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Surgical Op Note Presented by Nick Gawrit March 4, 2008

… the Premier Cardiovascular Information System for Improving Patient Healthcare. Surgical Op Note Presented by Nick Gawrit March 4, 2008. The Goal! Written Tree Diagram. Starting With…. Data Model Design Features Patient centric Longitudinal

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Surgical Op Note Presented by Nick Gawrit March 4, 2008

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  1. …the Premier Cardiovascular Information System for Improving Patient Healthcare Surgical Op Note Presented by Nick Gawrit March 4, 2008

  2. The Goal! Written Tree Diagram

  3. Starting With… • Data Model Design Features • Patient centric • Longitudinal • Integrated • Retrospective data entry • Enthusiastic Users

  4. Data Model Design Features • Patient centric • Longitudinal • Integrated

  5. heartbase Data Model™

  6. Goals of Op Note Reporting • Prepare an Open Heart Surgery Op Note • Interface with transcription • Collect data points for registries • Provide perfusionists with data they need • Reduce surgeon time needed for preparing an Op Note • Sync Up database with Op Note • Improve Workflow

  7. Goals of Op Note Reporting • Ease of Use • Create Consistency • Improve Data Accuracy • Ensure Completeness • Provide Data for Research • Improve Patient Satisfaction • Eliminate Data Redundancy

  8. Steps to create Op Note • Receive the aid of a physician champion to design a report for CABG only cases • Meet with the perfusionists to review design and get input into data entry • Meet with transcription to review requirements and set up automatic transfer to transcription system. • Meet with IS to insure proper implementation • Utilize heartbase data administrator and staff to coordinate all activities

  9. Surgical Op Note Workflow

  10. Surgical Op Note Workflow

  11. Programming Issues • Schema changes • Develop a Custom Data Entry Form • Interface hospital demographic and admission discharge data • Create custom paragraphs and CSV file in PQL. • Integrate SIR with Microsoft Word (macros) • Interact of hb generated op-note with hospital transcription department(EHR) • Implement SIR in a wireless environment • Create a graphical representation of patient coronary tree • Interact with flash drives • Create a Patient pocket handout • Allow Surgeons to dictate of additional findings in the OR which in turn become part of the EHR. • Prevent Op-notes from being completed unless key fields are entered.

  12. Schema Changes • Needed by: • Surgeon • Perfusionist • heartbase • Performed with Modify Schema

  13. Custom Data Entry Form • Create a new data entry screen that reflects the needs of the perfusionist, hb data collector, surgeon, and transcription.

  14. heartbase Data Model™ ADT Data Interchange Brings in Demographic, Hospitalization and ICD9 Information

  15. Custom PQL • Auto generate paragraphs from data entry fields • Creation of a CSV file to be used with Mail Merge later. • Be aware of SIR CSV Save File max limit • Audit function • Graphical tree creation with narrative data, including wallet sized output • Event Management • Triggers

  16. Risk Factor Paragraph Example • MYINDr=9 • IFTHEN(CRSMOKE=1 )myindr=myindr+1;compute ind(myindr)='current smoker'; • elseif(smoke =1)myindr=myindr+1;compute ind(myindr)='history of smoking'; • endif • if(FHXCAD=1)myindr=myindr+1;compute ind(myindr)='family history of coronary artery disease' • if(DIAB=1)myindr=myindr+1;compute ind(myindr)='diabetes' • if(HYPCHOL=1)myindr=myindr+1;compute ind(myindr)='dyslipidemia' • if(HRENFL=1)myindr=myindr+1;compute ind(myindr)='renal failure' • if(HYPTN=1)myindr=myindr+1;compute ind(myindr)='hypertension' • if(HCVA=1)myindr=myindr+1;compute ind(myindr)='cerebrovascular accident' • if(INFEND=1)myindr=myindr+1;compute ind(myindr)='infectious endocarditis' • if(chrlungd GE 2)myindr=myindr+1;compute ind(myindr)='chronic lung disease' • if(IMMSUPRX=1)myindr=myindr+1;compute ind(myindr)='immunosuppressive treatment' • if(PVDIS=1)myindr=myindr+1;compute ind(myindr)='peripheral vascular disease' • if(PRCBVDIS=1)myindr=myindr+1;compute ind(myindr)='cerebrovascular disease' • ifthen(myindr=9)mysent=mysent+' Risk factors were not noted.' • else • mysent=mysent+' Risk factors include ' • ifthen(myindr=10) • . mysent=mysent+''+ind(10)+'.' • elseif(myindr gt 10) • . for sdsd=10,myindr-1 • . mysent=mysent+ind(sdsd)+', ' • write ind(sdsd) mysent • . end for • . mysent=mysent+' and '+ind(myindr)+'.' • endif • endif

  17. CSV Save File • CSV SAVE FILE FILENAME='surgnarr.dat'/HEADER/ • VARIABLES= • PDATE ('SURGDATE') • LNAME ('LNAME') • FNAME ('FNAME') • MINT ('MINT') • APROC(1) ('APROC1') • APROC(2) ('APROC2') • APROC(3) ('APROC3') • APROC(4) ('APROC4') • APROC(5) ('APROC5') • APROC(6) ('APROC6') • APROC(7) ('APROC7') • APROC(8) ('APROC8') • APROC(9) ('APROC9') • APROC(10) ('APROC10') • SSNUM ('SSNUM') • BILLNUM ('BILLNUM') • PATSSN ('PATSSN') • WBDATE ('WBDATE') • WADMDATE ('WADMDATE') • WCWTLB ('WCWTLB') • wchtfi ('WCHTFI') • PRONOUN ('PRONOUN') • MYSENT ('ind12')

  18. Audit Program • . IFTHEN(SEX =1)COMPUTE W9 ='1' • . ELSEIF(SEX =2)COMPUTE W9 ='2' • . ELSE COMPUTE W9 ='' • . ENDIF • . IFTHEN(EXISTS(W9)=0 or w9='') • . valfield(9,2)=valfield(9,2)+1;WERR=1 • . IFTHEN('<AUDITALL>' = 'Y' OR '<WW9>'='Y') • . WRITE (VALIDATE_STS_NAR.CSV)SSNUM MYC MYC MYC 'SEX' MYC 'STS0150 GENDER' MYC 'DEMO' MYC • . WLUDEMO=WLUDEMO+'SEX ';WLUDEMOQ='Y' • . ENDIF • . ALINEA=TRIM(ALINEA)+'|' • . ELSE • . valfield(9,1)=valfield(9,1)+1 • . ALINEA=TRIM(ALINEA)+TRIM(VALLAB(SEX))+'|' • . ENDIF

  19. Microsoft Word Integration • Utilize Word to produce the narrative letter by utilizing Mail Merge and Macros • Include header information for Softmed

  20. Transcription Electronic Health Record • Automatically send the case to transcription when all required variables are entered

  21. Wireless • Access heartbase via the hospital wireless network • Security • Accessing SIR Master and heartbase application

  22. graphical patient coronary tree • Use database to define grafts and then map these points graphically (thanks Tom!)

  23. Flash drives • Distribute information on flash drive

  24. Patient pocket handout

  25. Surgeon Dictation • Surgeon needs to enter additional findings in the OR

  26. Op-Note Completion Check

  27. Data Capture Rules we follow: • Optimize Workflow • Eliminate Data Redundancy • Offer Flexible Alternatives • Reduce FTE costs • Comply with Rules

  28. Real Time Data Capture Customized data collection screens can be tailored to the individual need • Perfusionist • Physician Specific • Nurse/Tech • In-Lab/In-OR

  29. heartbase Data Model™ Op Note

  30. Perfusionist Procedure MD Variables = Sentences and Paragraphs Graft Definition = STS Data Harvest Fields Data Collection: Op Note

  31. Run the Report See the Patient Coronary tree See the Narrative Report Send to Transcription Add Dictation Op Note Preparation

  32. Op Note ReportsWritten Tree Diagram

  33. Benefits of Op Note System • Savings of 20-30 minutes of surgeon time per op note • Validation of data in Op Note to data in database • Concurrent Data Collection • STS data completion • Perfusionist Report Preparation • Integration into hospital electronic medical record • Transcription savings • Physician ability to dictate additional findings

  34. Benefits of Op Note System(cont) • Electronic Signature • Op Note speed up to referring MD by 1-2 days • Medical record interaction • Flash drive patient record • E-Mail to referring cardiologist • Optional customization of report for physicians • Coding Improvements for billing • MD bonus program

  35. Demonstration

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