Creating ASC Efficiencies Outside the OR

Managing an ASC presents unique challenges both inside and outside the OR. Here are real-world solutions you can implement in your practice.

Dr. Koch: What are some of the challenges facing ASCs in the current political/economic/demographic climate?

Dr. Tyson: More baby boomers are approaching the age when cataracts become prevalent, so we'll be seeing more patients in our ASCs. We'll have to be more efficient to handle this volume. At the same time, we know Medicare reimbursements will decrease, which means we must be even more efficient. Politically and economically, our challenges will be to protect our independence while continuing to show that we provide a value-added service to the medical community by delivering excellent care in an efficient manner.

Mr. Sheffler: As the non-physician in this discussion, my view is that doctors are, of course, focused on clinical excellence and being efficient in the operating room. But many of my colleagues in OOSS who are physicians don't pay enough attention to the administrative and business side of their ASCs. As an example, medicine is the last bastion of non-usage of computers. Electronic medical records are just arriving, and electronic inventory is tremendously important. In our businesses, we spend the most money on supplies, not employees, yet most people don't have electronic inventory systems to see exactly what they have on the shelf. These types of efficiencies are the next important initiative. We have made surgery efficient. Now we need to make our administration of these facilities more efficient.

Dr. Tyson: The paperwork is becoming more of a nightmare. Whenever we receive a new set of regulations, all of our forms have to be changed. I estimate I spend more than 40 minutes just signing paperwork at the end of a surgery day. I've looked at many different EMR packages, and they're usually not ophthalmology-specific, so that's another challenge. Finding a package that manages your optical shop and your ASC, and does it well, is difficult.

Dr. Koch: I hold the view that medical records have not changed significantly since the Civil War, when they were written on paper and put in a box somewhere. Here we are, 150 years later, doing essentially the same thing.

The procedures for handling records may vary depending on the size of the ASC. For instance, in a facility with a large number of doctors, there may be various protocols. They may be more consistent in an ASC with only one or two doctors. How are you handling your medical records?

Seeking a Good EMR Fit

Dr. Waltz: In our ASC, we don't use electronic medical records in the usual sense. We use a hybrid system. I found I was filling out a form in the office—name, demographic information, and so on—and then filling out a form in the surgery center with the same information. Not only was this repetitious, but it also created numerous opportunities to make mistakes. Now, we use a program that populates our forms automatically. The program also corrects misspelled drug names and shows the various dosing options. We still use paper, but we are moving toward a fully automated process to decrease our costs, increase our efficiency and, at the same time, minimize errors.

Dr. Koch: What are some of the differences between using EMR in your office and in your ASC?

Dr. Wiley: We are two surgeons with the same protocols and relatively high volume. With cataract surgery, each patient is, at most, a two-event situation—cataract right eye, cataract left eye—compared to a glaucoma patient, for example, whom we may see 4 or 5 times a year. Repopulating paper charts for glaucoma patients is inefficient, so an EMR does make sense for that type of patient.

What may be holding us back is the current EMR technology. When you consider the advances that have been made in consumer and other business electronics, such as computers and cell phones, it becomes apparent that EMR technology for an ASC needs to catch up. I think it will get there, but it's not there yet.

Mr. Sheffler: We really must reduce our personnel and storage expenses as much as possible to stay profitable. We have to do it. It is imperative.

Dr. Tyson: As for the future, I believe we will start seeing EMR programs that are more flow-oriented, because now we must document every encounter with a patient throughout the OR day, not just check-in, check-out and how much we billed. Now, we need to track who touched which drugs, when each drug was administered, and when a patient went from station A to station B to the OR and discharge.

Dr. Koch: Looking at paper records and electronic records, I can use an analogy with our surgery center. Paper records are our disposables. We buy a product, use it once, and never use it again. Electronic records are our reusables. That is, we pay a higher price for the item in the first place and then use it over and over again, which is a savings compared with disposable costs.

New EMR Solution for ASCs

Dr. Koch: Lou Sheffler runs a group of surgery centers with 300 doctors, so he's responsible for managing numerous protocols. Tell us how you maintain efficiency, and also explain how being a member of OOSS can be beneficial in this area.

Mr. Sheffler: We had a hybrid paper and electronic record-keeping system but have switched to all EMR. We found that paper medical records are not free. In fact, they're expensive when you factor in the time and labor spent handling paper charts, as well as the supplies, such as toner and fax machines. Even in our smallest surgery center, where 2000 cataract surgeries are performed a year, we found we were spending $42,000 annually on paper records.

We now use a browser-based system by iMedicware called iASC, which addresses the needs of ophthalmology offices and surgery centers. The system is endorsed by OOSS and available to OOSS members at a discount. It's also compliant with federal guidelines for paperless offices.

Dr. Wiley: Is the system truly paperless?

Mr. Sheffler: Yes. Tests, such as EKGs, are faxed to us, and the system converts them to PDF files, which are placed in the electronic chart. All consent forms are signed electronically. Even the scheduling at the doctor's office is done via the Internet.

Dr. Wiley: That is a huge point. Unfortunately, not all EMR systems are paperless. You can be in a situation where you have an EMR, and you are still printing documents, having consents signed on paper and scanning, which is not efficient or cost-effective.

Mr. Sheffler: The iMedicware system is tremendously efficient because it enables you to manage records securely from any computer with Internet access at any time. In addition, records are fully auditable for the Accreditation Association for Ambulatory Health Care and the government. You can view every chart that has been signed, find out how many 4-diopter lenses you used in the last year, look at vitrectomy rates, surgeons' speeds, the efficiencies of nurses and time between OR cases. You can obtain metrics on numerous aspects of your practice.

Dr. Tyson: So this is more than just EMR. It's EMR plus ASC management system.

Mr. Sheffler: Yes. It's a complete ASC management system. The iMedicware system predefines by doctor by procedure, so everything changes based on the procedure: the operative report, the medications and the postoperative report. The system is the same in the doctor's office. When surgery is booked, all the patient's information comes across to the surgery center.