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.
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