HIS Project #1

Surgical Information Systems: A Clinical

Perspective
March 22, 2000
Tanaz Dutia
Debby Keller
Emily Zajano

Outline
I. Description of problem
II. Analysis of Requirements
III. Evaluate a system-how it meets requirements
IV. Gaps in SIS and solutions
V. Conclusion/Lead in to Project 2

Description of Problem and the Context

The operating room is the largest cost center and revenue
generator in most hospitals. It is the main source of hospital
admissions at a time where lengths of stay goals are decreasing. In
todays world of managed care and Medicare cutbacks, the operating
room is subject to demands for increased cost accountability and
quality

assurance.

The

operating

room

must

provide

ongoing

statistical records to account for material, fiscal, and human

expenditures.

In 1998, 13.5% of the Gross Domestic Product was

spent on health care. Of that amount, hospitals had the largest

expenditures, consuming $383 billion 1. It is apparent that hospitals
should look towards information systems to help decrease their
expenditures and increases their efficiency.
We are all aware of the increased permeation of information
systems in the hospital setting. But it is only until recently that
information technology has seeped into the walls of the operating
room.

However,

the

challenge

is

to

incorporate

information

technology tools into practices that will have a positive effect on the
operating room environment and hence on patient care.
Prior to recent surgical information systems there were solutions
available, but they came with a handful of problems. These solutions
were stand-alone implemented; the database format varied from
service to service, and the data that was collected was dependent on
the user. Here are some problems with the old systems:
1

Health Care Financing Association, Office of the Actuary (1999)

Little or no standardization of data elements.

Data elements had different meanings to different services.
Database development and maintenance was dependent on the
users knowledge.
When the developer/maintainer left, the hospital was left with
the complicated and difficult task.

Now

software

packages

make

it

possible

for

health

care

professionals to gain control of data produced in the operating room.

Once completely implemented, a comprehensive information system
in a surgical unit that has the capacity to track all data from
scheduling through post-operative services can save a hospital up to
30 40% of current costs. Clearly, benefits can be related to financial
return, but also to medical risks, procedures, and techniques. Medical
practitioners will now be able to care for their patients more capably.
Analysis of Requirements
Our analysis will focus on the clinical administration needs of the
operating room in relation to an information system for the operating
room. The changing health care climate has triggered important
changes in the management of high cost components of surgical
facilities. If the results of surgery are viewed as a product, everything
associated

with

surgery

can

be

evaluated

as

one

would

manufacturing process. All steps involved in producing the end result

can and should be analyzed with the goal of producing an efficient,
economical and quality product. By integrating and improving
management of various elements of the surgical process, health care
institutions are able to rationally trim costs while maintaining high-

quality services. The basic purpose of a surgical information system is

to meet these needs; to manage data in the clinical environment more
efficiently.
The following is a surgical data flow diagram that will help us to determine the
functions needed for an effective operating room information system2:

Anesthes
ia

Surgica
l
Service

OR
Coord.

Nursin
g

Anesthes
ia Data
Entry

Operatin
g Room

OR

Nursing
Data
Entry
Surgical
Service Data
Entry

The following is a list of functional areas requiring surgical data

and some of the data elements associated with them3:
Pre-Procedure Data
Pre-admission unit (scheduling, pre-certification)
Anesthesia (ASA physical status category, Anesthesiologists ID
number, principal anesthetic technique)
Nursing
Clinic
Patient (medical record number, birth date, presence of specific
diseases, allergies, address, patient milestones)
Surgical (surgical procedure, Surgeons ID number)
Peri-Operative Data
Anesthesia
Nursing
Post-operative wards
Nutrition care
Medical transcription
Development of a Comprehensive Surgical Information System at Madigan Army
Medical Center. Military Medicine. Vol. 161, March 1995.
3
An information system for quality ad utilization management in ambulatory
surgery. J Ambulatory Care. 1992, 15 (4), 24-29.
2

Clinics

Post-Operative Data
Anesthesia
Clinics
Physicians
Credentials
Medical transcription
Nursing education
After reviewing the workflow diagram, functional areas, and the
literature base that concerns surgical information systems the
following is a list of mandatory functions that a software vendor
should make available4:

Scheduling
Resource Use
Surgeon Preference Case Card
OR logs
Anesthesia
Staff Records
Infection Control
Case Costing
Patient Care Plans
Recovery Room
Pharmacy
Clinical Data
Patient Assessment
Medical Records
Pre/Intra Operative Data Management

The tasks desired in an effective surgical information system include:

A source of standardized and comprehensive content and format

the transmission of procedure-related risk and complications;
Captures and archives clinician behavior relating to use,
modification and disclosure of standardized knowledge sources;
Provides just-in-time access to procedural descriptions
information relating to risks and complications.
Captures, archives and makes available to the clinician patient
use of procedure-related knowledge resources.

The Case for Using Computers in the Operating Room. West J Med 1986 Dec;
145: 843-847.
4

Of course an assessment of the environment is also necessary

when implementing a surgical information system. There are a few
guidelines that should be followed when exploring computerized
information systems:

Gain input from all individuals who will be using the system and
explore security options for these users.
Communicate with all involved individuals throughout the
selection and implementation phases of the project.
Provide all parties with regular progress reports, deliver data to
those who need them, and inform all players of recent activities
and data acquisitions.
Make sure the system is user friendly.
Use a database, data entry, and viewing screens that are easily
adaptable to meet your needs.
Choose a vendor that is willing to customize basic computerized
information systems.

Clinical information systems can transform surgical processes into

an interactive process capable of evolving in response to the changing
institution-specified, provider-specified and patient-specified needs in
healthcare.

Evaluation of SIS
Surgical Information Systems

(SIS) is the chosen vendor and

product because it meets the needs of a desirable surgical information

system and contains the information management tools to improve the
clinical environment The SIS system captures all clinical, financial, administrative,
and archival data needed to manage surgical services and comply with JCAHO quality
monitoring requirements5. The surgical information systems product will
manage your schedule of surgical cases easily and efficiently to
maximize resource utilization. It also captures all clinical data at the
point of care. SIS integrates fully into existing hospital information
systems, which saves time in working with existing systems and saves
money for future IS scalability. Another attractive feature is an SIS
will eliminate redundancies in data entry; information need only be
entered once, and will then appear throughout the system wherever
appropriate. This feature saves valuable time for clinicians. Lastly, SIS
meets the current demand for a higher quality of care. The system
generates real time clinical reports (as needed or automatically
scheduled) and routes them through your organization, allowing the
staff to spend less time on non-clinical paperwork and more time on
patient care. The tools used by SIS to deliver these solutions and
streamline

the

management,

operating
nurse

suite

anesthesia

are

patient

scheduling

intraoperative

management,

anesthesia intraoperative management, and reporting modules.

http://www.smartor.com

data

To maximize room and physician utilization, as well as reducing

overtime and excess costs, operating room scheduling should be done
using

information

technologies.

Scheduling

systems

are

useful

because they have large memories, which allow for scheduling farther
in advance than most non-computerized calendar systems. Also, the
large memory allows users to create a database of past cases.
To prevent urgent surgeries from being postponed, the system
should be equipped with a tag that can be added when entering a case
into the system so that urgent surgeries are scheduled outside the
designated times for the particular physician involved in the urgent
case.
After assigning the day for the surgeries, the system should
assign time for surgeries to start.

The longest surgeries should be

scheduled for the morning, while shorter surgeries should be assigned

later starting times.

These surgeries are easier to move to other

rooms or other days when delays occur for the scheduled operating
room. By having the longest procedures earliest in the day, utilization
is increases, overtime for physicians and other staff is decreased and
more surgeries can be moved around in the event of delays from
earlier in the day.
SISs Patient Scheduling Data Management module is responsible
for the definition, management, and operation of scheduling functions.
This system provides the most effective use of surgical teams to
eliminate costly delays. Every aspect of scheduling is effectively and
easily managed using this intuitive, graphics-based system. Among

the benefits are that it can accommodate multiple procedures and

multiple surgeon, utilize integrated preference cards and pick lists,
access room, materials, personnel and equipment availability to
facilitate real time conflict checking. The system is integrated with
pre-admission,

pre-operative,

intra-operative

and

post-operative

modules to track and display patient progress throughout the surgical

process.
The application is visually based using a Graphical User Interface
(GUI) format for the presentation and manipulation of the surgical
schedule. This enables the scheduling staff to ensure that cases are
booked in an effective, efficient, and productive manner. Providers can
also easily query the system for the first case opening for the
specialty, practice, surgeon, or procedure that is requested. Once
cases have been scheduled the system, saves time for providers
because of SISs ability to review and query the schedule with equal
ease. This is useful in the clinical environment for finding a patient,
surgeon, practice, as well as being able to generate reports and
schedule summaries.
The scheduling tool ensures that the patient is dealt with in a
timely manner, free of excessive delay and inconvenience. The module
also allows the clinician to effectively plan their case day, efficiently
manage the staff to meet case requirements, and monitor and manage
case cancellation and reschedule patterns. The system streamlines the
operations of the surgical scheduling function.

The Intraoperative Anesthesia data management tool is designed to

be the focus of the Anesthesiologist's patient record-keeping duties
while in the OR. This tool is used to ensure that any data pertaining to
the patient is easily captured and stored; both machine-generated and
manually entered observation information is processed with equal
speed and facility. By combining connections to automated patient
monitoring devices and an easy to use computer interface, an
intraoperative anesthesia record is being created as the case
proceeds. Benefits of the Anesthesia Module are the ability to see real
time views of the patient's physiological condition at all times,
presentation of information in customized tabular or graphic views to
track any desired combination of observations, and summary of
anesthesia events during surgery that are generated automatically
and on-cue to optimize patient care.
Surgical Information System is designed to ensure that it is easy to
use in this most critical of environments.
The Reporting module offers almost unlimited flexibility to create
sophisticated

queries

and

production

reports

on

the

clinical

information stored in your database. In addition to a suite of standard

clinical and management reports, the IQ Objects reporting tool
allows custom clinical, financial and administrative reports to be
generated to meet specific needs. In addition, reports can be saved in
HTML format for easy distribution via email if desired. Benefits of this
feature are report in real time on any data element captured within
the system, accurate, up to the minute cost per case information,

utilization reports, comparisons by surgeon, service or payor, and the

flexibility to design any needed reports. SIS is set to deliver the
information you need, when you need it... automatically throughout
your organization in useful, readable formats.
The Intraoperative Nursing data management tool of the
Surgical Information System is another valuable asset. The features
include date and time stamps all activity in the OR, production of an
accurate, legible Nurse's Note as a legal record, pre-programming of
elective cases and charting by exception to complete the record. Also,
the format allows OR managers to research data for clinical pathways,
construct the most cost-effective pathway for your hospital, and
monitor pathway variances. These features are beneficial because
they improve efficiency and accuracy in charting cases, reduce the
time needed to document care, generate a complete, legible patient
record, and obtain timely performance reporting to support clinical
decision making.
There are many added benefits of the SIS product that
influenced our decision to choose this vendor over other available
surgical information systems. First, SIS is Windows format, which
is compatible with almost all OR computer platforms. SIS also uses
point and click, drag and drop technology. This feature improves both
the accuracy and the speed of data entry when capturing data, two
essential goals of clinical information systems. Further, the system
charts by exception, which adds to improving efficiency and accuracy.
Lastly, SIS has the ability to integrate with other hospital information

systems as required. With the increasing role of technology and the

hesitance of hospital administrators to invest capital in technological
equipment, the flexibility and adaptability of SIS are attractive
considering current and future IT needs.
Surgical

Information

Systems

not

only

provide

expert

technological service for clinical providers, they balance the IS needs

with

necessary

professional

customer

project

service.

managers

For

for

example,

each

client

SIS
to

provides
ensure

implementation of the system is handled efficiently and effectively.

Once the system is installed and in use, technical support is available
24 hours a day, 7 days a week via a toll-free hotline for users.

Gaps in SIS and Solutions

Surgical Information Systems did fail to meet our requirement
in several areas. The largest problem from our analysis is security.
This shortcoming with the chosen vendor is in relation to the markup
language used. A markup language is the technology used to record
structure and display the semantics of a document. Electronic Data
Interchange (EDI) is currently the widely accepted standard to
communicate information about products and services. This is the
preferred method to us because of its security and authentication
features. However, SIS uses extensible markup language (XML), an
evolving and scalable language. It has very broad support in browsers
and servers; thus, it will become the standard for encoding
information in documents for Internet applications. At this point,

though, it is not the norm, and fails to address the issues of security
and integrity of messages as EDI does. Despite the advantages seen
with XML, our proposed solution is for SIS to use the older and more
secure EDI technology.
Other problems seen with the Surgical Information Systems are
small and in flux. First, SIS is a relatively new product. Since it was
first introduced in 1997, there is low implementation of the product.
As of 1998, there were 3 implemented units. Also, SIS is extremely
costly. Each unit is priced at $350,000, more than double the price of
other popular surgical information systems. Our solution to these
problems is patience. We see correlations between the problems: as
the company is new, implementation is low and costs are higher to
generate revenue. We propose that use of the product will increase
and costs will decrease as time passes and XML becomes more
accepted.

Conclusion/Lead in to Project 2:
In the current clinical environment, computer-based decisionaids are hardly used. According to a recent study, only 7% of surgical
units utilize decision aids in the course of surgery6. From our analysis
in this assignment, we conclude that surgical information systems can
help save costly time and money, as well as increasing the quality of
care. We project that the inclusion of surgical decision support
Aust B, Ganslandt T, Sitter H, Prokosch U, Zielke A, Ohmann C. Formal decision
aids in surgery--results of a survey. Chirurg 1999 Jul;70(7):823-9.
6

systems will intensify the savings and satisfaction in the surgical

environment.
Despite the benefits of the systems, there is low usage by
providers. We feel the main reason for this disparity is that the users
were not included in the integration of the systems.

The attitudes

towards decision-aids in clinical environments are influenced by the

way the instruments are introduced and the way the users are
informed and involved in the process of implementation. Successful
implementation of decision-aids in the clinical environment should
therefore try to integrate the future users as much as possible. If the
provider does not use the technology available, it cannot help meet
providers meet the goals of decreased surgical expenditures and a
higher quality of care.

References
Aust B, Ganslandt T, Sitter H, Prokosch U, Zielke A, Ohmann C.
Formal decision aids in surgery--results of a survey. Chirurg 1999
Jul;70(7):823-9.
Hancock WM, Walter PF, More RA, & Glick ND, Operating Room
Scheduling Data Base Analysis for Scheduling. Journal of Medical
Systems 1998; 12(6):397-409.
Kanich, DG, & Byrd JR, How to Increase Efficiency in the Operating
Room. Surgical Clinics of North America February 1996; 76(1):16173.
Krishnan, R. The Internet, E-Commerce, and Health Care March 2000.
An information system for quality ad utilization management in
ambulatory surgery. J Ambulatory Care. 1992, 15 (4), 24-29.
Development of a Comprehensive Surgical Information System at
Madigan Army Medical Center. Military Medicine. Vol. 161, March
1995.
The Case for Using Computers in the Operating Room. West J Med
1986 Dec; 145: 843-847.
Health Care Financing Association, Office of the Actuary (1999)
http://www.smartor.com

Summary Table of Functionalities of SIS (Adapted from SIS Product

Literature)

Surgical Information Systems

Criteria

User Friendliness

Graphical User Interface

(GUI)

Surgical Scheduling

Block scheduling

Open scheduling

Conflict checking

Preference cards for

supplies

Patient charging for

inventory usage

Implantable device log

Materials Management

Bar coding capability

Exchange cart
management

Non-stock requisitioning

Pick-list/bin location
generation

System Functionalities

Dynamic day manager

Physician credentialing

Surgical Information Systems

Criteria

Pre-operative nursing
data

Remote physician
link/access

Reports

Case listings by date

Case listings by
operating room

Case listings by surgeon

Delays by cause

Inventory by case

Inventory by procedure

Inventory by surgeon/economic
credentialing

Utilization

Ad hoc reporting
capability

Data Management

Security/access levels

Simultaneous access by
multiple users

Archiving

Surgical Information Systems

Vendor Support

Criteria

Technical support 24X7

Training
program/resources
available

Hardware/OS

Pc-based network/clientserver

Windows environment

HL-7 compliance

Year 2000 compliance

Integration

Software cost

ADT interface

$350,000/unit