Spine Team Texas

Situation

Spine Team Texas specializes in minimally invasive back surgery and treatment at its seven locations in the Dallas Fort Worth Metroplex, which includes several ambulatory surgery centers (ASCs). As an organization that prides itself on remaining on the cutting-edge of care and the technology to support it, an antiquated dictation system and cumbersome op note-completion process was proving frustrating for many of its physicians. Challenges included:

• The need to dictate at specific computers.
• Increased risk of omitted case details due to delayed dictation.
• Increased risk of delinquent charts.
• Physician dissatisfaction due to slow, more manual processes.

“Our old system required me to be at a certain computer and go through a long series of steps and screens to complete my dictation and the op note,” said Anthony Berg, MD, an anesthesiologist and pain management specialist at Spine Team Texas. “Almost invariably, I would need to spend another 40 minutes dictating at the end of my day at the ASC for all the cases I saw that day. Since it was sometimes hours in between a case and dictation, I worried about omitting modifications to a procedure that needed to be noted.”

Some physicians would wait to dictate until they returned to their offices, which added stress to ASC staff, said Stacey Lopez, the ASC’s administrative coordinator. “There’s a rule in our ASCs that if the op note is not in the patient’s medical chart within 24 hours, your chart is considered delinquent. But sometimes it takes at least that long to get the op note from the physicians’ offices when physicians dictate in their own programs.”

Solution

To address these and other concerns, ASC administration, with support from physician leadership, turned to SIS Charts™, a cloud-based electronic clinical documentation solution from Surgical Information Systems (SIS) that features physician op note templates. The op note templates provide a user-friendly, streamlined approach to the completion of op note requirements. They are designed to walk physicians through all areas (variables) of the operative note physicians need to address, while also allowing the embedding of images into the note, if required.

Because SIS Charts is cloud-based, Dr. Berg said he appreciates the flexibility to complete his documentation wherever it best suits him. “I really like the web-based aspect because not only does it allow me to do my work in the ASC, but if I can’t quite finish it there, I can do it back in my office or even finish it up at home.”

Templates can be configurable to the needs of each physician and their specific cases. And thanks to the templates’ ease of use, Dr. Berg said it’s rare that he cannot finish his documentation between cases.

“Everything I need is on a single screen. I can walk to the computer we keep in between operating rooms and complete my post-op note and the procedure note using these templates in just a few minutes, tops. Even at that speed, the notes are highly descriptive and accurately depict what happened in the operating room.”

Because physicians using the op note templates typically finish documentation before they leave the ASC, there’s less for administrative staff to worry about, Lopez said. “It’s great to have our physicians’ notes in our chart instantly thanks to that capability. We’re not having to track the notes down from their offices and then figure out if anything is wrong or missing. We’re in better control of what needs to get done. If there are errors needing correction or addendums required, we can get our physicians to address these while they’re still here at the ASC. This helps keep our charts accurate and complete and allows us to get our claims out the door faster.”

Results

Spine Team Texas has worked to transition many of its physicians to SIS Charts — a process made easier thanks to the system’s intuitive design, Lopez said. While she works out of Spine Team Texas’s Rockwall location, she’s helping oversee implementation of SIS Charts at the organization’s other sites. “The templates are very easy to teach and maneuver through,” she said. “Building templates through adding variables, customizing layout, and editing fields is simple as well. I had someone from a different site call me for help how to get started on using templates and I could walk them through the process over the phone. It’s that easy.”