How Online Pre-op Questionnaires Can Eliminate Inefficiency & Improve Safety: Thoughts From MMF Systems
MMF Systems is considering expansion into the ASC industry. The company recently developed a new application — a preoperative questionnaire that patients fill out online prior to surgery. Here, Jerry Stonemetz, MD, and Fahad Ahmed, vice president of business development for MMF, discuss the value of a preoperative questionnaire to the surgical experience.
Why provide questionnaires online?
Dr. Stonemetz is on staff at Johns Hopkins and has been assisting MMF in developing preoperative patient questionnaires for about a year. Dr. Stonemetz works primarily in the operating room, but also devotes a substantial amount of his time to the pre-operative evaluation clinic, where about 40 to 45 percent of surgical patients are seen before their procedure. "The biggest problem is the patients we don't see," Dr. Stonemetz says. "Things fall through the cracks."
In 2007, Dr. Stonemetz went through Hopkins' Lean Sigma program, intended to improve healthcare processes by streamlining operations and cutting waste. He applied the program to the pre-op and pre-surgical process and realized that a substantial number of cases were delayed or cancelled due to missing EKGs, missing labs, missing consult notes and other similar problems. "Patients were frustrated, because the information seemed to go into this black hole where no one could find it," Dr. Stonemetz says.
Since Johns Hopkins kept a document management system in-house, the health system decided to buy scanners and install them in surgeons’ offices to increase the flow of information prior to surgery. "It was a failure," Dr. Stonemetz says. " There were simply too many errors and too many missing documents." In 2007, the health system converted to MMF for its document management, and Dr. Stonemetz says the transition has provided "a very robust product for us."
Problems with paper charts
But even with the document management system, there was still something missing. When a patient comes in for surgery, the hospital asks them to fill out a paper questionnaire, and according to Dr. Stonemetz, "no one ever uses or touches it. There's a big gap between what patients fill out and the medical record data," he says.
He says in trying to improve efficiencies, the hospital had to target the incomplete or inaccurate data that providers usually discover about 30 minutes before the planned case start. "This leads to poor patient care," Dr. Stonemetz says. "Over 60 percent of the sentinel events due to anesthesia are rooted in incomplete pre-op evaluation."
He gives the example of a patient who has a cardiac stent and needs to be on lifelong aspirin. With most kinds of surgery, the patient can maintain their baby aspirin up to the day of surgery without adversely affecting the outcome of the operation. But if the patient discontinues the aspirin, he or she is at risk of having a coronary in that time period. "The standard letter is to stop all aspirin products two weeks before surgery," Dr. Stonemetz says. "But in this case, the patient should have been better managed, because they didn't need to do that. Every single day, we have cases that we'd have planned and staged differently if we knew about the issues ahead of time."
In every OR in every hospital, the pre-op process is fragmented, Dr. Stonemetz says. "It's not a perfect system," he says. "We're trying to push management of the patient closer to the time that they're posted to the schedule, rather than one to two days before surgery." If the patient has a pre-operative consult two days before surgery and the nursing staff decides the patient needs a cardiac evaluation, the case will probably have to be cancelled. If the patient comes in for an evaluation 10-14 days prior to surgery, the cardiac evaluation can still happen before the scheduled procedure.
Enter the online patient questionnaire. "I'm a big proponent of [this method]," Dr. Stonemetz says. "If you're a healthy young patient, you don't want to come in to the hospital for a pre-op evaluation. You can easy provide that information online."
He says an online questionnaire is a better method than a paper questionnaire, since it eliminates room for error. An online questionnaire is transmitted automatically into the patient's medical record, rather than being transcribed and then faxed to the pre-op clinic and then entered into the EMR. If several questionnaires are unaccounted for on a particular day, the EMR can show which ones are missing automatically — rather than the provider having to line up the completed questionnaires with the schedule manually.
Effective implementation: the next hurdle
While systems like this exist, Dr. Stonemetz says the industry still has trouble implementing them effectively. "Part of the reason is that hospitals put something out there and say, 'Please use this,' but there's no real compelling reason to use it," he says. "There's also no good evaluation of who's using it and who's not." He says hospital systems like the Cleveland Clinic, which employs all its physicians, have been more successful in implementing questionnaires because surgeons are on staff.
"The Cleveland Clinic said, 'If your patients haven't filled out the questionnaire two days prior to surgery, we'll take them off the surgical schedule," Dr. Stonemetz says. While this proved effective, he says patients can also be brought into the process; instead of reminding the physician, the hospital can "ping" the patient until the questionnaire is completed.
Mr. Ahmed says one complaint against online forms is that not every patient has access to the internet. However, he says studies have shown that 80 to 90 percent are comfortable and capable with online forms, leaving only 20 percent to accommodate in the physician's office. "MMF offers two alternatives —a paper form can be faxed to a number provided by MMF, where it is indexed and stored digitally in an electronic folder created for each patient, and is accessible by staff through the web," he says. "The second option is that the surgeon's office can have a kiosk, and one of the staff can assist the person in filling it out before they leave."
Dr. Stonemetz and Mr. Ahmed predict a "dramatic impact on the efficiency of surgery" if hospitals and surgery centers were to implement questionnaires in conjunction with a Web-based document management service such as MMF provides that specializes in pre-op patient information.
Learn more about MMF.
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