Analyzing the Sharp End of Health Care
Perioperative services account for a huge chunk of hospital revenue, but they also account for a sizable slice of costs and medical errors. At the University of California–Irvine Medical Center, perioperative and anesthesia services were managed with rudimentary information technologies when Zeev Kain, M.D., came on board in 2008 as chairman of anesthesiology and perioperative care.
“We were basically at a horse and carriages stage with the I.T.—you had an OR environment where everything was state-of-the art but anesthesiologists were still using pen and paper to record what they did, and due to various workflow disruptions there was very little correlation between what they wrote down and what actually occurred,” Kain says. “To manage the OR we had to rely on green boards and mix of data that really didn’t provide insights into how to manage surgeries efficiently and ensure patient safety processes were being followed.”
One of the conditions for Kain accepting the position was the guarantee that the medical center would install a perioperative information system. The system—from Surgical Information Systems—went live in 2008 and UC-Irvine has since added a number of modules, including an analytics module a well as applications for clinical documentation for anesthesia, inter-operative and post-operative care, and a surgeon preference app.
All that makes for a lot of data, which can be analyzed in an “infinite” number of ways, says David Keymel, R.N., manager of perioperative/anesthesiology/cardiology informatics. “One danger from my perspective is that I get into the data and few hours pass by without me even noticing,” he says. “There are a number of preloaded views that come with the product, but I can add or delete fields depending on what we want to look at. And at this point we’re analyzing that data flow on a daily, weekly, and monthly basis.”
UC-Irvine’s focus has been on identifying the breakpoints that create financial and clinical inefficiencies. Chief among the process issues has been getting the OR in order for first case on-time starts. Oftentimes surgeries were delayed because rooms were not prepared, surgeon preference cards weren’t in order, and pre-operative antibiotics weren’t administered on time.
By drilling down through the delay codes logged for late procedures, UC-Irvine reconstructed its processes to address those breakdowns. First case on-time starts (“a data point every OR is looking at right now,” Keymel says) are more than 90 percent on a daily basis, compared with 60 percent before the analytics were brought online. Room turnover times also were reduced by 30 percent thanks to process improvements.
When the perioperative system first went live, the focus was to use the information to get the house in order, Kain says. From his perch as chairman, room turnover times and first-case on time starts are critical business components, as are billing and reporting quality measures from the Surgical Care Improvement Project (SCIP) required by CMS. “I’m looking at the clinical and administrative data points that help me make the OR service better,” he says. “Knowing what actually happened on a real-time basis, with every part of the process time-stamped, means you have a real opportunity to increase revenue and decrease paperwork.” In that vein, he points to 50 percent reduction in coding staff devoted to anesthesia billing, a significant decline in AR days, and a reduction in post-surgical time to submit a bill, which went from two weeks to under 24 hours.
That said, business and clinical efficiencies often go hand-in-hand. “While I’m focusing on those issues, we have other staff that are living in those analytics to ensure those process improvements are improving our clinical performance.”
The SCIP measures are a case in point. While the measures are tied to payment, their purpose is to increase patient safety. One measure is a patient’s body post-operative body temperature. The danger is that many patients under anesthesia become hypothermic during surgery, a situation that has a significant impact on outcomes—studies estimate that even mild hypothermia causes higher post-op infection rates and an increase in blood transfusions and assisted ventilation.
Keymel says that UC-Irvine is starting to get a “clinical effect” by tracking post-op documentation to analyze outcomes, including SCIP measurements such as body temperature, nausea and vomiting, and blood loss. For example, looking through anesthesia type and outcomes might show that certain inhalation agents commonly cause post-op vomiting, data which is provided to anesthesiologists to analyze. UC-Irvine plans to ramp up its clinical analytics program as it gets more retrospective data into the system, Keymel adds.