Running a hospital operating room, an ASC or any medical practice comes with a host of complex challenges. Staying on top of information management is a constant exercise in multitasking—from capturing and maintaining up-to-date patient records, to ensuring accurate documentation to maintaining compliance with regulations around secure communications.
Given the many pieces and high stakes involved in day-to-day operations, it’s crucial to minimize risks. However, effective risk management requires that you have a very clear idea of where those risks lie.
Here, we look at the three most common areas of vulnerability we have seen working with several surgical practices.
1. The risk of failing to comply with HIPAA regulations
The 1996 Health Insurance Policy and Accountability Act (HIPAA) exists to protect patients’ medical records and personal health information (PHI). All HIPAA-covered organizations have a duty to collect and store that information safely.
That’s a challenge for any healthcare organization, but if your scheduler is working with a paper-based system, it’s even more daunting. Although at this point everyone has adopted electronic medical records, administrators are often surprised to learn how much of the surgery scheduling process still takes place with paper and pencil—outside the electronic record. This is often exacerbated when practices and surgical facilities have separate disconnected electronic record systems. You need to make sure that everything is captured, recorded, and disseminated accurately, and that all the required surgical support—all those admission documents and anesthesia plans, clearance instructions and preoperative orders—are retained securely for the required period and then properly disposed of.
To be compliant with HIPAA, it’s not enough to simply avoid data breaches. Organizations can be penalized for not having the required technical, physical and administrative safeguards in place. And those penalties are not to be taken lightly — providers can be fined $100 to $50,000 per violation depending on the situation.
An internal registry can be difficult to track and impossible to share among a distributed remote work force. Online shared spreadsheets (e.g. Excel/Office Online can present a significant vulnerability and may not have the necessary authentication, auditing, and backup safeguards for HIPAA compliance. CaseCTRL’s HIPAA-compliant cloud-based repository provides a centralized location for essential forms, including pre-authorizations, doctor preference cards (DPCs), and patient surgical assessment forms. This system means surgeons and schedulers can access data from anywhere securely, and they don’t need to worry about updating software or syncing data across different devices and sites.
2. Risks caused by errors in patient information or surgery documentation
Accurate patient records are essential for identifying and tracking patients as they move through the stages of their care and to make sure patients are billed correctly.
Surgical teams need to communicate as many as 150 data points for one surgery. They also need to coordinate information from multiple stakeholders, track potential conflicts and identify and reserve equipment—all on schedule. Relying on paper-based systems for capturing and tracking patient details and records leaves the clinician vulnerable to inefficiency, error and non-compliance. Hard-to-decipher hand-written notes and amendments on posting forms can be a minefield, and even minor errors can result in case mismanagement.
Even if you manage surgery scheduling with an email or tasked-based system, there is still considerable manual transcription required, with the potential for missing or incorrect data. Poor data handling hampers the efficiency, and therefore profitability, of the OR—not to mention raising the possibility of litigation.
By investing in advanced surgery scheduling software, automate notifications, documentation of patient records, and eliminate legibility issues that can precipitate costly of errors at the ASC or hospital.
3. Risks caused by over-reliance on your surgery schedulers and slow, paper-based scheduling systems
Information silos are another top concern. Paper-based scheduling before cases are confirmed in the electronic medical record makes it harder for practice administrators and surgeons to access the information they need. When scheduling information is siloed in paper posting forms, schedulers cannot collaborate or share their work. Not having the right information on hand at the right time can cause unnecessary delays, cancellations or inaccuracies. And, whenever records or processes are updated, it’s a time-consuming mission to make sure everyone is up to speed.
Slowed down by those old paper-based systems, it can take schedulers about an hour to schedule just one surgery – and last-minute changes can derail the whole schedule. More worryingly, individual schedulers often carry information about schedules and operational procedures in their working memory. So, if the scheduler is unexpectedly absent (for instance, due to illness), the whole OR scheduling system can grind to a halt.
At some level, paper-based systems can even hurt the business at large by limiting opportunities to grow, hampering information exchange with additional locations or surgeons.
This is where shifting to surgery scheduling software can really make a difference. Digital tools allow the surgical team to seamlessly collaborate on a case schedule even when the scheduler is absent or offsite. An integrated dashboard that tracks pending, scheduled, completed, held and canceled surgical cases with their supporting information in one central, accessible location, improves workflows across the board and preserves business continuity. The entire care team can view patient records and have an understanding of progress and needs to date when and where needed.
Surgery scheduling software limits your information management risk
It’s vital to look at how you are managing information and take stock of areas where manual or paper-based processes might be exposing you to avoidable risk. Many EMRs are exceptional at storing patient information, but fall short in the coordination and management of surgical care.
Sophisticated graphic designers do not rely on the included Microsoft Paint to get their job done. They use advanced tools like Adobe Photoshop to deliver the best product. Likewise, why settle for an EMR’s basic suite of surgical scheduling tools?
Automation is often the best way to improve security and workflows in situations where schedules and notifications are done by email or manually, scheduling considerations depend heavily on the institutional knowledge of one individual or where paper documents are part of important workflows.
Advances in digital technologies and machine learning can empower healthcare providers to transform and optimize their surgery scheduling, data management and OR procedures. CaseCTRL’s adaptive, AI-powered, HIPAA-compliant software lifts administrative burden and improves accuracy and efficiency of surgical scheduling processes. Learn more about ways CaseCTRL can improve your surgical scheduling and document management process by talking with us or requesting a demo.