Rethinking OR and Procedure Room Documentation

What’s inside:

This blog looks at the need for effective point of use data capture and documentation.

We discuss:

  • Why operating rooms (OR) and procedural rooms are a vital data capture point
  • How surgical documentation data informs healthcare management
  • The tree biggest challenges for surgical supply documentation
  • Next-generation image recognition technology, the pathway to data integrity at the point of care

Overcoming OR and procedural room data challenges

Surgical documentation is about so much more than just updating the patient chart.

OR and procedural rooms are the major revenue drivers for any hospital, and this setting is therefore a vital data capture point that underpins business effectiveness.

In addition, medical inventory is the second largest expenditure for healthcare providers, so the accurate implant tracking of expensive OR inventory is crucial.

Put these two facts together and it’s clear that OR and procedural rooms are vital data capture points for healthcare management, in terms of both cost control and revenue optimization.

Yet despite the heavy significance of surgical supply chain data, current methods used to capture and document utilization in the operating room are often time-consuming and unreliable.

The power of OR utilization data

Let’s take a close look at how supply chain data is used.

Utilization data from operating and procedure rooms feeds into cross-organizational workflows and plays a crucial role in effective healthcare management:

 

Inventory management: Having the right products available, at the right time, prevents last-minute deliveries, delays, or cancellations.

 

OR inventory data underpins timely and accurate procurement, improves inventory control, reduces wastage, and lowers costs.

OR performance optimization: Failure to capture full data from all the billable items used in surgery compromises charge capture.

 

Capturing and digitally documenting the full details of consumed items optimizes OR revenue.

 

Robust records: Accurate utilization documentation in the EHR boosts patient safety and protects both staff and the organization.

 

Achieving full and complete clinical documentation ensures compliance with FDA UDI regulations and Joint Commission standards.

 

Gain insight into OR: Physician and case metrics provide management with a clear vision, informing decision-making and the planning of future healthcare provision.

 

It is only when you have a clear vision of where you are now, that you can tackle inefficiencies and plan for the future.

 

 

 

The three biggest challenges for OR data collection

Manual data entry and barcode scanning are the most common methods used to record product usage in surgery. However, both fail to cope with the complexities of data capture in the surgical setting.

OR and procedure rooms are some of the toughest places to achieve data integrity. Three major reasons for this are:

  1. Complex variety of products: The products used in surgery do not always come from stock. They may be bill-only, trunk stock, or just-in-time deliveries. They may not have an accompanying PO and may not be pre-listed in the system.

 

As these items are scanned, a system error comes on the screen if there is no Item Master pairing. This also occurs when the manufacturer updates the codes on stock items so that they no longer match the data on file. A longwinded, manual, process is required to record all these non-recognized items.

 

  1. Barcode scanning issues: Traditional point-of-use data capture methods fail to routinely record utilization. Limitations of this method include barcode readability issues, confusion over multiple labels on packaging, scanner failure, and the collection of only partial data.

 

The use of inefficient point-of-use data capture tools places an unnecessary admin burden on perioperative nurses and fails to systematically document consumption.

 

An error message in the POU systems that alerts and calls for the completion of missing information, which is done manually
An error message alert calls for the completion of missing information.
  1. Reliance on data entry: Some healthcare providers routinely use manual keying in as their main method of surgical documentation. Others rely upon data entry as a secondary method, when their chosen technology fails.

 

This dependence on the keying in of full or partial item data places an unnecessary admin burden on nurses, it is time-consuming and prone to errors and omissions.

 

When recording usage is this difficult and elongates clinical workflows, the risk of non-documentation in surgery is high which will result in inaccurate utilization data in the EHR.

With existing systems placing a heavy admin burden on busy perioperative nurses, many healthcare providers are searching for a more efficient way to collect OR data.

Impact of Inaccurate Clinical Supply Chain Data

When full, accurate data isn’t recorded at the point of care there are inherent risks:

  • Supply chain management: Without accurate utilization data it is impossible to ensure accurate procurement or minimize supply chain costs.
  • Patient safety: If the EHR is not complete, then recall management is slow and inefficient, and patient safety is compromised.
  • Case revenue: When full charge capture is not achieved in a timely manner, revenue is at risk.
  • Data-driven management: Effective supply chain management and future planning require accurate point-of-care data.

 

The surgical setting is one of the most complex supply chain data capture points, but it is important to ensure data integrity here as the information collected has a direct impact on healthcare management and margins.

With existing technology failing in the surgical setting, it’s time for a new approach.

Beyond barcodes – introducing image recognition

The limitations of existing technologies mean that it’s time to venture beyond barcodes.

The surgical suite requires a custom data-capture and documentation solution that can cope with the specific challenges of this setting.

Introducing Snap & Go – a next-generation data capture tool specially designed for OR and procedure rooms.

Recognizing the limitations of barcodes, (including 2D barcodes), IDENTI uses advanced image recognition and AI technology, heralding in a new era of simpler, more intuitive, point-of-use data collection.

 

Snap&Go - easy, accurate item and charge capture at the point of care
Snap&Go – easy, accurate item and charge capture at the point of care using computer vision and AI technology

Snap&Go: 3 steps to success:

This is what labor-lite clinical documentation looks like:

1. DATA CAPTURE: This is now a 3-second task.

The product is placed under Snap&Go’s sensor, where computer vision technology ‘reads’ the packet. A digital image of the product package is recorded, and all relevant item data is captured, including ‘tricky’ data such as batch number and expiry date. The system can also digitally capture and interpret hand-written Implant Sheets so that small consumables such as nuts, bolts, and screws are easily recorded.

2. ITEM IDENTIFICATION: This is now an automated process.

The combination of AI healthcare technology and a global product database breaks providers’ dependency on their Item Master for product identification. In the event that a match can’t be found on the global database, IDENTI’s back-office team will do all the legwork for you.

3. USAGE DOCUMENTATION: This is now an automated process.

Snap&Go‘s cloud software seamlessly integrates with your EMR, ERP, and MMIS, ensuring prompt transfer of vital OR data to drive through optimized OR management.

 

Optimizing OR management starts with good data.

Snap & Go is a unique and bespoke surgical data capture solution.

If you want to ensure full data integrity at the point of care, contact us to find out about the power of image recognition technology in modern healthcare management.

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About the author

Sharona is Marketing and Content Manager, charged with telling the world about IDENTI Medical, and its range of data sensing solutions. Sharona has worked in a range of industry settings, including healthcare organizations and SAAS companies. Sharona is also responsible for organizing network events across the US, creating opportunities for healthcare professionals to meet the team and see our products in action.