HISTORY BUFFS Robin Hutzler, RN, pre-admission coordinator of the Bailey Square Surgery Center in Austin, Texas, and Medical Director Stan Eckert, MD, review printouts of online registrations for the next day's cases.

Nurses and patients just hate the pre-op phone call, and who can blame them? For nurses, it's 30 or so tedious minutes spent craning their necks with the phone to their ear so they can handwrite a patient's medical history on a paper form — and then hoping the history is complete, accurate and legible. For patients, it's answering questions they've been asked 20 times before, trying to remember every allergy, medication and past surgery, without access to their medication and medical records. But like most everything else nowadays, pre-admission testing is moving online. As one vendor put it, "Online admissions are doing for health care what online banking has done for the financial world — using the Internet to streamline the process for both customer and facility." Read on to see why pre-op calls might soon go the way of shoe covers, cataract sandbags and other relics.

How it works
"Calling patients is not a very effective use of anyone's time," says anesthesiologist Stan Eckert, MD, medical director of the Bailey Square Surgery Center in Austin, Texas, one of a growing number of facilities that's discovered how online admissions streamline the proces of obtaining a patient's medical history.

"More than saving nurses' time, computerized medical screening is a huge step forward in patient satisfaction and safety," adds anesthesiologist David Lennon, MD, medical director of the Peak One Surgery Center in Frisco, Colo.

Online screening programs direct patients to complete their histories online, on their own time, at a protected, secure site. Once patients submit their histories — some software features a built-in scheduling interface so you can view any surgery date to see which patients have done so — your nurses simply verify that the information is complete and correct, and screen high-risk patients. Yes, nurses still have to phone to inquire further about a latex allergy, for example, or to order pre-op tests for high blood pressure. But many times, all patients need is a quick call with a reminder about when to be NPO, when to arrive for surgery and the amount of their co-pay.

"Before, our nurses had to call every single patient," says Alena Pochman, RN, the clinical director of the Peak One Surgery Center. "Now, if we see from the [online] answers that the patient is healthy, there's no reason to call that patient."

Peak One has been using online admissions for a year. About 50% of patients complete their histories online by themselves and another 40% do so with assistance from a nurse who enters data for the patient. "We're doing 900 to 1,000 cases per month," says Dr. Lennon. "So if we're saving 30 to 45 minutes on 500 patients, were saving a lot of surgery center manpower."

About 10% insist on giving their histories old-fashioned way: over the phone. "You can't please every one," says Ms. Pochman. "Some patients really don't want their information displayed on the Internet." If you encounter any such resistance, for the sake of consistency and convenience, Ms. Pochman suggests you fill out the online registration for the patient.

A hurdle you'll have to overcome early is getting the schedulers at your surgeons' offices to educate patients about online patient registration, says Dr. Lennon. "It adds one more item that surgeons need to tell patients before they book with you," he says.

Ms. Pochman appreciates that her online patient registration program will automatically populate her facility's anesthesia evaluation form, history and physical, and medication reconciliation form "with the most important information" for hard-copy printing or electronic storage. "Upon discharge, it makes the process easier, especially for elderly patients taking many medications," she says. "Because it's computerized, it's very legible. Not all of us have nice handwriting."

On average, some systems claim they can save 20 minutes of nursing time per patient admission, which can amount to hundreds of hours per year. Ms. Pochman says her nurses spend half the time they used to on pre-surgical phone calls. "We allocated those hours to other areas and we schedule differently," she says. "It's streamlined the whole process."

Access to better information
The No. 1 benefit of online patient histories? It's a tossup. Some say saving nurses and patients time and aggravation. Others say it's having access to better medical histories. Having comprehensive histories in advance of a procedure not only significantly speeds the pre-op process. It also reduces day-of-surgery cancellations. "It's bad for everyone when you have to cancel a surgery because of a medical problem you didn't know about," says Dr. Lennon.

When her nurses log in to review health histories, Ms. Pochman says they can bring a red flag to the attention of anesthesia. If additional tests or reviews are warranted, such as a blood pressure patient who needs to be seen by his primary care physician before surgery, they can get that taken care of before the patient is placed on the schedule, instead of cancelling the case when the problem is discovered on the day of surgery. Imagine giving legible health histories, all right there on a single piece of paper, a leisurely review instead of frantically chasing them down on the day of surgery.

"It's really transformed the way we initially review and get to know our patients," says Dr. Lennon. "If you can obtain detailed information about your patients in advance of their coming in for surgery, it allows time for follow-up if necessary. It lets us know as much as we can about the patient so that we can make proper patient selection. We want to know more about that patient before we anesthetize them in a surgery center."

Ms. Pochman says online histories tend to be much more detailed, revealing information and raising red flags you might not have gleaned over the phone. "If a patient has a latex allergy or diabetes," says Ms. Pochman, "you can schedule him as the first patient of the day."

Another example of how computerized pre-screening enhances patient safety? Dr. Lennon advises patients who indicate on their online health histories that they're on antihypertensives not to take their medication the day of surgery. "We found that their vital signs under anesthesia are more stable if they don't take it on the morning of surgery," he says.

Dr. Eckert warns that online medical histories are only as thorough as patients are willing to make them. "Don't assume that it's going to be 100% accurate," he says. "Confirm the important details. In the ambulatory surgery business, often the reason you have bad outcomes is because the caregivers didn't know enough about the patient that he needed to know."

Dr. Eckert worked with his vendor to customize the forms and the questions patients are asked. He's also working to add a risk evaluation form that would replace a manual screen for deep vein thrombosis, which he calls "a bit painstaking." Not only does he hope to incorporate the DVT screening questions he asks into his center's online questionnaire, but also a weighted value to the replies. "We'd apply each of the positive risk factors to a DVT risk-assessment score," says Dr. Eckert. "This will let us customize what prophylaxis might be needed for that patient."

Patient experience
Maybe the best way to realize the benefits of pre-admission software is to first experience it as a patient, something both Ms. Pochman and Dr. Lennon were able to do.

"I enjoyed using it. I could use it in my own time. I didn't have to listen to boring questions from the nurses," says Ms. Pochman, half-joking. "I was able to go online during my free time to answer the questions that nurses ask the day before surgery."

Twice as a patient at his surgery center, Dr. Lennon saw how user-friendly, intuitive, pre-admission software can make the pre-op phone call obsolete and streamline the time-consuming task of taking a patient's history by phone. "It's a well thought-out system," he says. "The drop-down menus, the simple questions and the pathways based on your answers make it very straightforward for a layperson."

Costs? "Probably less than paying 1 full-time nurse," says Ms. Pochman. One vendor estimates its charges to be a $1,000 implementation fee and monthly per-use fees that range from $300 to $800, based on patient usage.

"This is the future of health care," says Ms. Pochman. "More and more people are computer-savvy. They value their personal time more. This gives patients the power of choosing when they do their healthcare questionnaire."