Going paperless? Be prepared for pitfalls. Lots of them. Many of the 280 facility managers who completed Outpatient Surgery's OR management software survey have had it up to their laptops with the time and effort it's taken to work the kinks out of their systems. Yet even unhappy users are pressing on with their efforts to manage clinical operations electronically because they have faith in the promise of technology to streamline their surgical services departments and help them make smarter decisions. Here's a report.

Current state of affairs
If you still do everything with pen and pad, you're in a small minority - only 11 percent of the hospital outpatient facilities (n=117) and 6 percent of the ASCs (n=120) we surveyed don't manage any of their clinical operations electronically. Of the remainder, most use software to schedule their ORs, personnel and patients (case scheduling), and manage preference cards. Relatively few have gone fully electronic with the medical record, although more hospital-based facilities than ASCs are automating RN charting. ASCs are more likely to automate their outcomes and QA reports, and surgeons' operative notes. About one-fourth to one-third say they're "very satisfied" with their software packages, and generally just as many say they're "dissatisfied." About one-half say they're "satisfied," depending on clinical function.

The most popular brands of software among our hospital panelists were from McKesson (n=20), Meditech (n=12) and PICIS (n=11). Among ASCs, Source Medical is the clear market leader, with nearly two-thirds (63 percent) of our ASC-based panelists using AdvantX or SIS-SurgiSource.

Benefits realized
Nine in 10 panelists who use case scheduling software express overall satisfaction, with the greatest benefit being improved efficiency. About two-thirds of users say their software helps them use their ORs more efficiently, but only one-half say the software improves service to physicians and helps them better allocate OR personnel.

"Scheduling software lets us more effectively check for equipment conflicts, manage blocks, prevent double-booking and ghost-booking, and track volumes by service and by physician," says Kelly White, RN, BSN, CNOR, the divisional director of surgical services with the Medical Center Hospital in Odessa, Texas.

Nearly eight in 10 panelists who use electronic preference cards express overall satisfaction; two-thirds say their electronic cards make it easier to update changing surgeon preferences and one-half say they reduce opening of unused supplies. Electronic tracking of supplies also helps some managers get a better handle on actual costs.

"I know at the click of a button what today's procedures cost me and what we charged, as well as other statistical information I used to spend hours collecting," says Shelly Young, director of surgery with the Sutter Maternity and Surgery Center in Santa Cruz, Calif.

Some who chart the perioperative process electronically say they miss fewer charges because billable supplies no longer go undocumented.

Common problems
The most common complaint our panelists report is inflexibility. When it comes to case scheduling, many managers say their systems can't maintain electronic cancellation lists. Others say replacing one patient or case with another cancels out the original case information for good unless you reschedule it within a specified timeframe.

"Our system uses 15-minute increments, and this can allow too much time for procedures," says Marcia J. Schmidlin, the perioperative systems coordinator at Genesys Regional Medical Center in Grand Blanc, Mich.

Another gripe: Software isn't set up to handle cases involving multiple procedures or surgeons. This can cause duplication of supplies if your e-cards are set up for single cases and can't merge preference card data for combination procedures.

Users have the same types of complaints about charting software. "There's nowhere on the program to note patient allergies," says Susan Dievendorf, RN, BSN, the director of nursing at the San Antonio ASC in Upland, Calif.

Another common problem is a lack of interface. That is, in many facilities, the clinical functions don't communicate electronically with other functions, and this creates a need for duplicate data entry. "The H&P doesn't automatically transfer to our procedure pre-op record. This leads to redundant charting, and re-entering the documentation is time-consuming," says Debra A. Figueroa, BSN, RN, with the Center for Digestive Endoscopy in Orlando, Fla. Another common issue is the inability to transfer preference card data to supply purchasing and materials management programs.

Some say systems aren't always user-friendly or intuitive. Unlike a paper filing system, you don't create the logic for storing and categorizing information. Rather, you must learn the system's logic and conform to it, regardless of whether it makes sense.

"The preference cards are often difficult to find, as the case must be posted in the exact way the preference card is in the system or it won't automatically come up," says a panelist.

Poor tech support is also a fairly common complaint, followed by a lack of good training. Jayne Byrd, BSN, MSN, the director of surgical services at Rex Hospital in Raleigh, N.C., has automated her entire clinical process, but not without much angst. She says her vendor's implementation team knew its product only slightly better than it understood how her department worked - which is to say hardly at all. "We experienced a high frustration level and unnecessary stress and distrust. It was very disruptive," she says.

Achieve the potential
To smooth your way, we asked panelists for their best advice. Here are their top tips:

• Define what you need. Be very clear on the outcomes you expect. Develop clear criteria in advance for assessing the products. "We did a great deal of in-house interviewing and surveys with staff at all levels to understand what they liked about our old system and what they wanted in a new system. We also had an assessment team which included at least one person from every user group in the organization," says John Wipfler, JD, MBA, CEO with the Eyecare Medical Group in Portland, Maine.
• Go see it. Don't skimp on the evaluation process. Visit other sites and be highly critical. "Get input from another facility that is similar to yours. Do not settle for a hospital that the sales rep gives you. Ask for the complete listing of subscribing institutions, call them and ask the hard questions," says one director of surgical services. Focus as much on implementation as on the results you should be able to expect after you're up and running.

"You have to ask the right questions because many vendors will say, 'Oh, yes, our system lets you copy the op note into the data,' but you later realize that the work involved in actually getting the information into this module is extremely time consuming," says Diana Ellison, MBA, CASC, the executive director of the Hamden Surgery Center in Hamden, Conn.

Evaluate how the software's logic fits in with your pre-existing processes. "We have had to reformat many of our working processes to fit into their structure," says one manager.

• Guarantee IT support. Computers aren't the fort' of most clinical people. For this reason, you'll need a lot of dependable tech support for training and upgrades, whether in-house, at the vendor or both. "We often get a phone tree or must leave a message when calling tech support. Don't let this happen to you," says one manager. How long will it take your vendor to get to the field and install upgrades?
• Invest heavily in staff training. Any system, regardless of where it comes from, is only as good as the users. Don't underestimate the importance of training or overestimate your employees' computer abilities.

Target two people (super-users) to learn the system inside-out so there's always someone to turn to. Before documenting during a case, let your staff practice computerized charting, even if it means devoting money to overtime. "Realize that although different staff members learn at different rates, refusals to learn computerization cannot be tolerated," says one manager.

Let some time pass between your first and second rounds of training. One idea: Plan a training session with the company in the beginning, then schedule another on-site session after nine months. You should have an idea about what you need by then. "Don't schedule the second round of training too soon, like they did with us, as you haven't found out all of your technical glitches and questions at that point," says the Gregory P. DeConciliis, PA, administrator at Boston Outpatient Surgical Suites in Waltham, Mass.

• Allocate enough personnel. Don't think you can implement your new OR software without additional manpower hours. Allocate resources on the front end that are dedicated to nothing else but the implementation of the system, both in the OR, materials management and IT, says Bernadette McDonald, BSN, the administrative director of perioperative services at Leesburg Regional Medical Center in Leesburg, Fla. Also, consider the possibility that you may be doing more than going electronic with existing processes; you may be adding new work altogether. For example, if you have never done preference cards before, you'll need to account for the manpower needed to create and update them on an ongoing basis. Many panelists warn that this, in and of itself, is a significant amount of work.
• Don't box yourself in. To avoid software packages that all too quickly become obsolete, don't enter into a restrictive contract that will prevent you from going live with upgrades and updates when they become available. Select a system that will be continually upgraded. "It only takes a few years for some systems to become obsolete," says Rosemary Rundle, RN, CNOR, the surgical services manager for the Chino Valley Medical Center in Chino, Calif. Alternately, don't decide to go with a fully customizable package, either. While the idea of allowing yourself the freedom to customize a program may sound appealing, this option comes with its own set of challenges.

"More standardization of software would have been nicer than trying to learn our system at the same time as we customized it to meet our center's needs," says Ann Deters, MBA, CPA, the CEO of Seven D & Associates in Effingham, Ill.

Promise of the future
When it comes to OR management software, much of what you get out of it depends on how much you're willing to put into it. Sara Rapuano, MBA, COE, business manager with Wills Eye Surgery Center in Philadelphia, was able to make her electronic preference cards work well for combination cases, but only after a lot of work. Because her facility hosts a lot of multi-procedure/multi-surgeon cases, establishing effective preference cards for the various combination cases was a real challenge. "Now we've become far more effective with the case cost analysis since we've been using the preference cards for combination cases," says Ms. Rapuano.

Despite the challenges our panelists continue to experience, they believe that technology will ultimately help them bring efficiency to the next level, to the day when they can automate inventory, scheduling, patient tracking and perioperative documentation. Many are actively pursuing upgrades or add-ons, and some are rethinking their whole approach to electronic information management in the OR. Many long for the day when all of their clinical and financial systems will be integrated into one fully compatible, smoothly running system that never requires redundant data entry or compromises of any kind. Until then, keep the number of the help desk handy.