Standardized Perioperative Record a bold step forward
By Matt Gunn
News Editor/Writer
In the next several years, medical records in the United States will universally shift from print to electronic, representing a new era for health care data recording and - potentially - patient safety.
A new record-keeping system represents not only a shift toward emerging technology, but also a need to meet federal standards in pay-for-performance and patient safety. Though any change of that magnitude is a challenge, it is at the same time an opportunity to enhance perioperative practice- one that AORN hopes to further with its electronic, standardized perioperative record system SPRDRS, a working title initially known colloquially as "Spiders."
The Standardized Perioperative Record and Data Repository System (SPRDRS) is a functional approach to combine standardized operating procedure, an electronic record keeping system and a secure and confidential national database, along with other features, that can be implemented in operating rooms across the country.
"The SPR project is a Standardized Perioperative Record that would be able to be used in all of the operating rooms across the United States," said executive director Linda Groah, RN, MSN, CNOR, FAAN. "This means all operating rooms would be looking at the same data and would have the same opportunity to evaluate patient care, as well as efficiency and effectiveness in the OR."
Changes on the horizon
With a 2014 federal electronic records mandate adding to the urgency to develop new systems, the healthcare industry is looking at different ways to implement electronic patient record systems.
While many perioperative professionals are already using electronic documentation systems, there is currently no comprehensive way to document perioperative care that effectively integrates the PNDS and concurrently provides data for benchmarking purposes.
"With such diverse data it's hard to really capture good standardized, reliable information, so we're trying to solve that issue by developing a Standardized Perioperative Record that has a standardized minimum data set to be used in electronic software," said Carol Petersen, RN, BSN, MAOM, CNOR, Manager Perioperative Informatics in AORN's Center for Nursing Practice.
In addition to the federal mandate for electronic medical record keeping, healthcare facilities are also looking at the movement toward pay-for-performance being led by the Centers for Medicare and Medicaid Services (CMS) and other third-party payers. This increased accountability makes it more important than ever to organize the patient record-keeping process.
"It's going to be absolutely essential that there be accurate measures to document patient care, and this Standardized Perioperative Record will allow us to do that by providing the tools needed to share information with CMS and other third-party payers," Groah said. We will literally be comparing apples to apples and be providing the information needed for reimbursement of the hospitals, particularly in the operating rooms."
Building a standardized record
The task of putting together a computer-based system that standardizes OR record keeping and feeds into a data repository is possibly as complicated as it sounds. To help AORN move forward with the creation of the Standardized Perioperative Record, the association is partnering with Computer Sciences Corporation (CSC), a global information technology services firm that specializes in tailoring healthcare information systems.
"I certainly think that this is a very important relationship because it represents one of the first times that a professional organization and a company such as CSC have partnered together in an effort to provide the marketplace with a tool that has significant impact, both from a clinical standpoint, as well as an administrative standpoint," said Gary Boillotat, a CSC principal and former hospital executive working on the SPRDRS project team "Our role in this project is to support AORN in the development of the SPR itself as well as the broader development of the data repository that will drive the entire project."
In building that framework, current resources AORN members are already familiar with, such as the Perioperative Nursing Data Set (PNDS), will be utilized. This means standardized patient care measures, such as time the patient is in the room, antibiotics prophylaxis, and preoperative medical diagnosis, will be recorded in the SPR and tracked in the data repository, Petersen explained.
"One of the most important things for data analysis is how data is entered into a patient record and into a system and then how it's mined," she said. "In order to do that you have to have standardized data being documented and then standardized data being extracted. Our goal is to have standardized data extraction being captured in a national data repository, so that facilities across the country can be accessing data to compare themselves to other hospitals and facilities across the country that are the same size and compare actual procedures or other types of metrics."
What the product could mean for healthcare professionals
The intent is to have the Standardized Perioperative Record feed into a National Data Repository system, a database that could help in benchmarking performance, and ultimately assist in improving patient safety.
On one level the SPR project directly involves healthcare professionals working in the operating room. But as a system, its developers believe it could have an impact throughout a healthcare facility.
"The folks in the OR are able to understand what needs to be done from a patient care perspective, but often the importance of the issues that they deal with is lost in translation up to the senior executive suite," Boillotat said. "So one of the things that we certainly hope will come with this system is a much more open line of discussion."
Why now
The 2014 Federal mandate influences the timing of the SPR project, and with advances in technology, this year was chosen as an opportunity to begin development of a Standardized Perioperative Record.
But more importantly, an SPR created by AORN could bring balance to the future of electronic medical record keeping and provide a strong foundation from which to document and assess perioperative services.
"AORN believes that we can provide that information from an unbiased and neutral standpoint," Petersen said. "Because we have standards and recommended practices, we believe they can be applied to a standardized record set and then have that feed a national repository with an unbiased nature."
"Our mission is really to provide tools to our members to be able to provide the best quality of care and to assist them in achieving that as well as meeting efficient and effective standards of care," Groah said. "I think that this tool will definitely work right into our mission and into the things that we're hearing our members ask us to provide them with."
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