The electronic health record (EHR) is used to document key elements of patient care, but although it does an excellent job in many areas, healthcare providers are struggling with its limitations.
This article will look at:
- The cost of inefficient EHR data collection in surgery
- Common challenges documenting supply utilization at the point of care
- The five key things EHR systems need to get right for surgical supply documentation
- Using artificial intelligence (AI) to boost EHR efficiency
The electronic health record has become a crucial element of modern-day healthcare, but as well as recording clinical details, such as surgery and treatment details, the EHR also feeds vital OR consumption data into administrative and operational workflows, supporting efficient care delivery.
Making sure that the EHR contains full and accurate information has therefore become a clinical, operational and financial priority.
C-suite thoughts on EHR performance
As the value of healthcare data increases, many providers are realizing the limitations of their EHR systems, and there has been a growing trend in turning to third party technology for a solution.
Research on 100 healthcare C-Suite executives*1 on plans for 2024-25 identified that:
- Only 24% felt their EHR lived up to vendor’s promises “very well,”
- Only 17% strongly agreed that their current EHR will meet their needs moving forward
- 60% of respondents were prioritizing EHR optimization as their top technology initiative.
In light of ongoing EHR limitations, interoperable, third-party electronic health record (EHR) apps are being created to enhance the functionality and capabilities of EHR systems and fix data integrity issues.
If you find the right third-party EHR app, you can maximize the value gained from your EPIC system.
Point of use surgical supply documentation
One important task that the EHR commonly struggles with is recording surgical supply utilization. The operating room is a complex setting and the data capture capabilities of the EHR struggle with the wide range of medical devices, implants and consumables used in surgery – some of which are “non-contract” items that aren’t preloaded into the system.
So, let’s take a look at the areas that healthcare providers need to improve in terms of their EHR performance relating to surgical utilization documentation.
5 reasons you need an EHR optimization app for improved patient records
➡️ Usability: Surgical documentation needs to be “nurse friendly”
A study on electronic health record usability*2 found that 27% of respondents experienced usability challenges relating to data entry.
Documenting the implants used during surgery can be a frustrating task for the circulatory nurse. If direct data-entry is used, then there are pages of fields to complete and dropdowns to select from. Even when automated systems like barcode scanners are used, nurses still report issues, such as barcode readability, data gaps and system errors. An automated system should work for every item, every time, without the need for any data entry.
When nurses struggle with perioperative documentation, while at the same time trying to focus on the needs of the patient and the clinical team, this commonly leads to data entry errors, as well as undocumented implants.
Existing point-of-use systems for recording product usage in surgery are cumbersome to use and distract nurses from patient care.
➡️ Speed: Perioperative documentation needs to be a quick task
Nurses reported that only 48% of medical implants and consumables used during surgery are recorded.
Many existing systems simply aren’t efficient, with elongated or failed processes that commonly divert nurses into manual workarounds.
Even where data is captured accurately, if there’s no direct match in the hospital catalog, then an exception error will appear on the screen. An out-of-date hospital Item Master can derail documentation and result in a slow, manual process. “Off-contract” and “bill-only” items are particularly susceptible to being left unrecorded due to this issue.
Perioperative documentation needs to be streamlined and swift.
Nurses simply don’t have time for complicated documentation, and many will quickly give up if an item can’t routinely be recorded, leading to data gaps in the electronic health record (EHR).
➡️ Revenue Cycle Management (RCM): Charge capture needs to be complete and correct
57% of healthcare c-suite survey respondents rank growing revenue as the top strategic initiative.
When full charge capture is achieved in surgery it can increase reimbursement by 10-30%.
There are three things that result in revenue cycle management issues:
- Incorrect data entries
- Partial data collection
- Omitted items
Charge capture is a required outcome of product consumption documentation but all too often this crucial task is not carried out efficiently.
Providers are often aware of point of use data collection inefficiencies and therefore put in place post-surgery documentation reviews and reconciliation in an attempt to fix data gaps and errors. This task is time-consuming and resource-heavy, often involving senior staff, and is only necessary to compensate for poor POU supply documentation tools.
Preventing revenue loss in OR doesn’t need to be carried out after surgery, a good system will optimize charge capture during surgery, without the need for any additional activity.
➡️ Data Accuracy: Patient safety and smooth healthcare operations depend on good data
All of the data collected at the point of care is crucial and inaccuracies can impact patient safety.
Clinical issues such as adverse effects after surgery, as well as future product recalls, both rely on robust records containing all item data on every consumed implant, in order to ensure a swift and informed response.
Another issue with inaccurate OR data is that it misinforms the workflows it feeds. For example, missed items or incorrectly entered products will lead to procurement errors and risk stock shortages or stock-outs.
In addition, when this data is processed for business insights, its inaccuracies and omissions can mis-steer management.
➡️ Enhanced data analytics: Precise utilization records optimize insights
46% of healthcare c-suite survey respondents rank reducing costs as the top strategic initiative.
OR revenue can represent 50-70% of hospital profits.
Today’s healthcare leadership relies upon prompt and precise data to make smart, informed decisions.
With top priorities such as growth and cost reduction, OR data can be used to improve efficiencies, reduce operating expenses, and support key organizational goals.
An organization’s surgical spaces are its main income driver, so ensuring tight data collection in this setting is crucial for optimizing OR performance.
Collecting OR data can contribute to smarter decisions that lower the cost of care, maximize profits and ensure sound financial management.
With EHR’s struggling to perform to the necessary standard, C-suites are looking for EHR optimization technology to improve their surgical supply documentation capabilities.
Using AI and advanced technology to boost EHR performance
AI technology is part of many healthcare technology innovation strategies and if we go back to the c-suite report we can see that:
- 26% plan to invest in operational AI in the next 12 months relating to clinical notes and documentation
- 45% say integrating AI with clinical workflows has led to improvements in data quality and accessibility.
Point of care documentation technology has recently evolved and now a brand-new approach to recording surgical supply is available that not only slashes the time and effort involved in supply utilization, but also results in 100% item and charge capture in the EHR.
We reviewed four different point of use supply documentation methods, take a look at our recent white paper on Supply Utilization at the Point of Care – Traditional vs New Tech.
Unsurprisingly, the combination of AI and computer vision technology provided the most efficient documentation across key performance criteria.
Image recognition and AI for optimized OR supply consumption documentation
SNAP&GO uses unique image-recognition technology to take a ‘snap’ of the product packet or label. AI and machine learning, supported by a global SKU database that supplements the local item master, then work together to fix bad data, fill in any gaps, and validate the item, before documenting it directly into the patient file.
Product safety alerts are also displayed on the screen if any recalled or expired item has made it into the OR, providing a final, and vital, safety net prior to consumption.
The system generates real-time metrics, reports and analytics, ensuring that healthcare managers and leaders have full OR supply utilization insights to inform their decision-making.
SNAP&GO already has Cerner certification and EPIC interoperability, as well as numerous other electronic health systems. This unique, patented POU documentation tool won the Frost and Sullivan New Product Innovation Award in 2022 and achieved a Vizient Innovative Technology Designation Award in 2023.
See the speed and simplicity of documenting surgical supplies using AI technology at the point of care.
Product documentation using Snap&Go is a 3 second task using image recognition and AI technology – a brand new surgical data capture solution.
Providers looking to enhance their point of care software with improved product utilization functionality, should consider a third party EHR app like Snap&Go, that seamlessly integrates with our exiting EHR software, and can tackle the five key issues of useability, speed, charge capture, data accuracy and analytics.
Contact us if you’re looking for an EHR optimization app to optimize point of use item tracking and charge capture.