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Integration in the OR

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Three years ago, Baltimore Washington Medical Center adopted wireless technology in its 14 operating rooms. The goal, recalls Vice President and Chief Information Officer Dave Peterson, was to give the circulating OR nurses who document procedures more flexibility in their workspace.

Using mobile workstations, the nurses now work facing the patient, rather than having their backs to the action as they did before the 220-staffed-bed hospital upgraded its legacy information system. The change has been a real plus to the nurses, says Joyce Myers, director of perioperative nursing at the Glen Burnie, Md.-based hospital. “Nurses can face the patient in the sterile field while documenting,” she says. “They can change the position of the computer depending on the orientation of the OR table and what kind of case it is.”

But Baltimore Washington still confronts gaps in incorporating IT into its surgical service line, which spans general procedures to complex vascular surgeries. Anesthesiologists still document on paper, says Peterson, citing “the enormous amount of paperwork that has to be completed.” And if surgeons need to view radiology studies, staff members must fetch the films and hang them on light boxes. Asked about her IT wish list, Myers says the hospital could use an electronic tracking system to follow patients as they move through from pre- to postoperative care. The hospital is planning on installing a picture-archiving and communication system to expedite routing of images, but the other technologies will have to wait for now.

Baltimore Washington typifies the glaring contrast in the healthcare industry’s use of technology in the OR. On the one hand, surgical procedures draw on a remarkable array of hardware—witness the rapid expansion of minimally invasive procedures. But when it comes to documenting events, the technology can be primitive. Sharing information is difficult, as documentation is fragmented among numerous players. IT can ease the capture and sharing of surgical data, experts say, but hospitals that have automated OR documentation say the effort is extraordinarily expensive. Moreover, enhancing safety and communication in the complex OR environment goes well beyond sharing data electronically. Some hospitals are rethinking the political hierarchies that have long dominated the surgical suite.

Knocking down silos

Phoenix-based Banner Health is midway through a five-year clinical IT upgrade that will bring electronic medical record technology—including a PACS—to its 20 member hospitals. Scattered across seven states, these hospitals have ORs in need of clinical documentation automation, says Judy Van Norman, system director for care transformation. “The OR operates, not intentionally, in a silo,” she says. “We are looking to break down the silos between the emergency department, lab and pharmacy with an integrated record that everyone can share.”

Sometimes documentation in the OR can be downright primitive—even at highly touted facilities. In 2006, New York-based Memorial Sloan Kettering Cancer Center abandoned the OR white boards it once used to display information. Using magic markers, nurses would fill in details about the procedure on the board, recalls Daniel McGuirk, engineer specialist in Sloan Kettering’s medical physics department. McGuirk spearheaded the effort to bring more sophisticated documentation tools into Sloan Kettering’s new surgery center. Opened in May, the center houses 21 ORs and sports a bevy of information integration tools that combine video, sound and digital data.

At Banner Estrella Medical Center, importing electronic images into the OR has boosted surgical operations, says Donald Lottes, PACS manager at the Phoenix hospital. The 172-staffed-bed facility opened in January 2005 and serves as an IT model for the rest of Banner Health’s facilities. At the Phoenix hospital, “there are no paper charts,” says Debbie Carter, deployment manager. For surgeons, the PACS set-up means easy access to patients’ films and radiologists’ reports, adds Lottes. Surgeons can view films on monitors in the OR and consult with radiologists who are viewing the image simultaneously.

Surgery is increasingly guided by images, adds Chris Boivin, director of diagnostic services at Banner’s Phoenix facility. The PACS from Fuji enables surgeons to call on radiology subspecialists, even at remote locations, he says. “If a surgeon has a question, they can talk to a specialist at another Banner hospital and take the consult one step further to a radiologist who specializes in MRI or nuclear medicine.” The Banner surgical documentation system also includes built-in planning tools, such as “preference cards,” which spell out the particular needs of sometimes highly selective surgeons, adds Van Norman. “We are building in evidence-based practices,” she says. “We want the documentation system to prompt if certain implantables or medications are indicated.”

Big bankrolls

All of this technology doesn’t come cheaply. Banner Estrella is investing more than $100 million to equip its 20 hospitals with EMR technology, primarily from Cerner, Van Norman says. The new Phoenix hospital cost $175 million to build, including IT infrastructure. Of that total figure, nearly $2 million went to testing PACS interfaces and hiring people to build them, notes Boivin. Sloan Kettering invested about $70 million in its new surgical center, which spans four buildings and occupies 72,000 square feet. Even with money to spend, McGuirk says finding a vendor who could consolidate all the OR information feeds and meet Sloan Kettering’s specifications was difficult. “Nobody in the medical world does this,” he says.

McGuirk wound up hiring LiveData, a company that has built integrated information displays for utilities. In tandem with several other vendors, LiveData built the “wall of knowledge” that now hangs in Sloan Kettering’s ORs. Receiving data from formerly independent information systems, the large-screen monitor displays patient demographics, names of people on the surgical team, and various physiological readings taken from monitors.

Although the information display has yet to undergo formal evaluation, Aileen Killen, director of nursing for perioperative services, says it upholds a new way of thinking about the way surgical teams work together. Sloan Kettering’s cancer surgeries can be lengthy procedures with rotating teams with as many as 20 participants. Now staff can enter a procedure in progress and know what has transpired by looking at the information display. Making sure team members know one another helps facilitate communication, Killen says. “We have flattened the hierarchy in the OR, so a med student is not afraid to question a senior surgeon,” she says. “It was crucial to get everyone’s first names on the board.”

Next on the horizon for Sloan Kettering, says McGuirk, is a radio frequency identification tracking system. Eyeing deployment by this fall, McGuirk says the RFID system will keep track of equipment location and maybe even personnel. Even surgical sponges could sport the RFID tags, he says. “We could know if anything was left in the patient.”

Gary Baldwin is technology editor of HealthLeaders magazine. He can be reached at gbaldwin@healthleadersmedia.com.