $26,000 each year. A report on case cancellations may help expose systematic patterns and provide a better understanding of the causes for cancellations. Process improvement initiatives can be implemented as a result of this type of report. Block time utilization also can be monitored by computer-generated reports without requiring a staff member to go through the painful task of manually creating these reports. Additionally, inventory reports can be vital in identifying overstocked items or items that are not commonly used and can lead to reduced overhead and costs. Another type of report that can be designed in an electronic documentation system can identify item charges that have been inadvertently omitted or numbers that were entered inaccurately. For example, consider a suture that has an item charge of $10. Although this type of suture commonly is used at least once a day for surgical procedures, if no charges are processed for the use of this suture on any of the 260 working days in a year, this would translate to a loss of at least $2,600 a year. The same is true for other items not charged because of a lack of charge entry. Lost revenue could be substantial for items such as implants that can cost thousands of dollars. ILLEGIBILITY OF RECORDS. Historically, illegible handwriting in charts and on orders has been the cause of fatal medical errors. Resultant malpractice lawsuits can cost a health care facility millions of dollars, and they create a negative image for the institution. With electronic documentation, illegible handwriting no longer is of concern. As is true for any technological advancement, patient safety should be the primary consideration when investigating an electronic documentation system. The long-term investment required to implement this type of system can be a win-win situation both for the patients and health care providers.
STRATEGIES
FOR IMPLEMENTATION
To maximize the value of an IT system, administrators and clinicians must select the right system carefully. The System Development Life Cycle model22 comprises several phases use-
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ful for analyzing and designing an IT system: • Phase 1—identify the problems, opportunities, and objectives; • Phase 2—determine the system requirements; • Phase 3—analyze the system needs; • Phase 4—design the system recommendations; • Phase 5—develop and document software; • Phase 6—test and validate the system; and • Phase 7—implement and evaluate the system.22 Developing and designing the software is crucial for successful implementation of an IT system. End users should actively participate during this phase to ensure better integration of the system into the workflow of the users. Including end users in the development process also gives them first-hand information about the system functionalities and will encourage them to take ownership of the project. A survey of end users’ workflow and their expectations of the program functionalities can assist engineers in developing the software. Users’ responses on a survey also will help engineers identify users’ needs and will provide them with a better understanding of the workflow. Information technology can add efficiency to clinical and organizational processes. An ASC could increase productivity with careful analysis of daily case load and block time utilization as well as by establishing an efficient inventory of supplies and accurate billing processes. Additionally, development teams should collaborate with software developers to program the types of reports that will assist in improving the efficiency and quality of service. With careful planning and consideration during the development of the software, reports that focus on quality assurance or on budgetary issues also can be built into the system. Each organization will define utilization differently, so each will have different requirements for the content and expected outcomes of reports (Table 1). Although software development is the engineers’ domain, developers must be informed of the users’ requirements in order to create a system that supports end users’ needs. It is essential that software be tested and validated after the design is completed to ensure the system works according to specifications.
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TABLE 1
Sample Reports Generated by an Electronic Documentation System Type of report Infection control
Quality
Area of concern
Reason for action
Wound classification
Identify wound class report by service
Early detection of infection outbreak
Antibiotics given
Track down time and dosage administered
Report on most commonly used antibiotics and on dosages and times given
Surgery cancellations
Identify consistent patterns or causes to improve processes
Prevent gaps in patient preparation and improve volume in ambulatory surgery centers
Eliminate unusually long turnover, which reduces OR productivity Volume
Expected outcome
Reduce turnover time by reengineering workflow
Number of procedures done each day
Identify causes for decreased volume
Increase volume by reassigning block time
Room utilization and staff member use
Identify trends to provide adequate staffing
Assign more staff members on busy days
Utilization
Block time and scheduling conflicts
Address delays from procedures going over assigned block time or surgeons not using allotted time slots
Additional block time provided to avoid delays and reduce waiting time and/or reassignment of block time
Trends
Type of procedures performed
Analyze trends
Volume analysis: Procedures done per day, week, month, and year Identify types of procedures most commonly performed by surgeon and/or specialty
Budget
Revenues
Identify cost per case
Cost containment and adherence to budgets
Supplies
Maintain supply inventory
Inventory maintained within par level or reduced, as appropriate
BARRIERS TO IMPLEMENTING ELECTRONIC DOCUMENTATION One of the primary considerations in adopting an electronically driven DSS is its clinical effectiveness. Alerts and reminders are features that are intended to assist providers in making
decisions. Although alerts are designed to improve patient care, there is evidence in the literature suggesting that providers may not comply with them. Health care providers may find multiple alerts and reminders confusing, and these alerts actually may interfere with the AORN JOURNAL •
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workflow. Clinicians may choose to ignore an alert because of time constraints and work overload or when the alert interferes with patient contact. Inadequate training also may result in a clinician ignoring an alert. Along with the potential benefits of electronic documentation are several limitations that may limit efficacy in practice. Like any other computer system, the usability of a DSS is limited by its design. A system can only perform according to its programmed capabilities. Also, a DSS cannot perform reasoning processes. It cannot be programmed with creativity, intuition, or imagination. The human factor will always play a part in the successful utilization of a DSS. Systems must be designed to communicate information in a manner that is easily understood by the user in order for it to remain useful at the point of care.7
SIGNIFICANCE
TO
APNS
Advanced practice nurses can help facilitate the integration of IT systems in ASCs. They can combine their clinical expertise with the expertise of IT professionals to design an efficient and user-friendly system that will suit the decision support needs of the ASC. An APN can use his or her ingenuity to inspire the creation of a system that will simplify complex problems, which will improve efficiency and productivity. With little data available on effective training styles and implementation strategies, an informatics nurse should consider performing a prospective study on these issues. The focus of such a study should include an evaluation of training styles, implementation strategies, lessons learned, and areas for improvement. This information would benefit other ASCs that have future plans to implement an IT system, and it might prevent them from having to “reinvent the wheel.” Being aware of the potential barriers to compliance should help an APN consider how to reengineer the workflow during the initial implementation of an IT system. To allow users adequate time to adjust to the system without compromising patient care, managers should consider extra staffing (eg, asking part-time employees to work extra hours for the first two weeks of implementation, discouraging regular
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staff members from taking vacation during this time) to facilitate case turnover. In addition, the volume of procedures may need to be reduced during the first few weeks until all staff members are comfortable with the system and any major problems with the system can be addressed.
STRATEGIES
TO
HELP ASSESS
A
DSS
To justify the value of electronic documentation in ASCs, users’ satisfaction with various systems should be assessed. The Clinical Information System Implementation Evaluation Scale (CISIES)23 is a 37-item measurement instrument originally used to assess an IT system at a medical center in Florida. The CISIES focuses on users’ satisfaction with the implementation process and not on the system itself. Gugerty et al23 developed the first Clinical Information System Questionnaire to measure staff member involvement and response to the implementation of an IT system. With a panel of experts, Gugerty further revised the instrument to improve the validity of its content. The questionnaire that they created addresses issues concerning practice improvement, effects of the IT system on workload, and assessment of patient communications. It also measures how effectively the system was introduced.23 The evaluation tool allows staff members to provide feedback in all of these areas. Although the questionnaire is still a work in progress, the results of its previous administration indicate its reliability and ease of use.23
SUMMARY Electronic documentation has the potential to improve the functions and productivity of ASCs. It is a costly strategy to improve the delivery of care, but it promises a positive return on investment in terms of patient safety and productivity. The installation of an IT system that is capable of capturing and storing data and supporting decision making is a long process that requires a special commitment on the part of both users and stakeholders to make it work. Barriers to compliance, as described in the literature, should be eliminated where possible to ensure successful implementation and
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use of a DSS. Additionally, nurses with advanced preparation in informatics can help facilitate the conversion to a DSS, and they can be invaluable in evaluation of the system. Nurses are strategically positioned to help identify both user satisfaction issues and areas for improvement.
REFERENCES 1. Health care spending in the United States slows for the first time in seven years [news release]. Baltimore, MD: Centers for Medicare & Medicaid Services. January 11, 2005. http://www.cms.hhs .gov/apps.media/press/release.asp?Counter=1314. Accessed August 9, 2007. 2. FASA. The history of ASCs. http://www.fasa.org /ascs/aschistory.html. Accessed August 22, 2007. 3. Kennedy P, Pronovost P. Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century. Crit Care Med. 2006;34(3)(Suppl):S1-S6. 4. Javitt JC, Steinberg G, Locke T, et al. Using a claims data-based sentinel system to improve compliance with clinical guidelines: results of a randomized prospective study. Am J Manag Care. 2005; 11(2):93-102. 5. US Department of Health & Human Services. Health information technology: American health information community: background. http://www .os.dhhs.gov/healthit/community/background/. Accessed August 15, 2007. 6. Fitzmaurice JM, Adams K, Eisenberg JM. Three decades of research on computer applications in health care: medical informatics support at the Agency for Healthcare Research and Quality. J Am Med Inform Assoc. 2002;9(2):144-160. 7. Marakas GM. Decision Support Systems in the Twenty-First Century. 2nd ed. Upper Saddle River, NJ: Prentice Hall; 1999:3-9. 8. Carr K, Bangalore D, Benin A, Holmboe ES. Leveraging the benefits of health information technology to support healthcare delivery model redesign. J Healthc Inf Manag. 2006;20(1):31-41. 9. Androwich I, Bickford CS, Button PJ, Hunter KM, Murphy J, Sensmeier J. Clinical Information Systems: A Framework for Reaching the Vision. Washington, DC: American Nurses Publishing; 2002:2. 10. Krohn R. Closing the “loop” of clinical performance improvement. J Healthc Inf Manag. 2006;20(1):12-14. 11. Bates DW, Kuperman GJ, Wang S, et al. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a re-
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ality. J Am Med Inform Assoc. 2003;10(6):523-530. 12. Carayon P, Hundt AS, Alvarado CJ, Springman SR, Ayoub P. Patient safety in outpatient surgery: the viewpoint of the healthcare providers. Ergonomics. 2006;49(5-6):470-485. 13. Garg AX, Adhikari NK, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005;293(10):1223-1238. 14. Donley R. Challenges for nursing in the 21st century. Nurs Econ. 2005;23(6):312-318. 15. The Leapfrog Group for Patient Safety. http:// www.leapfroggroup.org/. Accessed August 15, 2007. 16. Illinois Hospital Association. Hospital Report Card Act (HRCA). March 2004. http://www.iha today.org/issues/safety/updates/faqs.pdf. Accessed August 22, 2007. 17. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144(10):742-752. 18. Zaroukian MH, Sierra A. Benefiting from ambulatory EHR implementation: solidarity, six sigma, and willingness to strive. J Healthc Inf Manag. 2006;20(1):53-60. 19. Patterson ES, Doebbeling BN, Fung CH, Militello L, Anders S, Asch SM. Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods. J Biomed Inform. 2005;38(3):189-199. 20. Fung CH, Woods JN, Asch SM, Glassman P, Doebbeling BN. Variation in implementation and use of computerized clinical reminders in an integrated healthcare system. Am J Manag Care. 2004;10 (11)(Pt 2):878-885. 21. Agrawal A, Mayo-Smith MF. Adherence to computerized clinical reminders in a large healthcare delivery network. Medinfo. 2004;11(Pt 1):111-114. 22. Nahm ES, Mills ME, Feege B. Long-term care information systems: an overview of the selection process. J Gerontol Nurs. 2006;32(6):32-38. 23. Gugerty B, Maranda M, Rook D. The clinical information system implementation evaluation scale. Stud Health Technol Inform. 2006;122:621-625.
Estela O’Meara, RN, MSN, CNOR, was the director of nursing at the Illinois Sports Medicine and Orthopedic Surgery Center, Morton Grove, at the time this article was written. She currently is an educator in the Perioperative Surgical Services Department at Highland Park Hospital, Buffalo Grove, IL.
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espite efforts to shorten the length of hospital stays and the use of managed care services to contain hospital costs, the price of hospitalization continues to rise. The Centers for Medicare & Medicaid Services (CMS) reported that in 2003, the United States spent $1.7 trillion for health care services.1 Concerns about rising health care costs have caused a major shift in the location of health care delivery from traditional health care settings to the outpatient or short-stay setting. The health care industry has recognized outpatient surgery as an economically acceptable substitute for inpatient surgery. As of 2005, there were more than 4,000 ambulatory surgery centers (ASCs) in the United States.2 The health care system continues to evolve with new processes to improve
ABSTRACT ELECTRONIC DOCUMENTATION can improve organizational processes in health care settings and may be of particular benefit to ambulatory surgery centers. A DECISION SUPPORT SYSTEM (DSS) can be integrated with an electronic documentation system. A DSS can identify potential errors and deviations from best practices and provide electronic alerts for health care clinicians to support patient screening and care. BARRIERS TO IMPLEMENTATION of a DSS include practitioner noncompliance with alerts and limitations in system design. NURSES CAN BE INSTRUMENTAL in overcoming the barriers that prevent some clinicians from adopting these useful information systems. AORN J 86 (December 2007) 970-979. © AORN, Inc, 2007.
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patient safety and quality of care. Newer techniques have been developed that have shortened surgical procedures and improved anesthesia delivery. Research has shown, however, that 44,000 to 98,000 preventable deaths per year are the result either of unnecessary actions taken or of practitioners not using evidence-based therapies.3 This discrepancy in delivering quality care has resulted in the creation of several nationwide initiatives to improve patient safety and to investigate mechanisms that would improve the delivery of care. The goal of these efforts is to provide structured interventions that will reduce the margin of error in patient safety. One of these is the implementation of information technology (IT), including electronic health records systems that replace paper-based documentation systems. An additional application of technology in the health care industry is the development of decision support systems (DSS). In a DSS, raw data from an electronic health record can be converted into useful information for making important patient-care decisions. A DSS offers health care providers decision-making tools and identifies potential medical errors and deviations from best practices.4 In an effort to support the development of IT systems in health care settings, President George W. Bush proposed that the fiscal year 2005 budget include $100 million for projects to test the effectiveness of using electronic health records in DSS. These funds also were earmarked to establish best practices standards for the integration of this technology in the health care industry. The President expressed his commitment to ensuring that most
© AORN, Inc, 2007
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Americans will have electronic health records by the year 2014.5 Federal agencies and private organizations have similar interests in supporting IT research. The Agency for Healthcare Research and Quality (AHRQ) has funded several research projects on informatics to assist in the development and standardization of electronic DSS.6 Crucial to the success of a DSS, however, is the creativity of key players, RNs, and other providers in performing the cognitive thinking required to make logical choices.7
BENEFITS
OF A
DSS
Before the advent of electronic health records systems, all providers relied on paper documentation systems. Duplication of data was a predominant issue because of redundant requests for similar information. Illegible handwriting resulted in fatal medical errors, and this became a legal and ethical issue that increased concerns about the effective delivery of care. Longer hospital stays were attributed to missing patient records and the inaccurate or inadequate documentation of patient progress. Massive amounts of paper documentation created a medical records nightmare. The transfer of records to other facilities for storage purposes made the retrieval of information a challenge to health care providers.8 Building reports with aggregated data for research purposes was an arduous task made even more difficult by the absence of standardized documentation. Information technology systems are not just alternative methods for documentation. They can capture and store important information in a “data warehouse” that can support management decision making in administrative and financial transactions.9 There are clinical performance benefits associated with IT systems as well. These include improving outcomes in patient care by assisting in the development of working diagnoses and implementing the proper courses of treatment.10 The more advanced forms of information systems can be designed with clinical alerts that serve as tools for changing behavior and improving quality of care (eg, alerts for patient allergies or an adverse reaction in the form of a
An electronic information system is more than just an alternative method of documenting patient information. A well-designed system can capture important data that can be used to support administrative and financial decisions.
flashing red light or audible alarm). These alerts can be an effective tool for improving adherence to preventive care and screening guidelines. Decision support systems can be created with many capabilities designed to improve processes in the OR. Among these functionalities are • surgery scheduling, • management of preference cards, • case cart and pick list management, • charge services, • reports available for managers, • case reporting, • inventory of supplies and their specific locations, • standardized documentation of patient records, • equipment conflict management, • preoperative testing documentation, • preoperative nursing documentation, and • intraoperative and postoperative nursing documentation.
HUMAN
FACTORS
Human factors play an integral part in the success of electronic documentation. For eight years, Bates et al11 implemented and studied the impact of electronic documentation in the clinical setting and discovered several factors important to its success. The goal of these researchers was to share lessons learned and to maximize providers’ output through the use of the DSS. Users’ expectations of an ideal system included speed and the ability to anticipate AORN JOURNAL •
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clinician needs in real time. Other expectations included user-friendly functionalities that fit well with the users’ workflow and accurate displays of physiologic values (ie, normal versus abnormal) with little time required to navigate to the desired screen or information. An ideal DSS should follow evidence-based guidelines, and it should provide suggestions that require simple interventions. It also should use an accurate database and quality assurance tools to monitor health care provider compliance with alerts and reminders.11
LITERATURE REVIEW A review of the literature was conducted to identify evidence of the relevance and use of IT systems in ASCs. This review focused on the benefits, barriers, and possible outcomes of IT solutions in patient care. The keywords used in the search were “decision support,” “information technology,” and “ambulatory surgery.” FACTORS AFFECTING PATIENT SAFETY. In a 2006 article, Carayon et al12 reported on physicians’ and nurses’ perceptions of patient safety in outpatient surgery. The goal of the study was to identify factors in the workflow affecting patient safety. Five outpatient centers in Madison, Wisconsin, participated in this study, yielding a total of 79 responses. The study focused on health care providers who could give information on the quality and safety of patient care. The area that elicited the most concern was the cancellation of procedures because of inadequate preoperative preparation of the patient. The authors strongly recommended further research in outpatient surgery centers. This study highlighted several areas where ASCs could benefit from the information captured and stored by electronic documentation. These areas include the preoperative preparation of the patient and the workflow that influences the quality of patient safety. Through data captured by electronic documentation, it is possible to identify the causes of these cancellations and patient safety issues, thereby providing immediate decision-making strategies to address the issues. PRACTITIONER’S PERFORMANCE. Garg et al13 performed a systematic review of 100 studies to identify how practitioners’ performance as a
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result of using electronic documentation to support clinical decisions affected patient outcomes. Ninety-seven studies assessed clinical outcomes, and of these, 62 (ie, 64%) showed improvement in practitioners’ performance as a result of using electronic documentation. In 52 trials out of 100 identified randomized and nonrandomized trials that assessed patient outcomes, only seven (13%) using computerized DSS reported positive outcomes. The authors concluded that there is insufficient information about the effect of using a DSS on patient outcomes. They suggested that further research should be focused in this area.13 HEALTH CARE CHALLENGES. Articles from 2005 and 2006 provided a review of the challenges facing health care providers in the twenty-first century. In 2005, Donley14 focused on the nursing shortage and the aging population of nurses. This article also discussed how nurses should start “thinking out of the box” to create a new perspective in nursing and adjust to the fast transformation in the delivery of care.14 In 2006, Kennedy and Pronovost3 focused on patient safety and the stakeholders who could make significant safety contributions. Regulators such as the CMS and organizations such as the Leapfrog Group15 and the AHRQ are working to make patient safety a priority. The performance of health care providers is becoming increasingly visible as hospitals comply with requirements to report their staffing patterns and morbidity and mortality rates. This is one of the provisions specified in the Illinois Hospital Report Card Act (ie, SB59).16 This law allows the public access to information about hospital staffing and patient outcomes, and hospitals are required to submit quarterly reports of these metrics. As consumers become more educated and have ready access to webbased medical information, the demand for quality care heightens. Both Donley14 and Kennedy and Pronovost2 also addressed the systematic obstacles prohibiting institutions from adopting IT systems. They suggested that national legislation is required to reduce structural barriers and to speed up the process of standardizing IT systems, system formats, and functionalities. This would eliminate competing products in
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the industry and may lower the cost of these systems. They believe a public policy should be in place to regulate the cost of adopting electronic information systems and to approve government funding to help absorb the high costs of implementation of this technology. Additionally, people have to be educated in the areas of health care IT systems to reengineer workflows and to improve methods of delivering safe patient care. Training is another aspect of adopting technology in health care settings that some believe has not been addressed in the literature.6
To support facilities in their decision-making processes, more information needs to be made available regarding the costs of information technology systems in health care settings.
IMPACT ON QUALITY, EFFICIENCY, AND COSTS. Chaudhry et al17 performed a systematic review to identify the impact of health IT systems on the quality, efficiency, and costs of medical care. They reviewed 257 studies dating from 1995 to January 2004. In their review, 25% of the studies were from four institutions with internally developed IT systems; only nine studies reported on commercially developed systems.17 The authors were asked by the AHRQ to review evidence on the costs and benefits of using IT systems. Another objective of the review was to identify gaps in the literature and to present current evidence. The systematic review showed that health IT systems have had a positive effect on improving quality of care by assisting health care professionals in adhering to protocols, improving disease management, and reducing medical errors. On
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the downside, very little data were obtained on • the effects of multifunctional, commercially developed systems; • system costs; • interoperability (ie, easy access to the system with better coordination of health care information, regardless of the patient’s location in the system); and • consumer health information technology (ie, public access to medical information to facilitate decision making). The length of time required for documentation and provider-patient contact was a negative effect of new IT systems during the initial phase of implementation. This negative effect improved over time as providers became more familiar with the systems. No published evidence was found on critical decision-making processes in selecting and implementing a desirable information system. The necessary redesigning of workflow during implementation of IT also was not addressed in the literature.17 This systematic review suggested some areas that could be addressed to add to the body of literature regarding the use of IT systems in health care settings. Contributions in the form of quantitative and qualitative descriptions of implementation processes for the information systems would greatly enhance the decision making of stakeholders (eg, administrators, health care providers) who are interested in using this technology in the future. Secondly, more information on the costs of the systems, including additional fees such as maintenance and licensing fees, should be published to educate organizations that are considering the pros and cons of implementing an IT system.17 Without this type of information, both hospitals and ASCs will find it difficult to perform a cost/benefit analysis of implementing a DSS.18 ADHERENCE TO CLINICAL REMINDERS. Three studies conducted by the Veterans Health System identified several barriers to health care providers’ adherence to clinical reminders. The Veterans Health Administration (VHA) is the largest integrated health care delivery system in the United States and has invested heavily in IT systems. To identify barriers to the effective use of clinical reminders, Patterson et al19 conducted a
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longitudinal study in a VHA system, making ethnographic observations of providers specialized in treating HIV at six VHA sites from October 2001 to October 2002. They also conducted semi-structured interviews of available personnel. Six barriers to the effective use of HIV clinical reminders were identified at two of eight outpatient clinics. Among these were • busy workloads, which led to the inability to use reminders; • lack of time to document; • inappropriate reminders at some care points; • inadequate training to use clinical reminders; • reduced eye contact with patients; and • inconsistent use of paper forms.19 The first four findings from this study were identical to those identified in a separate survey by Fung et al,20 in which 261 primary care providers (eg, physicians, nurses, physician assistants, advanced practice nurses [APNs]) participated. In this cross-sectional study, questionnaires were given to volunteers from 104 VHA facilities at a national electronic health care meeting. The strength of this study lies in its national scope involving VHA facilities nationwide.20 Most respondents blamed inadequate training and inapplicability of reminders for not adopting a DSS. The results of the study suggested the importance of adequate training of users to ensure compliance in adoption of a DSS. These authors also recommended evaluating the specificity and ease of using reminders to assess their relevance and applicability to the workflow.20 Agrawal and Mayo-Smith21 conducted a descriptive, longitudinal study, collecting data during a 30-day period in 2003. The data contained standardized reporting of adherence rates, which were determined by calculating the total number of “applicable reminders” (eg, protocols, options to maintain normal physiologic state, warnings of sound-alike medications) and “due reminders” (eg, reminders of medications or laboratory tests that require immediate attention) that clinicians responded to during a given period. A total of 451 clinicians were evaluated in this study. Physicians, nurse practitioners, and physician assistants in 49 VHA clinics were tested for adherence to 15 clinical reminders. The data demonstrated a wide range in adher-
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ence rates.21 Researchers suggested that without the full participation of all health care professionals, the success of implementing electronic documentation would be jeopardized.
DISCUSSION The literature review revealed evidence about the benefits of and barriers to using electronic documentation to support decision making. There was no discussion, however, of system costs, training styles for effective implementation, or positive patient outcomes related to use of electronic medical records. It also is unclear how the push to implement electronic health records by the year 20145 is going to affect the growing number of ASCs. The directive may create a financial burden for these facilities, which likely would result in higher fees for the patient. If this happens, it would defeat the intention of using ASCs to lower the cost of health care. Small ASCs also may be unable to compete with large organizations that have more financial resources available. Clearly, one consideration in adopting an IT system will be the initial costs involved, but equally important is whether the long-term financial benefit of increased efficiency will justify the initial investment. Stakeholders should consider the positive impact of electronic documentation and its potential effects in the long run. Ideally, the costs of acquiring and implementing this technology would be recouped through increased efficiency. ELECTRONIC REPORTS. With the aid of electronic documentation, reports can be created easily, in less time, and without the hassle of manually going through medical records. Reports on idle time, turnover time, the number and type of procedures performed, and unusual scheduling patterns can be created readily. Charges also can be entered and tracked more easily. Computerized reports allow clinicians and providers the opportunity to carefully examine the workflow and to design strategies for improving processes. For example, idle time in the OR can cost a health care facility many thousands of dollars each year. If the average cost of an OR is $10 per minute, 10 minutes of delay per day would translate to a AORN JOURNAL •
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cost of $100 per day. This figure, multiplied by 260 working days a year, amounts to a loss of $26,000 each year. A report on case cancellations may help expose systematic patterns and provide a better understanding of the causes for cancellations. Process improvement initiatives can be implemented as a result of this type of report. Block time utilization also can be monitored by computer-generated reports without requiring a staff member to go through the painful task of manually creating these reports. Additionally, inventory reports can be vital in identifying overstocked items or items that are not commonly used and can lead to reduced overhead and costs. Another type of report that can be designed in an electronic documentation system can identify item charges that have been inadvertently omitted or numbers that were entered inaccurately. For example, consider a suture that has an item charge of $10. Although this type of suture commonly is used at least once a day for surgical procedures, if no charges are processed for the use of this suture on any of the 260 working days in a year, this would translate to a loss of at least $2,600 a year. The same is true for other items not charged because of a lack of charge entry. Lost revenue could be substantial for items such as implants that can cost thousands of dollars. ILLEGIBILITY OF RECORDS. Historically, illegible handwriting in charts and on orders has been the cause of fatal medical errors. Resultant malpractice lawsuits can cost a health care facility millions of dollars, and they create a negative image for the institution. With electronic documentation, illegible handwriting no longer is of concern. As is true for any technological advancement, patient safety should be the primary consideration when investigating an electronic documentation system. The long-term investment required to implement this type of system can be a win-win situation both for the patients and health care providers.
STRATEGIES
FOR IMPLEMENTATION
To maximize the value of an IT system, administrators and clinicians must select the right system carefully. The System Development Life Cycle model22 comprises several phases use-
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ful for analyzing and designing an IT system: • Phase 1—identify the problems, opportunities, and objectives; • Phase 2—determine the system requirements; • Phase 3—analyze the system needs; • Phase 4—design the system recommendations; • Phase 5—develop and document software; • Phase 6—test and validate the system; and • Phase 7—implement and evaluate the system.22 Developing and designing the software is crucial for successful implementation of an IT system. End users should actively participate during this phase to ensure better integration of the system into the workflow of the users. Including end users in the development process also gives them first-hand information about the system functionalities and will encourage them to take ownership of the project. A survey of end users’ workflow and their expectations of the program functionalities can assist engineers in developing the software. Users’ responses on a survey also will help engineers identify users’ needs and will provide them with a better understanding of the workflow. Information technology can add efficiency to clinical and organizational processes. An ASC could increase productivity with careful analysis of daily case load and block time utilization as well as by establishing an efficient inventory of supplies and accurate billing processes. Additionally, development teams should collaborate with software developers to program the types of reports that will assist in improving the efficiency and quality of service. With careful planning and consideration during the development of the software, reports that focus on quality assurance or on budgetary issues also can be built into the system. Each organization will define utilization differently, so each will have different requirements for the content and expected outcomes of reports (Table 1). Although software development is the engineers’ domain, developers must be informed of the users’ requirements in order to create a system that supports end users’ needs. It is essential that software be tested and validated after the design is completed to ensure the system works according to specifications.
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TABLE 1
Sample Reports Generated by an Electronic Documentation System Type of report Infection control
Quality
Area of concern
Reason for action
Wound classification
Identify wound class report by service
Early detection of infection outbreak
Antibiotics given
Track down time and dosage administered
Report on most commonly used antibiotics and on dosages and times given
Surgery cancellations
Identify consistent patterns or causes to improve processes
Prevent gaps in patient preparation and improve volume in ambulatory surgery centers
Eliminate unusually long turnover, which reduces OR productivity Volume
Expected outcome
Reduce turnover time by reengineering workflow
Number of procedures done each day
Identify causes for decreased volume
Increase volume by reassigning block time
Room utilization and staff member use
Identify trends to provide adequate staffing
Assign more staff members on busy days
Utilization
Block time and scheduling conflicts
Address delays from procedures going over assigned block time or surgeons not using allotted time slots
Additional block time provided to avoid delays and reduce waiting time and/or reassignment of block time
Trends
Type of procedures performed
Analyze trends
Volume analysis: Procedures done per day, week, month, and year Identify types of procedures most commonly performed by surgeon and/or specialty
Budget
Revenues
Identify cost per case
Cost containment and adherence to budgets
Supplies
Maintain supply inventory
Inventory maintained within par level or reduced, as appropriate
BARRIERS TO IMPLEMENTING ELECTRONIC DOCUMENTATION One of the primary considerations in adopting an electronically driven DSS is its clinical effectiveness. Alerts and reminders are features that are intended to assist providers in making
decisions. Although alerts are designed to improve patient care, there is evidence in the literature suggesting that providers may not comply with them. Health care providers may find multiple alerts and reminders confusing, and these alerts actually may interfere with the AORN JOURNAL •
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workflow. Clinicians may choose to ignore an alert because of time constraints and work overload or when the alert interferes with patient contact. Inadequate training also may result in a clinician ignoring an alert. Along with the potential benefits of electronic documentation are several limitations that may limit efficacy in practice. Like any other computer system, the usability of a DSS is limited by its design. A system can only perform according to its programmed capabilities. Also, a DSS cannot perform reasoning processes. It cannot be programmed with creativity, intuition, or imagination. The human factor will always play a part in the successful utilization of a DSS. Systems must be designed to communicate information in a manner that is easily understood by the user in order for it to remain useful at the point of care.7
SIGNIFICANCE
TO
APNS
Advanced practice nurses can help facilitate the integration of IT systems in ASCs. They can combine their clinical expertise with the expertise of IT professionals to design an efficient and user-friendly system that will suit the decision support needs of the ASC. An APN can use his or her ingenuity to inspire the creation of a system that will simplify complex problems, which will improve efficiency and productivity. With little data available on effective training styles and implementation strategies, an informatics nurse should consider performing a prospective study on these issues. The focus of such a study should include an evaluation of training styles, implementation strategies, lessons learned, and areas for improvement. This information would benefit other ASCs that have future plans to implement an IT system, and it might prevent them from having to “reinvent the wheel.” Being aware of the potential barriers to compliance should help an APN consider how to reengineer the workflow during the initial implementation of an IT system. To allow users adequate time to adjust to the system without compromising patient care, managers should consider extra staffing (eg, asking part-time employees to work extra hours for the first two weeks of implementation, discouraging regular
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staff members from taking vacation during this time) to facilitate case turnover. In addition, the volume of procedures may need to be reduced during the first few weeks until all staff members are comfortable with the system and any major problems with the system can be addressed.
STRATEGIES
TO
HELP ASSESS
A
DSS
To justify the value of electronic documentation in ASCs, users’ satisfaction with various systems should be assessed. The Clinical Information System Implementation Evaluation Scale (CISIES)23 is a 37-item measurement instrument originally used to assess an IT system at a medical center in Florida. The CISIES focuses on users’ satisfaction with the implementation process and not on the system itself. Gugerty et al23 developed the first Clinical Information System Questionnaire to measure staff member involvement and response to the implementation of an IT system. With a panel of experts, Gugerty further revised the instrument to improve the validity of its content. The questionnaire that they created addresses issues concerning practice improvement, effects of the IT system on workload, and assessment of patient communications. It also measures how effectively the system was introduced.23 The evaluation tool allows staff members to provide feedback in all of these areas. Although the questionnaire is still a work in progress, the results of its previous administration indicate its reliability and ease of use.23
SUMMARY Electronic documentation has the potential to improve the functions and productivity of ASCs. It is a costly strategy to improve the delivery of care, but it promises a positive return on investment in terms of patient safety and productivity. The installation of an IT system that is capable of capturing and storing data and supporting decision making is a long process that requires a special commitment on the part of both users and stakeholders to make it work. Barriers to compliance, as described in the literature, should be eliminated where possible to ensure successful implementation and
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use of a DSS. Additionally, nurses with advanced preparation in informatics can help facilitate the conversion to a DSS, and they can be invaluable in evaluation of the system. Nurses are strategically positioned to help identify both user satisfaction issues and areas for improvement.
REFERENCES 1. Health care spending in the United States slows for the first time in seven years [news release]. Baltimore, MD: Centers for Medicare & Medicaid Services. January 11, 2005. http://www.cms.hhs .gov/apps.media/press/release.asp?Counter=1314. Accessed August 9, 2007. 2. FASA. The history of ASCs. http://www.fasa.org /ascs/aschistory.html. Accessed August 22, 2007. 3. Kennedy P, Pronovost P. Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century. Crit Care Med. 2006;34(3)(Suppl):S1-S6. 4. Javitt JC, Steinberg G, Locke T, et al. Using a claims data-based sentinel system to improve compliance with clinical guidelines: results of a randomized prospective study. Am J Manag Care. 2005; 11(2):93-102. 5. US Department of Health & Human Services. Health information technology: American health information community: background. http://www .os.dhhs.gov/healthit/community/background/. Accessed August 15, 2007. 6. Fitzmaurice JM, Adams K, Eisenberg JM. Three decades of research on computer applications in health care: medical informatics support at the Agency for Healthcare Research and Quality. J Am Med Inform Assoc. 2002;9(2):144-160. 7. Marakas GM. Decision Support Systems in the Twenty-First Century. 2nd ed. Upper Saddle River, NJ: Prentice Hall; 1999:3-9. 8. Carr K, Bangalore D, Benin A, Holmboe ES. Leveraging the benefits of health information technology to support healthcare delivery model redesign. J Healthc Inf Manag. 2006;20(1):31-41. 9. Androwich I, Bickford CS, Button PJ, Hunter KM, Murphy J, Sensmeier J. Clinical Information Systems: A Framework for Reaching the Vision. Washington, DC: American Nurses Publishing; 2002:2. 10. Krohn R. Closing the “loop” of clinical performance improvement. J Healthc Inf Manag. 2006;20(1):12-14. 11. Bates DW, Kuperman GJ, Wang S, et al. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a re-
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ality. J Am Med Inform Assoc. 2003;10(6):523-530. 12. Carayon P, Hundt AS, Alvarado CJ, Springman SR, Ayoub P. Patient safety in outpatient surgery: the viewpoint of the healthcare providers. Ergonomics. 2006;49(5-6):470-485. 13. Garg AX, Adhikari NK, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005;293(10):1223-1238. 14. Donley R. Challenges for nursing in the 21st century. Nurs Econ. 2005;23(6):312-318. 15. The Leapfrog Group for Patient Safety. http:// www.leapfroggroup.org/. Accessed August 15, 2007. 16. Illinois Hospital Association. Hospital Report Card Act (HRCA). March 2004. http://www.iha today.org/issues/safety/updates/faqs.pdf. Accessed August 22, 2007. 17. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144(10):742-752. 18. Zaroukian MH, Sierra A. Benefiting from ambulatory EHR implementation: solidarity, six sigma, and willingness to strive. J Healthc Inf Manag. 2006;20(1):53-60. 19. Patterson ES, Doebbeling BN, Fung CH, Militello L, Anders S, Asch SM. Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods. J Biomed Inform. 2005;38(3):189-199. 20. Fung CH, Woods JN, Asch SM, Glassman P, Doebbeling BN. Variation in implementation and use of computerized clinical reminders in an integrated healthcare system. Am J Manag Care. 2004;10 (11)(Pt 2):878-885. 21. Agrawal A, Mayo-Smith MF. Adherence to computerized clinical reminders in a large healthcare delivery network. Medinfo. 2004;11(Pt 1):111-114. 22. Nahm ES, Mills ME, Feege B. Long-term care information systems: an overview of the selection process. J Gerontol Nurs. 2006;32(6):32-38. 23. Gugerty B, Maranda M, Rook D. The clinical information system implementation evaluation scale. Stud Health Technol Inform. 2006;122:621-625.
Estela O’Meara, RN, MSN, CNOR, was the director of nursing at the Illinois Sports Medicine and Orthopedic Surgery Center, Morton Grove, at the time this article was written. She currently is an educator in the Perioperative Surgical Services Department at Highland Park Hospital, Buffalo Grove, IL.
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