Surgical Op Note

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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
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Starting With

• Data Model Design Features
• Patient centric
• Longitudinal
• Integrated
• Retrospective data entry
• Enthusiastic Users

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Data Model

• Design Features
• Patient centric
• Longitudinal
• Integrated

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heartbase Data Model
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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

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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

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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

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Surgical Op Note Workflow
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Surgical Op Note Workflow
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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.

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Schema Changes

• Needed by
• Surgeon
• Perfusionist
• heartbase
• Performed with Modify Schema

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Custom Data Entry Form

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

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

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Risk Factor Paragraph Example

• MYINDr9
• IFTHEN(CRSMOKE1 )myindrmyindr1compute
  ind(myindr)'current smoker'
• elseif(smoke 1)myindrmyindr1compute
  ind(myindr)'history of smoking'
• endif
• if(FHXCAD1)myindrmyindr1compute
  ind(myindr)'family history of coronary artery
  disease'
• if(DIAB1)myindrmyindr1compute
  ind(myindr)'diabetes'
• if(HYPCHOL1)myindrmyindr1compute
  ind(myindr)'dyslipidemia'
• if(HRENFL1)myindrmyindr1compute
  ind(myindr)'renal failure'
• if(HYPTN1)myindrmyindr1compute
  ind(myindr)'hypertension'
• if(HCVA1)myindrmyindr1compute
  ind(myindr)'cerebrovascular accident'
• if(INFEND1)myindrmyindr1compute
  ind(myindr)'infectious endocarditis'
• if(chrlungd GE 2)myindrmyindr1compute
  ind(myindr)'chronic lung disease'
• if(IMMSUPRX1)myindrmyindr1compute
  ind(myindr)'immunosuppressive treatment'
• if(PVDIS1)myindrmyindr1compute
  ind(myindr)'peripheral vascular disease'
• if(PRCBVDIS1)myindrmyindr1compute
  ind(myindr)'cerebrovascular disease'
• ifthen(myindr9)mysentmysent' Risk factors
  were not noted.'
• else
• mysentmysent' Risk factors include '
• ifthen(myindr10)

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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')

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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)1WERR1
• . IFTHEN('ltAUDITALLgt' 'Y' OR 'ltWW9gt''Y')
• . WRITE (VALIDATE_STS_NAR.CSV)SSNUM MYC MYC
  MYC 'SEX' MYC 'STS0150 GENDER' MYC 'DEMO' MYC
• . WLUDEMOWLUDEMO'SEX 'WLUDEMOQ'Y'
• . ENDIF
• . ALINEATRIM(ALINEA)''
• . ELSE
• . valfield(9,1)valfield(9,1)1
• . ALINEATRIM(ALINEA)TRIM(VALLAB(SEX))''
• . ENDIF

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Microsoft Word Integration

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

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Transcription Electronic Health Record

• Automatically send the case to transcription when
  all required variables are entered

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Wireless

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

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graphical patient coronary tree

• Use database to define grafts and then map these
  points graphically (thanks Tom!)

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Flash drives

• Distribute information on flash drive

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Patient pocket handout
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Surgeon Dictation

• Surgeon needs to enter additional findings in the
  OR

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Op-Note Completion Check
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Data Capture

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

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Real Time Data Capture

• Customized data collection screens can be
  tailored to the individual need
• Perfusionist
• Physician Specific
• Nurse/Tech
• In-Lab/In-OR

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heartbase Data Model Op Note
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Data Collection Op Note

• Perfusionist
• Procedure MD
• Variables Sentences and Paragraphs
• Graft Definition STS Data Harvest Fields

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Op Note Preparation

• Run the Report
• See the Patient Coronary tree
• See the Narrative Report
• Send to Transcription
• Add Dictation

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Op Note Reports Written
Tree Diagram
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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

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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

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Demonstration