Episode 28: Documentation in the OR with AORN

In this episode of The Informonster podcast, Charlie Harp talks with Janice Kelly, President of AORN Syntegrity, Inc., (Association of periOperative Registered Nurses) with over 25 years of informatics experience. Janice shares how AORN is working to enhance workflows with surgical schedules and perioperative nursing. She also gives insights into how AORN collaborates with healthcare institutions to stay ahead of the curve when it comes to new procedures, CPT codes, and preference cards. 

Charlie and Janice explore the unexpected ways data quality impacts healthcare and how AORN's contributions are helping healthcare professionals maintain the gold standard in procedure lists and standard terminologies. 

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Transcript

Charlie Harp:

Hi, I'm Charlie Harp, and this is the Informonster Podcast.

Today on the Informonster Podcast, I have Janice Kelly from AORN Syntegrity, and we're going to talk about what they do and the content they provide and how it can be used. But first, I want to start out by allowing you to tell us a little something about yourself, Janice.

Janice Kelly:

Oh, thank you, Charlie. Thank you for inviting me on this podcast today. I am Janice Kelly. I'm the president of AORN Syntegrity, which is a subsidiary of AORN.

Charlie Harp:

Great. Sure. So why don't you start by telling us a little bit about yourself?

Janice Kelly:

Okay. I am a nurse and I'm an informatics nurse. I got into nursing because my mother was a nurse. I think she was probably my biggest influencer. I just remember one time as a teen, I went into the clinic she worked at and saw her in action, and as I watched her, it was evident the physicians and patients trusted what she was doing. And I think it was at that moment, I decided I wanted to be a nurse like her.

I became an informatics nurse because I happened to be at the right place at the right time. I think it was back in the mid 1990s. Seems like a long time ago and makes me feel old. The facility I was working at converted from one EHR to another, and my director at the time saw how easily I used the current EHR and volunteered me to work on the implementation team. Little did she know that I would find a new love.

I loved what I was doing; discussing workflows, designing screens, developing reports, training nurses, and I wanted to make sure I was doing it right. So I started searching for knowledge and I found out about the specialty of nursing informatics. No idea it even existed. I took any courses, webinars, attended conferences related to health information technology, became a HIMSS member, an ANIA member. I became one of the earlier nurses board certified in informatics, and I obtained my master's with a focus in healthcare informatics.

My informatics career has been a wide range of things. Like most informatics nurses, I started with the implementation of an EHR. I think that's how most informatics nurses get started. I then moved into a permanent role overseeing nursing and ancillary documentation build and training staff on the EHR. I also implemented advanced clinicals, such as barcode scanning of medications and computerized provider order entry before most organizations even knew what those were.

I then landed a role as a director of nursing informatics in CNIO, overseeing the informatics team and inpatient applications for the transition to a new EHR. Seems like that's what I always like to do. That was for multiple facilities. And then I did it for an enterprise wide EHR implementation throughout multiple states. That was probably the most complicated implementation. I then made my way to AORN Syntegrity because I wanted to experience the vendor side of informatics.

Charlie Harp:

Great. So what you're saying in a nutshell is you're not a newbie, number one, and number two, if you like migrating EHRs, you're a little bit of a masochist. Is that fair?

Janice Kelly:

I would say yes, definitely.

Charlie Harp:

Well, I think that my experience, I've had the pleasure throughout my career of knowing a lot of nurses. My mother-in-law, for example, is a nurse, and working with a lot of nurses and pharmacists and lab techs and physicians. But I do think that when you look at healthcare, nurses are kind of the unsung heroes that make healthcare work at the end of the day. I think that the nice thing about nursing informatics is it's a very pragmatic, practical side of what we need from an information perspective to actually get things done, and I don't always think that it gets the attention that it deserves. So I'm really excited to have you on today.

Janice Kelly:

Thank you so much.

Charlie Harp:

Sure. So for the listeners who are unfamiliar with AORN, could you give us an overview of what it is that AORN does and then we can talk about a AORN Syntegrity?

Janice Kelly:

Yeah, sure. So AORN, or the Association of Perioperative Registered Nurses, is a membership organization. I started, I believe, somewhere back in the 1940s as a community of operating room nurses who wanted to get together to share best practices for patients undergoing surgery. And today, AORN provides those best practice resources that are used in every hospital and ASC across the country. This includes the evidence-based guidelines for perioperative practice which we develop and are considered the gold standard of care in the OR.

Charlie Harp:

Okay. What about the Syntegrity group?

Janice Kelly:

Yep. Syntegrity, it's sometimes hard for people to understand what AORN Syntegrity solution is, but basically it's think of it kind of as a perioperative information data model or content that optimizes an organization's perioperative EHR application. It is a two-part product that includes a library of operative and other invasive procedures that are mapped to CPT, ICD-10-PCS, and SNOMED CT, for those geeks that are out there that know those code sets. And they're used in scheduling systems.

And then the second part is the perioperative nursing documentation templates that indicate what nurses should document based off of evidence-based practices. It also includes links to clinical practice support resources for perioperative nurses so they can easily access the information they need to know of how to provide care to the patient undergoing a surgical procedure. And we have links that take us into what we call our e-Guidelines Plus. It also provides the ability to standardize the capture of patient outcomes.

The solution is really used to enhance the workflows associated to surgical scheduling, which sometimes can have some major issues. It improves perioperative nursing documentation. And we're really focusing on that documentation burden, which is a buzzword that you've probably heard a lot about, because we don't want the nurses sitting behind that computer or standing behind that computer and not focusing on what's going on in the OR. We want them to be proactive instead of reactive. And then they also can capture the data to measure the impact that perioperative nursing care provides on patient outcomes.

Charlie Harp:

Okay. So no product comes into being out of ether for no reason. What's been developed by AORN and what's included in what you're describing as part of this Syntegrity offering; what would you say the main pain point is that drove the development of products?

Janice Kelly:

I think the main pain point was the fact that EHR vendors developed content and some of those vendors didn't even have perioperative nurses on staff. They were just saying, "Ah, this is what we think nurses should be documenting in the OR, whether it's evidence-based or not." Or maybe they pulled it from, "Oh, well this organization does a great job, so we think their documentation should be great, so we're going to pull it into our EHR."

And so organizations we're looking at their documentation and they're like, "Well, it's missing this. It's missing that. It's not following the AORN standards." And so we wanted to create something to make sure hospitals could demonstrate they were following those standards that they're required to follow by the Joint Commission, DNV, HFAP, whoever their Medicare accreditation organization is.

Charlie Harp:

And so for the content itself, do you guys integrate it into the EHR into the OR systems that the hospitals and ASCs use?

Janice Kelly:

The organizations actually implement the content. We assist them, answer questions, help them where we can. But we're also the model content for Oracle, Cerner, and Altera Digital, which used to be known as Allscripts.

Charlie Harp:

Sure. All right. Why don't you share with the folks how you guys became affiliated with Clinical Architecture?

Janice Kelly:

Yeah, sure. We became affiliated with Clinical Architecture because we had one of your clients, who also uses our procedure list, and they want to standardize their procedure list throughout their entire organization, which is a lot of hospitals. And so they looked at your Symedical product to help them with that.

So AORN Syntegrity is available and Clinical Architecture's Symedical solution to clients who are licensed to use our procedure list content. And the procedure list can be used to improve the quality of healthcare data by providing a standardized terminology to support surgical procedure scheduling. And Symedical's Portal provides users the access to manage and update their surgical procedure list and those associated code set mappings that I talked about earlier using the AORN Syntegrity procedure list.

Charlie Harp:

Which is very cool because one of the things that we try to do with our clients, and we have clients that kind of go across the different verticals in healthcare, but a lot of them are IDNs, and a lot of them are large IDNs with multiple clinics, surgery centers, hospitals, and a lot of what these folks struggle with is the standardization issue where, like you said, these different applications have dictionaries where people can put in whatever they want, and then when they try to do meaningful things with that data at scale, they have to deal with some form of harmonization to make that happen. It also ends up creating a bunch of, let's call it, service variation across the enterprise because everybody's doing things in slightly different ways.

And so whenever we come across content like what you guys provide that could help our clients do a better job or reduce the amount of work they have to do to A, build content, integrate content, map content, it's a no-brainer for us to try to work with the folks that are putting those great products together and make them easily available to the folks that use the Clinical Architecture's product. So we're very excited to have you guys working with us through this subscription portal and making that content available.

Janice Kelly:

We definitely enjoy this because we have the same, I think vision is that we want to make sure organizations can have that standardization so they can do those benchmarkings, those data analytics, the reporting, all the things that you need especially in the OR.

Charlie Harp:

Absolutely. So if an organization wants to standardize its surgical scheduling procedures, how would they normally go about that across the enterprise?

Janice Kelly:

Yeah. So if an organization wants to standardize its procedure list, they need to understand it's not a one and done project. It will require ongoing maintenance to update and modify procedure terms and associated code sets. Because CPT is not stagnant, it is always changing, every year we have an update, they retire codes, they might edit a code, they add new codes, so those need to be added to your procedure list file. And surgeons are always performing new approaches, a new minimally invasive technique, a new robotic, or laparoscopic procedure, things like that. So your procedure list is definitely not static.

And so you need to really have a team of appropriate stakeholders that should create a governance process to manage and have oversight of the surgical procedure list. Because once you've created that original list, you need to make sure not every single person can get in there and make changes and add procedures because now you're going to have a mess again. And so the team should really have that governance process in place. It should consist of the individuals whose departments or business units are impacted by the procedure list. And they should also be responsible to monitor the data quality to ensure the desired outcomes are achieved for the procedure list.

The team might include maybe your OR business manager, your perioperative director, definitely that informatics nurse, your OR scheduler, maybe the revenue cycle manager, IT, and you want to make sure surgeons are involved. And the team should really be responsible to determine the processes and resources necessary to create and maintain that procedure list. And if multiple facilities are involved, the investment in a standardized surgical scheduling procedure list instead of doing it yourself is probably more efficient, as well as a tool, such as Symedical, will also make the process more efficient.

Charlie Harp:

Janice, how often do you guys update the standard procedure list and mappings?

Janice Kelly:

We update it quarterly. Every quarter we're adding new procedures. Maybe we might retire a procedure or two because they're no longer really performed. And then again, because we're doing code set mappings to the CPT to the ICD-10-PCS and SNOMED, well, those owners of those code sets, they're doing either yearly or sometimes twice a year updates. So we want to make sure we're maintaining those updates.

Charlie Harp:

I think a lot of people realize when they're doing procedure mapping, especially to those types of codes, that it's not super straightforward, especially mapping the codes like CPT codes because they're not just a single code. They actually typically represent multiple things in a single code.

Janice Kelly:

Exactly. Yes, it all depends on the granularity or the broadness of your procedure. And those mappings can be a one-to-one, a one-to-many. Especially ICD-10-PCS, it's going to be a one-to-many.

Charlie Harp:

Absolutely. So when it comes to the surgical procedures themselves, because I always say healthcare kind of evolves at the edges, I would imagine you guys have a very collaborative style of relationship with your clients to stay ahead of how the field is changing. Is that true?

Janice Kelly:

Oh, definitely. We rely on our clients to say, "Hey, guess what? We're performing this new procedure."

We had an organization who was going to perform a face transplant. Never heard of a face transplant before. So we were doing some research and come to find out they're the first one to do this. So we had to build that procedure for them and then try to determine which CPT codes. Well, more than likely it was probably those unlisted procedures, like those CPT codes that end in 99, that we had to use for that one.

Yeah, we definitely collaborate with our clients. We even have a feedback mechanism to submit new procedures or they can reach out to us directly.

Charlie Harp:

And that's a feature that people don't always think about when they're working with a content vendor that approaches the market that way, is that if you're working with all these folks and they're all introducing new things for most institutions that means that by the time they encounter that procedure, you've probably already got it because you're collecting these things from all these different sources.

Janice Kelly:

So true. We also do CPT gap analysis. So we look at what new CPT codes are being added and do we have a procedure to cover that? We're always looking at the code sets as well to see what new procedures are they adding into those code sets that we might need to add to our procedure list. So we're trying to be proactive as well.

Charlie Harp:

One of the things we chatted about before was the surgical preference cards. We worked on a project for a large client who was trying to manage preference cards. They're also not straightforward. You had an example around preference cards.

Janice Kelly:

Oh yes, preference cards. Preference cards for those who do not know are basically the recipe for how the OR room should be set up, what instruments should be available, what supply should be available, how the surgeon wants the patient positioned, how they want the patient prepped, all of these things. There's a lot of things that go into a surgery, and if you don't have the right preference card associated to your procedure, then you're going to have an issue. You're not going to have those supplies that you need. You might end up having to cancel that case, and now you've got a frustrated patient because they have to reschedule their surgery for another day. You've also left that OR opened. And an OR that is opened for one minute, you're losing dollars.

So it's really important that you have a clean preference card list, and those preference cards are really associated to the procedure list. So you really need to have that clean procedure list as well. So it really starts with that procedure list; having that clean procedure list, then you can clean up your preference cards because they should match your procedures. And if you have one thing off, it's going to cause chaos in your OR.

Charlie Harp:

It makes a lot of sense. I could certainly see in the clients that we've worked with, one of the things they were really trying to do... and I'm hoping that now that you guys are in the subscription portal, if they're not already using you, which they might be, I might have to make a phone call... but one of the things they were trying to do was create what they consider to be their gold standard procedure list across all their facilities. And that's essentially what you guys are providing. It's not only that gold standard procedure list, but it's the gold standard procedure list with all the mappings they would need to do things using standard terminologies.

Janice Kelly:

Correct.

Charlie Harp:

It's very cool what you guys are doing.

Janice Kelly:

Yeah. The other thing that we kind of helped with that we never really thought about when we created these mappings because we really did the CPT mappings to the procedure list, to help with making sure the right procedure was scheduled, because if you don't schedule that correct procedure at the beginning, you're going to have issues.

And so we use the CPT because a lot of surgeons know the CPT codes because that's how they bill for those surgeries. So they might say, "Hey," to their staffing folks, "call the hospital. Tell them I want to schedule a 25550." Well, the person in the physician's office might know what that CPT code is, but that scheduler at the hospital probably doesn't have a clue. And so when that other scheduler says, "Hey, I want to schedule this 25550 procedure," the scheduler at the hospital is like, "What?" And they're like, "Can you speak English to me?"

So we've really created the procedure list to not only just standardize, but to help improve the communication to make sure the right surgery is scheduled. Also, what happened with that is with the CPT mappings, people started to realize we can use those CPT mappings to say these are the CPT codes we need pre-authorized for this procedure.

Charlie Harp:

Yeah, absolutely.

Janice Kelly:

And so it's helping with those pre-authorization workflows.

Charlie Harp:

So you're saying in the beginning was almost being used like a synonym to help find code?

Janice Kelly:

Yes.

Charlie Harp:

Okay. It's interesting how you do some of these things and you realize later... We do it all the time at Clinical Architecture. I call it brilliant by mistake. You do something later and you're like, oh, well, that worked out-

Janice Kelly:

I like that. I'm writing that down.

Charlie Harp:

One of the things that you said that I really liked, and it's something that I tell clients all the time, is that I usually say data quality, but I kind of think what you guys do is data quality too. I'm not kind of; I definitely think what you guys do plays a role in data quality. And it's kind of like these things we do in informatics; they're not projects; they're lifestyle choices. It's the kind of thing where I think too often people think that when it comes to dictionaries and terminologies and ontologies and all these things that we help people build and manage that it's a project that you do it and you're done.

I'm always telling people, part of the reason why I started Clinical Architecture and part of the reason we do all these things, it wasn't just because I love the glamorous life of somebody that runs a company that works in informatics, but because this whole idea that we need to constantly manage and curate and monitor what we're doing with the data or it'll get away from you. It's like your yard. You got to mow it. You got to weed it. If you leave it alone, it's going to be much more work to try to sort it out later, and you're not going to like where you end up.

So I really appreciate that perspective because that's something I say all the time. It's a lifestyle choice. It's not a project.

Janice Kelly:

Exactly. I tell all my clients, "This is not something you're just going to do once and then forget about it. You have to keep those CPT codes updated because CPT changes every year and it could lead to billing issues if you're using outdated CPT codes, ones that have been retired." And so it really is, like you said, it's a lifestyle.

Charlie Harp:

You guys really focus close in on surgical procedures. One of the things we find people struggling with is when you look at the domain of terminologies for, let's just say, procedures in general, there's kind of a mixed collection of things. So you have RadLex for imaging, and some of it's in LOINC. You have CPT codes. CPT codes are really classification around billing, so they don't really work great as clinical codes. SNOMED has some of these things. ICD-10-PCS has procedures, but the way they're defined are not... I think people really struggle with the hierarchical Yoda-like nature of ICD-10-PCS. Do you guys ever think about expanding out beyond surgical procedures?

Janice Kelly:

We do address surgical and other invasive procedures. So we do have cath lab procedures, interventional radiology, the bronchoscopies, the scopes, GI. So we've expanded out to that, but we haven't looked at, and I don't think we will because it's not our domain of expertise to look at radiology. There are some radiology codes, lab, there's LOINC. We're not going to try to compete with that. Our focus was really ensuring that the right surgery was scheduled for the right patient because that's what AORN is all about. We're really about patient and staff safety.

Charlie Harp:

So do you see anything new and exciting in the future for you guys from a development perspective, or is there anything in particular going on in healthcare that you're super excited about in your space?

Janice Kelly:

We're really excited about the use of ambient voice technology because the nursing documentation is such a burden. All these vendors are focused on physicians, but nurses are the ones who are using the EHR the most. And so we would really like to work... Because we have this standardized documentation for nurses, how easy can it be to help create that ambient voice technology for letting the circulating nurse just dictate in a little headset or something?

We're also interested in artificial intelligence to guide nurses on what to do appropriately for that patient. Whether it's a bariatric patient, a geriatric patient, a pediatric patient, because of certain patient assessments, you might need to change how you provide care for that patient. And so we want to make sure that we can provide nurses that right information at the right time.

Charlie Harp:

No, that makes a lot of sense. In fact, we were working with a very large client and they were doing an initiative, it's been a little while now, but it was very focused on labor and delivery. It was very focused on nursing documentation. They had done a time study. I don't have the data in front of me, but they had documented that a nurse during a labor and delivery procedure had to document, I want to say it was several thousand pieces of information. And they were trying to go back and look and see how many of those pieces of data actually got used downstream, and it was an incredible amount of time.

And when you think of everything that nurses are trying to do, the documentation burden is a non-trivial stressor, I would imagine. I know it's hard for physicians as well, but I do think that too often we kind of forget that nurses are doing a lot in healthcare and they're also struggling with the same type of burden that these systems that we put in place create for clinicians.

Janice Kelly:

Yeah. And that's what we've really looked at for the perioperative documentation is what are those sacred cows? What have we been doing all these years that we really don't need to be doing? For example, it's not being used downstream.

We had a committee, and we really looked at a lot of that documentation, got it down to what we think we could get down, but there's still a lot more documentation that the circulating nurses have to do. Implants; we have to document what implants are being put into the patient. We have to record the time in, the time out, who's entered the OR, who's left the OR. These are things that can be automated. And so that's what we're trying to do is find different partners where we can say, let's automate these things.

Charlie Harp:

That's very cool. I tend to be a little skeptical about ambient, but I think that in a controlled environment like an operating room as opposed to in the hospital walking around doing things, I could certainly see how ambient could be applied in that type of setting in a very effective way. So that is cool.

Janice Kelly:

And it may not be a true ambient that's on all the time, but it's kind of like a hey Siri type thing; I want to document this. Because you don't want to hear the surgeon sometimes with what they might be saying in the background or the music that might be playing.

Charlie Harp:

Yeah. When we were doing the preference card project, that was one of the things that I didn't expect, one of the choices of what music do they have on in the background while they're doing surgery? I thought that was interesting, but it makes sense though.

Janice Kelly:

Yeah, exactly.

Charlie Harp:

All right, so Janice, anything else you want to throw out there for the people that are listening?

Janice Kelly:

Yeah, if anybody's interested in talking with me, I'll be attending the OR Excellence Conference, October 4th to 6th in Phoenix, Arizona. And, of course, there's always the AORN Global Surgical Conference and Expo. That'll be March 9th through 12th next year in Nashville. And if anybody wants to contact me, they can just go to the aorn.org website and click on the AORN Syntegrity link at the top.

Charlie Harp:

Excellent. Well, Janice, thank you so much for talking to me today and for sharing this information, and I'm sure that the people listening will find it interesting and useful. I appreciate the time today. Thanks.

Janice Kelly:

Well, thank you Charlie. I greatly appreciated the time you have given me.

Charlie Harp:

All right. Well, I'm Charlie Harp and this has been the Informonster Podcast. Thank you so much for tuning in. Talk to you next time.