From Paper Charts to Ophthalmic Electronic Reports
One ophthalmic ASC administrator shares her experience making the switch
True confession: I used to look on many of our referring ophthalmology and optometry clinics with no small degree of jealousy. While they got to enjoy all the benefits of an electronic health records (EHR) system, we at Empire Surgery Center, an ophthalmic ambulatory surgery center (ASC) in Bakersfield, Calif., remained glued to paper-based operative reports and nursing notes documentation through the first half of 2019.
Indeed, our front desk staff would receive a patient demographic sheet and pre-surgical paperwork from the surgery scheduling department. They would then insert a patient label and print out a standard surgical charts from a template. This paper chart would then be filed into a cabinet organized by surgery date. Our nurses would pull these charts to perform their pre-surgical chart checks, call patients and physicians to track down any missing orders or clearance packets, and provide pre-surgical instructions. On the day of surgery, the surgeons would sign the preoperative orders and H&P documents. Post-surgery, each surgeon would review and sign the pre-printed operative report, making sure to note any deviations from standard operating procedures and processes. Once the patient left recovery, the nurse would make a final check of the chart and file it away.
If it all sounds complicated and tedious, let me assure you, it was. Thankfully, it’s all a thing of the past now that we have modmed® ASC, Modernizing Medicine®’s ASC electronic reports system, in addition to EMA®, the company’s ophthalmology EHR.
We went live with modmed ASC in early June, and to be frank, I was somewhat anxious about making the transition from well-organized paper workflow to an electronic-based system. Among my primary concerns were staff acceptance and training, as well as whether the electronic reporting would improve and simplify our processes — or make them more complicated and cumbersome.
I was pleasantly surprised at how well our nurses, anesthesia providers, and ancillary staff took to the system. The anesthesia providers, especially, were the most resistant to change initially, but once they saw how much less time they would need to spend on documentation, they were much more open to electronic reporting implementation. Besides obtaining staff buy-in, other challenges we had to overcome involved building the charts to match our workflows and remaining compliant with local, state, and federal regulations. Modernizing Medicine’s customer service team was invaluable in this respect; they helped us tailor the system to our needs and built the more straightforward components so we could focus our time on the more dynamic aspects of our electronic charts, such as the pre-, intra-, and post-operative nursing notes and anesthesia forms.
Today, our workflows have improved significantly with modmed ASC. The most obvious benefit we have experienced thus far is the ability to completely customize our surgery forms and charts for the various types of surgery performed at our facility. For example, we no longer use the same standard chart for Cataract Extraction with IOL insertion as we do for Blepharoplasty procedures. Each has its own customized chart that addresses only that which is applicable to the specific procedure type.
modmed ASC has also streamlined communications within our ASC and between our facility and its referring clinics. Everything from the smallest of details — timestamping signatures on pre-surgical clearances, surgery orders, and discharges, making pre-surgical chart checks, and direct messaging and faxing of surgery documents — all takes place with just a few clicks of the keyboard. No more intraoffice envelopes!
modmed ASC also helps us run any number of reports to help create quality assurance and performance improvement projects. For example, it helps us to identify delays in surgical flow and to pull demographic data, and allows us to us quickly and easily retrieve the data needed to meet the reporting requirements of local, state, and federal regulatory agencies, as well as those of The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).
As an administrator who regularly fields questions about patient clearances, surgery schedules, and a multitude of other related issues, I can’t begin to explain how nice it is to be able to simply log into our ASC electronic records and retrieve all the information I need — in seconds — without having to search through paper-based folders myself or with the help of busy staff. Indeed, after almost two months since we began implementing modmed ASC, I can’t imagine going back to a paper-based system, and I must make one final confession: I hope you’re jealous.
Tricia Frank is Administrator of Empire Surgery Center in Bakersfield, CA.