In a perfect world, orthopedic surgeon Michael Haak, M.D., would love to access and manipulate digital images, and to have those images near the operating table as he performs surgery. But Haak — an associate professor of orthopedic surgery at the Feinberg School of Medicine at Northwestern University, and associate director of the spine trauma service at Northwestern Memorial Hospital in downtown Chicago — is no idealist. He knows the tools needed for such a setup are still evolving, and in some cases, not even on the horizon. For one thing, Haak notes, because he specializes in traumatic spine surgery, the images that do come in are presented in many different formats, and have to be accommodated as such.

Fortunately, Haak works at Northwestern Memorial, an 897-bed academic medical center whose IS and clinician leaders are committed to the use of leading-edge technology in imaging, surgery, and other key clinical areas. Haak acknowledges that he is also lucky to have Tim Zoph, vice president and CIO, at the helm of the IS ship at Northwestern. Zoph and his team are strategizing daily on how to optimize workflow and practice conditions for the hospital's surgeons and other medical specialists.

Of course, exactly how to proceed in the optimization of the hospital operating room is a question that continues to vex CIOs and clinician leaders nationwide, given its complexity and multi-dimensionality. First, there is the major issue of how to optimize the use of PACS in surgery and ORs. There is also the question of how to further optimize clinical operations by implementing niche surgical information systems, or surgery components of core clinical vendors' documentation and patient safety systems. And then there is the broad problem of how to coordinate these enhancements with overall IT strategy. Is the OR an island unto itself, as English poet John Donne once mused? Or is everything really connected after all?

According to Zoph, CIOs are faced with one of two core strategies around optimizing the OR, though ultimately, far down the road, those two strategies will have to merge. “There are two primary directions you can go here,” he says. “You will have organizations that will be automating surgery from the perspective of the global electronic health records strategy. And there, as you think about documentation, medication reconciliation, and so on, you find that there's an argument to say that information integration from surgery to all other venues of care to the coordination of care becomes critical, including in the medication management area.”

“On the other hand,” Zoph continues, “there is also the strategy of continuing to build on a surgery-specific suite of applications. The argument there would be that surgery, unlike other areas, has a well-installed base of surgical applications,” and that surgeons and other clinicians need to take advantage of those. At Northwestern, Zoph and his colleagues are following the notion that, “the enterprise view that PACS and PACS imaging and our ability to deliver multi-modality images to surgery becomes an enterprise strategy.” Appropriately, they continue to upgrade image access and capabilities in their state-of-the-art surgical suites, under the overall umbrella of enterprise-wide integration and development.

Some kind of strategy will be needed, even at the most practical level of space management, says George Bowers, a former CIO and a current principal at Baltimore-based Health Care Information Consultants. “We've seen ORs expand tremendously in terms of square footage in the past 20 years,” he says, “and there's more and more equipment being crammed into ORs.”

Providing the various types of surgeons with convenient ways to view and use diagnostic images remains a complicated task because of a variety of workflow and basic physical reasons, he says. Meanwhile, only a small number of hospitals have surrounded surgeons with some of the perioperative and interoperative information systems (for use by nurses, anesthesiologists, and other clinicians) that can further optimize surgical processes, he says.

Arizona, Florida and New York

Despite the manifold challenges, industry-leading hospitals and health systems are automating surgical suites in a variety of ways. For example:

• At the University Medical Center in Tucson, Ariz., IS leaders have deployed PACS capabilities throughout the 355-bed academic medical center's surgical suites, with diagnostic-level workstations in all operating rooms, reports Jeff Schafer, director for diagnostic and therapeutic services for the hospital. Each of UMC-Tucson's 16 ORs has at least two flat-panel monitors, while two ORs, the neurosurgery and orthopedic surgery suites have four.

• At the seven-hospital Florida Hospital organization in Orlando, IS leaders continue to develop image-viewing capabilities in surgery. According to Ed Majors, executive director of imaging and PACS for the organization, most surgeons are now partaking of Web-based digital image viewing in surgery.

• At the 180-bed Mary Imogene Bassett Hospital in Cooperstown, N.Y., the flagship facility for the Bassett Healthcare system, surgeons view PACS images on flat screens atop rolling carts, and can manipulate and use the images themselves, using keyboards equipped with cleanable skins, says Kathy Brooks, administrative director, anesthesia and surgical support systems, for the health system. In addition, Bassett has implemented a wide-ranging perioperative information systems with components for perioperative, interoperative, and post-operative care, and anesthesia management, from Surgical Information Systems (SIS, Alpharetta, Ga.) Using the anesthesia component from SIS, anesthesiologists at Bassett are among the few in the industry currently documenting patient data electronically in real time during surgery.

Interestingly, optimization, at least in the short run, doesn't always mean adhering to a single vendor-source strategy, say IS executives. “We were ready to go to the next generation of PACS and RIS, and we had partnered with Siemens Syngo to do PACS, RIS, and voice integration,” says UMC-Tucson's Schafer, speaking of the Malvern, Pa.-based Siemens Medical Solutions. “But we had some issues, so we decided to upgrade hardware and software with Fuji” (the Stamford, Conn.-based Fujifilm Medical Systems USA). “So we're going to keep Fuji for PACS and go with Siemens for RIS.” The key with both PACS and RIS in the context of the OR, he adds, is that “You've got to keep it pretty simple, because the doctors are demanding.”

Meanwhile, Bassett Healthcare's Brooks says she believes that implementing perioperative systems will be another key to optimizing surgeons' work, as those systems will continue to improve patient flow, OR nurse and anesthesiologist workflow, and overall OR efficiency. “There are a number of hospitals moving ahead right alongside us,” she adds. “I believe that many of the hospitals, particularly academic centers, cutting-edge hospital systems, will be looking in this direction,” and moving forward both on surgery PACS and on perioperative systems at the same time.

So what should CIOs do when they think about what surgeons like Michael Haak want? “I think the biggest thing is just appropriate planning and engagement, as you migrate from a film-based to a digital world,” says Florida Hospital's Majors. “It's a different conversation than everybody was having five years ago, because acceptance of digital images has now taken place. So it's just providing the right tools and environment, along with the existing surgical environment, to really meet their needs, which are diverse across all the different surgical specialties.”

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Takeaways

Experts and those in the trenches say that CIOs should:

• Think strategically about how their OR automation plan fits into their overall strategic IT plan.

• Consider not only surgery PACS, but also other systems that enhance the process of surgery, such as perioperative and interoperative systems, including those that allow OR nurses and anesthesiologists to document patient vital signs and other measures in real time.

• Keep in mind the diversity of needs of different surgeons (cardio-thoracic, orthopedic, neurologic, urologic, etc.), and the different needs based on planned or emergency surgery requirements.

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Healthcare Informatics 2008 November;25(11):43-45