Electronic operative notes at Royal Derby Hospital.
Improved communication of surgical information – The InfoFlex electronic template has allowed for higher quality and more timely production of operative notes at Royal Derby Hospital via the implementation of a fully integrated electronic template for upper limb surgery.
Key improvements after InfoFlex implementation
- Accuracy and detail of notes improved
- RCS guidelines adherence elevated to 100%
- Fully informed medical decisions
- Eliminated risk of lost or illegible notes
- Ongoing improvement such as DVT prophylaxis assessment
- Rapid surgical information communication
- Reduction from 11.6 days to less than a day on average in typing of dictated notes
- Printed notes generated on same day as surgery
- ICD-10 diagnosis, OPCS coding and comorbidities easily queried and audited, due to template integration into the existing InfoFlex database
- Full documentation available, essential for any medico-legal issues
- Projected savings of £16,500 over the year on administrative costs
- No additional funding required as InfoFlex software already licensed for other services at Royal Derby Hospital
- Linking ICD-10, comorbidities and OPCS coding could improve remuneration
Ease of use
- Straightforward to configure template with enthusiasm from IT staff
- Quick and easy for IT staff familiar with InfoFlex to make changes
- Additional training provided where necessary
“The goal of the project was to find a way of getting accurate and ‘rapid information from the operative notes straight to the clinical notes and [to] have it available straight away.’”
Prior to the implementation of the electronic template, upper limb surgeons at Royal Derby Hospital wrote brief notes about surgical procedures and post-operative instructions to inform staff during the handover and recovery phase. Full operative notes were dictated and subsequently typed up by administrative staff to be filed in the patient’s case notes.
Baseline measurements showed that on average there was a delay of 11.6 days in typing up the notes after dictation.
Kanthan Theivendran, Consultant Orthopaedic Surgeon at Sandwell and West Birmingham Hospitals NHS Trust and formerly a Senior Upper Limb Fellow at Royal Derby Hospital, led the Quality Improvement project at Derby. He stated that the goal of the project was to find a way of getting accurate and “rapid information from the operative notes straight into the clinical notes and [to] have it available straight away.’’ As a result, fully informed medical decisions could be appropriately made without delay, whilst eliminating the risk of lost or illegible notes.
Additionally, there was a necessity to produce more accurate and detailed operative notes, in line with the RCS guidelines. A baseline measurement showed 71% adherence to the guidelines in the Upper Limb Unit. An electronic template would provide an aide memoire for surgeons and could be designed to ensure full documentation, essential in case of medico-legal issues.
Finally the department was looking for an optimal solution that would, on the same page, link ICD10, comorbidities and OPCS coding that could improve remuneration for the trust.
Design and implementation
InfoFlex was chosen as the software on which to design and build a shoulder arthroscopy and arthroplasty surgical notes template. No additional funding for the project was required as InfoFlex software had been licensed for Cancer, Trauma and Orthopaedic services at Royal Derby Hospital for 4-5 years prior. Being data-base driven the software offered “ease of audit and querying” and the project benefited from the fact that ICD 10 and OPCS coding had been integrated into the system, prior to the template development, by David Clark (Consultant Orthopaedic Surgeon at Derby). The system usefully allowed for drop-down menus as well as free text entry.
Kanthan Theivendran coordinated the QI project as part of his BOA (British Orthopaedic Association) Clinical Leadership Fellowship programme. The design and specialist content of the template was a result of close collaboration between members of the Shoulder and Upper Limb Unit, IT staff and departmental secretaries.
He commented on the importance of engaging stakeholders and utilising “people’s strengths’’ during the process, noting the enthusiasm and knowledge of the IT department in particular.
Kanthan remarked on how quickly the template was configured and that during the design and development phases, IT staff familiar with InfoFlex could easily “tweak the design and respond very rapidly’’ to required changes.
“During the design and development phases, IT staff familiar with InfoFlex could easily ‘tweak the design and respond very rapidly’ to required changes.”
The surgical template was approved for implementation after 3 PDSA (Plan, Do, Study, Act) cycles during which it was trialled with a “test” patient, underwent a “real world trial’’ and a range of content and formatting refinements. It was made available to all consultants in the unit after a final presentation of a worked example at the Shoulder and Upper Limb Unit Departmental Meeting.
Once the electronic template had been introduced, further improvements were made. For example, DVT prophylaxis assessment was added (after adherence to RCS guidelines had risen to 91%) increasing compliance to RCS guidelines to 100%.
Further training was given to familiarise surgical staff with the template and software environment to address any issues that arose, such as some doctors finding it longer to complete the template than to dictate operative notes.
Results and benefits
“A projected saving of £16,500 across a year… improved and more timely communication of surgical information to relevant staff.”
Over 4 months, 109 separate electronic notes were produced on the same day as upper limb surgical procedures. There was therefore no delay in the production of full, printed operative notes as well as the concomitant benefits of reduced administrative time and costs (a projected saving of £16,500 across a year was calculated) and improved and more timely communication of surgical information to relevant staff.
Compliance with RCS guidelines was raised to 100%. Also, being easily configured, InfoFlex enabled medical staff to integrate agreed upper limb details in order to produce truly bespoke, high quality post- operative documentation.
Access to ICD-10 diagnosis, OPCS coding and comorbidities made the electronic template ‘’unique’’ in its ability to be both descriptive and highly searchable for audit and research purposes.
“Being built in InfoFlex makes the template a very cost effective and sustainable solution”
Kanthan Theivendran said: “Quality Improvement is about continuing to improve.’’
He asserted that being built in InfoFlex makes the template a very cost effective and sustainable solution, with continuing improvement most obviously achievable by converting the template directly into InfoFlex Web.