The Case for Using Computers in the Operating Room

Medical Intormatics

The Case for Using Computers in the Operating Room MARION J. BALL, EdD, Baltimore; ANN WARNOCK-MATHERON, RN, and KATHRYN J. HANNAH, RN, Calgary, Alberta, and JUDITH V. DOUGLAS, MHS, Baltimore

The largest cost center and revenue generator in most hospitals, the operating room is subject to demands for increased cost accountability and quality assurance. Information technology tools can be incorporated into the operating room and have the potential to positively affect practices there through addressing nursing, administrative/financial and medical needs. Microcomputer-based operating room systems now on the market can provide functions from scheduling and case costing to medical records and market analysis. Of 21 functions identified, 10 can be characterized as mandatory and the remaining as optional. Individual systems offer varied configurations, providing from 0 to 21 functions. These enhanced capabilities for data collection, monitoring and analysis enable health care professionals to provide both better and more cost-effective care for surgical patients. (Ball MJ, Warnock-Matheron A, Hannah KJ, et al: The case for using computers in the operating room, In Medical informatics [Special Issue]. West J Med 1986 Dec; 145:843-847) Over the past 20 years, the computer has had a major impact on hospital information resources management. A historic perspective makes evident two areas where computerization has made its earliest and greatest contribution. 1 The first area includes activities that require a high volume of repetitive data processing. The other area encompasses the services in the health care environment that generate high levels of revenue. Thus, the computer found a home first in the business office and from there moved on to the clinical laboratory, then to the pharmacy and radiology departments. During the past decade, computerization has been implemented in practically all other areas of the hospital such as central supply, dietary services and medical records. Remarkably, however, one of the areas that fits both criteria for early introduction of computerization has only in the past few years emerged as a major locus for computer use. This is the hospital surgical suite. Unlike the laboratory, where a high level of transactions occurs with a single laboratory test, in the operating room a high volume of information is obtained with a relatively low level of transactions. This attribute characterizes the surgery environment and presents a special set of concerns when computerization is discussed. In this paper we intend to examine the needs of the surgical suite, to describe the capabilities of computing to meet those needs through a detailed review of available software pack-

ages and to discuss the potential effect of computerization on operating room practices.

Needs of the Operating Room Today the operating room (OR) serves as a theater for the more radical and innovative medical practices. It is also the main source of hospital admissions in this time of decreasing inpatient days. The largest cost center in the typical hospital, it is one of the last areas to become subject to cost accounting. Thus, the long-standing problems of scheduling operating room use are compounded by administrative concerns regarding cost efficiency and documentation as operating rooms are subject to intensifying scrutiny, especially in the areas of quality assurance and cost containment. For hospitals now facing the cost-accountability requirements of diagnosis-related groups (DRGs), this constitutes a major problem. According to a recent study, most hospitals surveyed report increased activities to analyze surgical costs in response to DRGs.2 A cost center as well as a revenue center, the OR must provide ongoing statistical records to account for the cost effectiveness of material, fiscal and human resources.3 To address cost-containment issues and the related area of quality of care, hospitals clearly need improved management and utilization tools. "This challenge is also an opportunity to rethink the basic principles of OR management, to explore

From the Information Resources Management Division, University of Maryland, Baltimore (Dr Ball and Ms Douglas), and the Faculty of Nursing, University of Calgary, Calgary, Alberta (Ms Warnock-Matheron and Ms Hannah). Reprint requests to Marion J. Ball, EdD, University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD 21201.

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COMPUTERS IN THE OPERATING ROOM ABBREVIATIONS USED IN TEXT DRG = diagnosis-related group JCAH = Joint Commission on Accreditation of Hospitals OR = operating room

new ways of reducing costs, and to develop new relationships and more efficient management procedures."4 To do so, health care professionals must first collect reliable data and then complete an objective diagnosis. In the recent past, the attempt to address scheduling difEculties very often resulted in the creation of additional operating rooms, requiring the allocation of more resources to these costly facilities. With the advent of DRGs has come tighter management of health care costs, even in the operating room, one of the last areas to be subject to cost constraints. An alternative approach now becoming prevalent involves the systematic review of the surgery arena. Such review encompasses a wide range of data, for patient care in that arena involves a high volume of clerical work, generally completed by specially designated OR nurses. Among their duties are the following: * Creating the OR record * Doing inventory functions * Recording the details on which billing is based * Completing clerical housekeeping tasks of varying degrees. In addition, the nursing staff is responsible for supervising OR activities on behalf of the hospital and ensuring compliance with the guidelines set forth by the Joint Commission on Accreditation of Hospitals (JCAH). Currently, both data and objectivity are in short supply. It is crucial that professionals take a fresh look at what in fact goes on in operating rooms and how those facilities are managed. This requires analysis, determining use, assessing the current manual systems being used and further assessing the users, both professional health care providers and patients. It also requires defining a set of goals to be addressed in looking at operating room management.

Computerization of the Operating Room Health care institutions have at this moment the opportunity to utilize the tool of the 20th and 21st centuries, the computer, to harness the data being produced in exponential fashion and to manage those data to generate information that will ultimately result in better care for patients and more effective support for the institutions. To realize this opportunity, health care professionals must address the questions of what information is needed and how it should be applied to the practice of medicine. This necessitates a change from the old data-processing mentality to an information resources management approach. The magnitude of this change is made possible by the new information technologies, but its true potential lies in the capabilities it provides to the health care field. The task is not simply to obtain access to such tools and bring them into the operating room. "Microcomputers are now a reality in the OR and are already having 'a significant impact on surgical practice"' (Fourth Annual Joint American College of Surgeons/Association of Operating Room Nurses Symposium: "The OR Environment Revisited," Surgical Practice News, 1986 Mar, pp 1,7-8). The challenge is to 844

incorporate the tools of information technology into practices that will have a positive effect on the operating room environment and hence on patient care. Responses to Demonstrated Needs Three categories or areas of demonstrated need for introducing computer systems in the operating room can be identified: nursing, administrative/financial and medical. All three must be addressed to produce a workable product. Nursing is the key component that hospitals depend on to deliver their services to patients. Operating room nurses perform a wide range of clerical and clinical functions. With the assistance of information technology, nursing can focus on issues directly affecting the quality of care, including the full range of management concerns in the operating room arena. Recently developed operating room computer systems offer the capability to support the clerical and managerial functions of the nursing role and also provide needed reports on a specified periodic or a demand basis. In more sophisticated environments, these data can be transported from the operating room computer system to the hospital information system to be integrated into a patient's medical record. Administrative and financial management concerns must be addressed comprehensively by the new surgical software, as hospitals attempt to cope with the reimbursement revolution resulting from implementing DRGs. As the health care shifts from a cost-reimbursement to a fixed prospective-payment base, it is critical to identify specifically which costs occur and where they arise in the treatment of patients. Operating room software provides the capability not only to track these costs, but also to itemize operational expenses in such categories as direct versus indirect and chargeable versus non-

chargeable costs. Medical care issues are also affected by the computer in the operating room. The cost-containment crisis comes at a time of unprecedented focus on the quality of medical care. As medical technology develops, techniques once considered miracles, such as heart, kidney and other organ transplants, have become routine procedures. These and other biomedical advances are accompanied by new legal and financial barriers to providing patient care. The malpractice crisis is accompanied by increased stress on quality assurance. The environment thus demands that professionals complete cost-benefit analyses ofmedical treatments, especially in such areas as surgical interventions, where both costs and medical risks are high. Surgeons must have the ability to objectively evaluate and manage each surgical procedure in such a manner as to control the costs associated with nosocomial infections and iatrogenic problems such as surgical accidents and conditions that may manifest themselves postoperatively. In responding to quality assurance issues and to cost-containment requirements, hospitals have at their disposal the new management tools that information technology provides. These include software packages that support * Productivity * Independent learning * Statistical analysis * Data base development * Report functions * Medical and management decision making. THE WESTERN JOURNAL OF MEDICINE

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Other tools enhance clinical activities and communications capabilities. The potential of these tools is just now presenting itself in the form of software packages specifically produced for the surgical suite. To meet the needs for quality assurance and cost-accounting functions, certain other software features may be required. Selection of a system should be based on a user's specific situation. Features of concern to end users are those that they themselves can evaluate, not those that are of concern only to a computer professional. Changing circumstances may dictate that any number of items be addressed in varying combinations. Items of interest within the ad hoc reporting function might include * Instruments and equipment used by a physician, the type of operation, specialty request and repair, statistics and costs. * Inventory tracking by room, patient, surgeon, results, staff and case type. * Reports and records statistics by room, staff, case, surgeon, type of operation, diagnosis and outcome. Software Review As a research evaluation study of operating room systems indicates, software capabilities can go beyond scheduling to fulfill hospital needs for cost tracking, clinical abstracting and other information requirements in support of the overall goals of cost containment and quality assurance. As part of the study, we reviewed the literature to determine which functions should be considered in evaluating an operating room system. In all, 21 functions were identified in the literature. Ten were considered important by most of the authors reviewed and therefore are labeled mandatory within this review; 11 were of lesser importance. It should be realized, however, that these lists can serve only as a guide to a specific institution establishing its own set of mandatory and optional functions.

The authors of the evaluation study also analyzed information provided by the vendors of 18 software packages now available, to determine which functions those packages provide. The mandatory functions include the following: Scheduling Staffrecords Resource use Inventory control Surgeon preference case cards Case cart supply lists OR logs Infection control Anesthesia Case costing The 18 software packages now available were further analyzed to determine which of these functions each package provided. Five of the systems address fewer than five mandatory functions, with one package including no mandatory functions. Three-Enterprise Systems, Intellimed and Health Care Computer Works-offer all ten mandatory functions; six offer nine of the ten. The functions offered most frequently include OR scheduling, anesthesia and OR log recording. Least frequently offered functions are infection control and staff record maintenance. Noteworthy is the fact that the mandatory functions do not include patient-related areas, but rather are limited to monitoring and record keeping in areas prescribed by the JCAH guidelines, standard operating room procedures and hospital accounting requirements. For detailed results, see Table 1. The additional functions, ranked by the authors reviewed as of lesser importance, include the following 11 areas: Equipment control Clinical data Patient care plans Patient assessment Recovery room Market analysis Pharmacy Medical records Electronic mail Vendor analysis Implant information These functions are provided less frequently than the mandatory functions. In all, 16 ofthe packages include equipment control and 15 allow for medical records, but other features

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are less frequently provided. Only three systems provide care plans. Table 2 details the results.T'wo packages, CHIRPS and Intellimed, offer all 21 functions. Three, Enterprise, Health Care Computer Works and Micro Med Technologies, offer 18 functions. For a complete ranking, see Table 3. Vendors of all 18 software packages reviewed indicated that they had the ability to support the production of user-defined reports; thus, the presence or absence of specific reports or online inquiries is not at issue. Needs, however, cannot be met effectively without the provision of a report generator or a high-level query language that allows users to produce ad hoc, reports without vendor or inhouse programmning support.

Certain caveats should be noted by those considering acquiring this software. First, the packages reviewed should be considered at this point as stand-alone systems. Extensive data definition and data-base development would be required before linkages between systems become possible. "Even the common notions like admnission, discharge, bed-day, ward, etc, often turn out to lead to confusion" (Fourth Annual Joint ACS/AORN Symposium: "The OR Environment Revisited, " Surgical Practice News, 1986 Mar, pp 1,7). Second., response time and other technical aspects can be objectively measured only through a formal benchmarking process. Third, cost comparisons must be weighted by performance

considerations.

Potential Effect of Computerization The software packages available make it possible for health care professionals to gain control of data produced in areas as diverse as infection control, case cart supplies and surgeon preference case cards. The resulting information can serve not only to establish enhanced knowledge bases but also to change the operating room environment. Computerization makes possible improved care for surgical patients through analysis in the areas of: * Operating room practices and techniques , * Efficiency and productivity factors, * Treatment outcomes, alternatives and objectives, . Scheduling, staffing patterns and performiance, . Costs incurred in specific procedures. Thus, computerizing the operating room functions can enable health care institutions to allocate resources and manage assets and costs more effectively. By relating costs not only to financial return but also to procedures, techniques and medical risks, medical practitioners will meet more capably their responsibility to patients-a responsibility nowhere more evident than in the surgical suite. The recently revised JCAH standards on quality assurance 846

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require that hospital surgical staffs establish mechanisms to monitor and evaluate patient care. A monthly review of all cases is recommended. The effect of these revisions is to move the concept of monitoring beyond "random identification of problems to systematic, facility-wide screening."5 The considerable demands that these revisions place on the operating room environment may in fact be amplified as the JCAH completes its new chapter on surgical quality standards to be included in its accreditation manual. Fortunately, in this time of unprecedented pressures to control costs and risks, software packages such as those reviewed above are now available for the operating room arena. Designed to run on machines with increased speed and enlarged memories, such as the IBM AT-RT and the A T & T Company's 3B type microcomputers, these packages mark the beginning ofthe development of sophisticated fourth-generation data bases and associated applications software, pro-

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ducing systems to be used by medical and management professionals as well as support personnel. Thus, within information technology exists the capability to address the spectrum of needs in the operating room, facilitating the delivery of cost-effective, high-quality medical care. The computer may be late in entering the surgical suite, but it brings with it invaluable tools for managing that complex environment. REFERENCES

1. Ball MJ, Hannah KJ: Using Computers in Nursing. Reston, Va, Reston, 1984 2. Diomede B: DRGs and surgical procedures: A survey of hospitals' cost analyses. AORNJ 1985; 42:914-918 3. Balzer MJ: Computerized systems for the OR: Management applications. AORNJ 1986; 43:187-193 4. Arnold WW, King SS: Recommendations for controlling costs in the university teaching hospital operating room. Periop Nurs Q 1985; 1:1-6 5. Bakker AR: Health and hospital information systems-The scene for the years to come, In Van Bemmel JH, Ball MJ, Wigertz 0 (Eds): Proceedings of the Fourth World Congress on Medical Informatics. North Holland, Elsevier Science Publishers BV, pp 6-9

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