New Business & Clinical Technology Provide Powerful Tools For The Surgery Center

By Kathy Dix

Technology has a way of keeping us on our toes — the minute we acquire a new piece of hardware or software, it’s outmoded, and time to start thinking of upgrading again. today’s surgicenter spoke to several organizations with up-and-coming offerings.

NewBold Corporation, for example, manufactures and distributes the Addressograph line of patient registration/ ID systems. The card-based system is currently used in many healthcare facilities, says product manager Mark Hathaway.

“This system consists of the Model 610 plastic patient card embosser, patient card imprinter and the plastic cards,” he says. “When a patient enters a facility, whether it be inpatient, outpatient or emergency, a plastic card is embossed with patient information and then is used to imprint the patient information onto the various forms.”

NewBold also offers newer technology in the patient registration/ID process with its Eforms software solution PatientWorks, which allows a facility to put patient information directly onto electronic forms, wristbands and labels, eliminating the need for preprinted forms. Facilities’ forms can be scanned or designed and then are stored on a server, available for printing via a laser printer. It also allows the ability to barcode forms, wristbands and labels.

Samuel Mahaffey, MD, a pediatric surgeon and president of StatCom, discusses how technology can assist in managing patient flow. “Most surgery centers get very proficient at eliminating wait times for patients, which is why many hospital ORs use patient flow software,” he explains. “Surgery centers that use Web-based patient flow software are usually addressing communication to (and between) surgeons and anesthesia providers. Web-based patient flow applications can automate communication to surgeons, anesthesia providers and nurses. It can also interact with other communication devices such as pagers and PDAs. For instance, one of our clients sends escalated pager prompts to the anesthesia provider — and eventually the anesthesia chief — if he or she isn’t in pre-op when the pre-op nursing evaluation begins. This is particularly important in multi-site facilities, or in a surgery center connected to a healthcare organization.”

Another issue, he says, is “invoking workflow rules to ensure the proper procedures are assigned to the proper facility. With APC codes, the government mandates that certain types of surgery patients must be admitted for post-operative care. Patients are often inadvertently scheduled to a surgicenter despite the fact that they must remain for post-surgery care. A patient flow system that has workflow rules built in will not allow the patient to be scheduled in the surgery center if he/she must stay overnight; alternatively, it will allow the scheduling but will set up communication and transport between the surgery center and the hospital to eliminate confusion or resource issues.”

Supplies are an enormous responsibility for a surgery center; Perry Cain, chief technology officer and vice president of Suppleye.com, offers the example of cataract surgery. “According to the National Eye Institute (NEI), the number of Americans affected by cataracts and undergoing cataract surgery will dramatically increase over the next 20 years as the population ages. In fact, cataract surgery procedures are the largest-volume surgery performed in the U.S.”

“Because the intraocular lenses and many of the supplies used in cataract surgery must be replaced as soon as they are used, supply ordering is a critical part of the success of this and other types of eye surgery businesses. [It] is a daily procedure itself — one that is often marred by inaccuracies and inefficiencies,” he explains.

Supplyeye.com, an e-commerce solution, was developed specifically for ASCs and suppliers. It uses WebSphere Commerce and IBM Web Services to automate the entire paperwork chain, cutting manual processes from hours to minutes. Wireless, it allows nurses in the field to scan patient data, surgery logs and re-order information into handheld devices, then download it to the Web site by cradling the handheld.

Facilities are often created to handle multiple related procedures in a more efficient manner than in a hospital. The Montclair Breast Center (MBC) in Montclair, N.J., specializes in a personalized approach to early detection and treatment of breast cancer with breast imagers and breast surgeons working together. The center provides routine yearly mammograms, screening ultrasound and breast physical exams, especially for women at increased risk or with breast symptoms. It provides all breast-related services, including MRI and surgery onsite.

Nancy Elliott, MD, FACS, founder and director of the center, explains how the center itself is technologically advanced. “Forty percent of MBC patients are diagnosed with breast cancer at stage zero. Additionally, 52 percent are diagnosed at stage one. MBC offers digital mammography, and breast ultrasound in all exam rooms. Ultrasoundguided physical breast exams are performed by a breast surgeon. The images are then displayed on a video monitor that patient and breast imager can view together. The MBC also offers minimally invasive breast biopsies in which results are available in 24 to 48 hours, and same-day surgery to its patients,” she says.

MBC is one of the few facilities with certified breast imagers (who specialize in breast only and who have done additional fellowships in breast.) Elliott says, “The images can be directly transmitted to the OR in the same building. Patients also get a stereotactic needle location in the office before taking the elevator directly to the OR where their images are waiting for them. By the end of this year, MBC will be the first facility in the United States to offer specialized magnetic resonance imaging (MRI) equipment developed by GE Medical Systems. This ground-breaking MRI, designed solely for breast imaging, will revolutionize the way breast cancer is diagnosed, staged and treated.”

Manuel Peña, MD, observes that “simple concepts can provide a more impressive result than $40,000-worth of technology.”

Peña performs a “Feather Lift” technique in plastic surgery, which lifts, contours and suspends sagging tissues of the face and neck. “The Feather Lift Procedure can provide fast and relatively bloodless lifting for patients who may need only little to moderate rejuvenation,” he says. “The Feather Lift (or APTOS Lift) is Kolster Methods, Inc.’s (KMI) trademark name for using monofilament, polypropylene threads with cogs or ‘barbs’ called APTOS® threads to lift the underlying tissue and contour the face.”

He continues, “The APTOS threads have cogs that are strategically placed in a specific direction and used to open up the subcutaneous fat and finally are tugged into place. The tissue is caught slightly in these cogs, suspended and lifted. The threads are placed in carefully predetermined areas to support the tissue and lift it. The Feather Lift procedure is considered much less invasive than traditional mid-face, face and brow lifts, requiring less operating room time and less downtime.”

Mauro C. Romita, MD, is a plastic surgeon who has pioneered a Gore-Tex™ mid-facial rejuvenating technique. The outpatient procedure requires less anesthesia (since the operation takes significantly less time), less healing time and fewer potential complications than a traditional (longer scar) face lift.

Romita also takes extra steps in post-operative care. For example, patients who receive liposuction can also take part in his medical spa’s “Cellulite Program.” The program combines new technologies such as endermologie (a French technique that uses external suction and compression to smooth surface irregularities), pressotherapy (“air massage” that drains excess water), thermo-freeze (a wrap that uses hot and cold therapy) and mud detoxification.

“We’re able to do a lot more through a minimal incision than we were able to do years ago, and create the results you get from a long scar face lift in the vast majority of women,” he says. “The results are as good as or better than the older techniques. You have faster healing, because you don’t dis rupt as much of the blood supply, much less bruising and swelling.”

The Gore-Tex suture also allows dramatic results without invading the deep muscle planes and risking nerve damage, increased swelling or bruising, or compromising the blood supply. “The Gore-Tex suture, in my opinion, has the greatest longevity of repair of any suture used in the face,” he adds. “Gore-Tex is a very soft suture, and it’s relatively large in diameter for its strength, so it doesn’t cut through tissue when you pull tightly on it. It also has a little bit of give, and that also stops it from cutting through the tissue and allowing the tissue to relapse. It’s extremely well-tolerated, because it’s porous, it integrates very well, and there’s good tissue in-growth, so the suture itself incorporates.”

The Gore-Tex suture, he adds, has a great deal of holding power. “In this operation, skin laxity is not the issue; it’s primarily the deep tissue, which is losing support, losing structure, losing integrity. If you repair that, the skin comes right back into position. That’s why it eliminates the need to rotate or pull the skin, so the results never look pulled or distorted,” says Romita.

He points out, “There’s no real need to use absorbable sutures deep if the permanent suture is well-tolerated, because even if the absorbable sutures last for three months, and you think the healing is complete, they lose a lot of their strength after the first four weeks.”

Marc Koch, MD, MBA, president and CEO of Somnia, Inc., an ambulatory anesthesia provider, anticipated that once simpler procedures had transitioned to ASCs, they would then also move into office-based environments. “Compared to a surgery center or hospital, it was cheaper,” he points out. “You don’t have the administrative or infrastructure components that are typically costly and can boost the cost of medicine.

“From about 1995 to now, there has been a proliferation of office-based surgery. In 2004, SMG Marketing predicted up to 21 percent of all surgeries would be performed in physician’s offices. This is a huge shift from 15 years ago.”

Somnia provides anesthesia services in office-based and ambulatory environments. Few states prohibit office-based anesthesia; some states have rules and regulations, but they are not consistent nationwide. Therefore, Somnia voluntarily follows all accreditation requirements of the AAAHC and is fully accredited. “We help ensure that patients receive safe care in the office-based environment,” Koch explains. “We have a thorough quality assurance program, a peer review program, a credentialing and privileging program, a logistics department that addresses medication, supplies and equipment. We have a vast infrastructure to ensure that care in the office-based setting need not fall short of care that you would receive in more traditional locations.”

Somnia provides anesthesiologists for both ASCs and physician offices, simply because it is often so difficult to differentiate between these two types of facilities. The company has nearly 50 physicians located in five states. The anesthesiologists are grouped geographically and “deployed” to nearby ASCs and offices.

“When you provide anesthesia services in a physician’s office, there are a variety of issues that are oftentimes taken for granted in a hospital,” he adds. “Do you have a quality assurance program? Who’s interfacing with physicians to make sure any data-indicated changes are facilitated? Who’s doing peer review? Who’s taking care of your medications, supplies, equipment? Who is making sure privileges and credentials are up-to-date? Who is making sure you have undergone an appropriate orientation, and that your benefits, accounting, billing and collections are done? We let the anesthesiologists and surgeons operate and we take care of the back office details.”

Anesthesiologists receive an alert on a Blackberry device; they arrive at the physician’s office ready to provide care. By the time they arrive, Somnia’s logistics department has already made provisions for medication, supplies and equipment, as well as documentation and consents.

“This phenomenon, office-based surgery, is only going to get bigger. That’s because as cost containment strategies take on even more importance, by shifting procedures to less expensive environments, such as the office-based surgical environment, it really will help contain costs,” Koch says.

Software can also assist the ASC in staying updated. Max Systems, Inc. designs, develops and markets healthcare management software solutions for medical, chiropractic and radiology clinics. The company is currently fine-tuning a major software application, which, when implemented, will substantially increase the operational efficiencies wherein patient load capabilities could increase by as much as 30 percent to 40 percent. In point of fact, there are currently a number of healthcare institutions utilizing this software solution with a daily patient load capacity increased from 150 per day to 230 per day without increasing staff complements, says Hank Ross, director of communications for the company.

Jordan Dolin, CEO of Rightfield Solutions, offers Emmi (Expectation Management and Medical Information™), a risk management and patient satisfaction tool. Emmi combines clinical and legal best practices into a Webbased, interactive tool. “Emmi walks the patient step-by-step through an upcoming surgical or diagnostic procedure, with a basic anatomy lesson, what’s wrong with you, why your doctor has recommended this procedure, the risks, benefits, alternatives. It arms you with all the information you need to make an informed medical decision,” Dolin says.

“While it’s doing this, we’re tracking what you’re doing, and we’re keeping a permanent record of everything you’ve done, said, and questions you’ve submitted. We’re actually reducing the risk of lawsuits.”

The primary cause of malpractice lawsuits is missed expectations, Dolin points out. The key is to set patients’ expectations appropriately by educating them. “There are a number of reasons why patients’ expectations aren’t typically met,” Dolin says. “Patients expect the perfect outcome.”

Additionally, he says, “Surgeons can be very poor communicators. Much of it is not even their fault. Patients more often don’t understand or can’t comprehend the information they’ve been presented. It’s too complex, or they’re too anxious. There are some great statistics saying that patients forget 60 percent to 80 percent of what a physician has told them by the time they get to their car.”

So, he concludes, “A physician in a pre-surgical consult has about 10 minutes with the patient, and spends about 18 seconds listening to their concerns. So you have patients unable to listen because they’re anxious, and doctors pressed for time, and they’re not good at speaking to people at a sixth-grade comprehension level. Poor communication plus insufficient information equals dissatisfied, angry patients. According to the Journal of the American Medical Association, that combination is a recipe for litigation.”

To counteract that, the patient receives detailed explanations that can be accessed multiple times, and shared with family and friends. Since the explanations are documented with time and date and patient responses to questions, there is evidence that is allowed in court should a lawsuit occur.

For example, a patient experiencing night glare after undergoing LASIK might sue the surgeon, saying he hadn’t been told of this risk. Even if the doctor disagrees, the plaintiff’s attorney asks for proof. “We are able to shift the dynamic and say to the patient, ‘We did tell you, and you acknowledged this risk,’” says Dolin. “In Emmi, you acknowledge every single risk as you’re going through the program, and you can ask questions [of the physician].

“You’re able to manage a patient’s expectations; facilitate dialogue between the patient and physician — because if you’re pre-educated about how he’s going to remove your gallbladder, you can spend that time having a more meaningful conversation addressing your actual concerns. Further, educating the patient and enabling a twoway dialogue with the doctor helps build a bond between the physician and patient, and strengthening that relationship also prevents the risk of lawsuits. Patients don’t sue doctors they like. Doctors they communicate with, they tend to like more,” he says.

And, he adds, this can enhance compliance with physician instructions, as patients learn what is expected of them and why. Dolin recalls, “A plastic surgeon did a case of breast augmentation. After these cosmetic procedures, you can’t bathe until you’ve been back to the doctor; don’t swim, don’t take off your bandages, don’t expose your sutures. This woman comes home, and her partner tells her she needs to put Vitamin E cream on her stitches, so she takes off her bandages, puts on Vitamin E cream, she gets a massive infection, goes back in the hospital and the doctor gets sued. The doctor made it very clear, ‘You don’t do this,’ but you can claim, ‘He never told me not to.’ Not taking off your bandages is not in your informed consent document. In Emmi, we say very clearly, ‘after surgery, don’t remove your bandages,’ and we can prove you received this information.

“We live in a blame-based culture. The last thing a doctor wants is for a patient to have a bad outcome. And yet it happens. The perception is that if patients don’t have a perfect outcome, somebody must have messed up, and that’s not necessarily the case. The majority of people who sue have not, in fact, suffered medical negligence.”

Emmi is multilingual — available in English and Spanish, and it can be translated into 96 languages in a culturally sensitive manner. Questions that physicians and other staff members hear regularly are implemented into the core Emmi training.

“We found that one doctor who orders unnecessary tests is going to have a lot of delays, and his patient satisfaction is going to be overall lower, because the real measure is how long the patients wait to be seen,” says Todd Warden, MD, president of Emergenuity, which has partnered with AptSoft to offer a unique management system for physicians. “We started changing physician behavior, and moving them away from unnecessary testing. We were able to manage physicians retrospectively; but the thing we were missing was the ability to manage physicians real-time.”

Warden eventually liaised with AptSoft, which was able to add a real-time aspect to the system. “Physicians traditionally [practice medicine] with little change. New [tests, etc.] come along, but the new stuff gets layered on the old stuff, and becomes another test, as opposed to an opportunity to stop using the old test. That’s one of the reasons healthcare costs are going up so much.

“If you think about transactions that occur in other industries, like banking, stocks, telecommunications, those are all single, sequential, linear transactions. You can only do one phone call at a time. When a patient comes into the emergency department (ED), you’re ordering labs, X-rays, medications, but each one of those systems is a single sequential transaction,” he says.

“AptSoft has a listening device, or what they call a connector, that sits on each stream, so there’s a connector to the lab, pharmacy, radiology, etc.,” Warden explains. “I direct that stream to be reproduced and fed directly into my clinical system, so every X-ray ordered gets put next to that patient’s name, and every lab. When the result comes back, they ‘listen’ for the results and can lay that into my system as well. You can set the device so that the doctor or nurse can say, ‘If you see this series of events, either block the person from making [a new order], or send an alert to them, by pager, handheld, phone, text paging, to let them know what’s going on.’”

One example Warden gives of a new offering that was “layered on” rather than replacing other tests was the D-dimer. “It’s looking for a blood clot, and if it’s negative, it’s pretty clear you did not have a pulmonary embolus. In most cases, you don’t need to get a CAT scan of the lungs to see if there’s a blood clot. It was one more thing to help you rule out a pulmonary embolus, as opposed to stopping the ordering of a CAT scan when it’s unnecessary. If you’re waiting for the D-dimer to come back, and the doctor decides to order a CAT scan, the system has heard that you’ve ordered a D-dimer, and if it hears you ordering a CAT scan before the results are back, then it can put up a screen asking, ‘Are you sure you want to do this?’ It’s helping to make a judgment or move a physician away from a certain behavior or toward a certain behavior.”

Alerts can be set for hyperkalemia; a particular level could be set to alert the physician on a handheld device as a “panic value;” also, in the case of an acute myocardial infarction (MI) or congestive heart failure, certain significant treatments are not being offered by physicians because they’re not “up to speed” on the literature. The system can alert the physician to use those particular medications.

“When you buy a software package, it’s all hard-wired in that package, and you have very little flexibility unless they come out with a new edition, and then that’s old by the time you get your hands on it,” Warden observes.