When Dr. Isaias Irgau and Kemal Erkan purchased a failing ambulatory surgery center in 2014 and turned it into the American Surgery Center, they inherited the problems and inefficiencies that came with the old center’s business practices. These included a medical record system that still was 100% pen and paper. Patients’ charts and medical histories were collated in manila folders and stored in filing cabinets.
The two men made it a priority to seek out a viable electronic health records system – though not because the old system couldn’t work. A small to midsize ambulatory surgery center could survive on such a system for years.
The workload wasn’t so large that tracking patient history and taking dictation was untenable. But such a system was at odds with the cofounders’ vision for the ASC because, they felt, it would certainly impede success and profitability.
“From a pure business perspective, such an antiquated system is too cumbersome and inefficient to compete with larger hospital systems, and I want to be clear here: Ambulatory surgery centers are in direct competition with hospitals, and therefore need to keep pace in both the technology in the center and the talent and effectiveness of the staff,” said Erkan, chairman of the board at American Surgery Center and United Medical ACO and CEO of United Medical.
“But more importantly, we needed to upgrade to an EHR for the comfort and ease of surgeons as well as our support staff,” he continued. “After all, surgeons are used to EHRs from both their private practices and any work they do in a hospital environment.”
Forcing surgeons to revert to a paper-and-pen recording system – what Erkan jokingly refers to as stepping back into 1967 – creates a massive disconnect with how they want and expect to do their job, he added.
“My goal as an owner of an ambulatory surgery center is to make that center the most desirable place for surgeons to want to perform their surgeries,” he explained. “Surgeons don’t want to travel back in time and be forced to use poorly functioning, unintegrated systems of patient tracking.
“We wanted to create a heaven for our surgeons and nursing staff, because doing so creates a heaven for patients, and having satisfied patients is the key to a successful ambulatory surgery center,” he said.
With implementing an EHR a priority, Erkan immediately started shopping around for software. He quickly learned that, at the time, there were no systems that matched American Surgery Center’s needs.
Several systems existed that worked well for doctors’ private practices, but those didn’t have all the capabilities and recording metrics a surgery center needed, he recalled. A variety of platforms met the needs of large hospital systems, but they were overloaded with functionality the center did not need, and they were much too expensive to be viable.
“It looks expensive on paper, but the value to efficiency and effectiveness of the entire surgery center’s workflow is worth the cost many times over.”
Kemal Erkan, American Surgery Center and United Medical
“No one was catering to small-to-midsized surgery centers like us, which I think is the reason why so many surgery centers have yet to upgrade to EHRs,” he observed. “Likely they were told, ‘You’re just too small,’ in the past, just as we were when I started the process.
“Fortunately for us, my existing working relationship with Cerner through my other company, United Medical, gave us an edge, and Cerner stepped up to tackle the problem rather than simply turn me away,” he continued.
“They already had software for both large hospitals and small practices. Upon seeing this gap in the market, they offered to work with Dr. Irgau and myself to create a platform that would work for American Surgery Center.”
For Cerner, this didn’t mean simply scaling one of their other platforms and shoehorning it into the center. The center needed something that felt organic to the surgery center environment, not something simply jury-rigged to partially fill needs.
“Cerner put their best team on the project and had several engineers come out to shadow the Christiana Institute of Advanced Surgery surgeons for several days to fully grasp our workflow,” Erkan explained. “Dr. Irgau is exceptionally knowledgeable about both the private practice software and the hospital software, and he was able to help the Cerner team understand how our needs differed from private practice and hospitals, alike.
“In the end, Cerner was able to develop a system that precisely met our needs,” he continued. “We didn’t help Cerner create a software platform specific to American Surgery Center. We worked with them to create a system that would meet the needs of other surgery centers that had yet to upgrade to an EHR.”
There is a wide variety of electronic health record vendors on the market today, including Allscripts, athenahealth, Cerner, eClinicalWorks, Epic, Greenway Health, Medicomp Systems, Meditech, Medsphere Systems and NextGen Healthcare.
MEETING THE CHALLENGE
Everyone in the American Surgery Center has access to the Cerner EHR in order to process and monitor a patient on the day of their surgery. The software manages the flow of a patient through the six stages of a surgical procedure: arrival, check-in, pre-op, intra-op, post-op, and discharge and departure.
“This is vital because patients are not alone when they come to the surgery center,” Erkan said. “Progress needs to be communicated with families and caregivers. And the surgery center itself has a variety of departments and staff, all of whom need to be able to ‘see’ what stage the patient is in at any given time through the various tracking boards in the system.
“This information cannot be accurately tracked and easily accessed using a paper-and-pen system,” he continued. “Much like it’s difficult to imagine what life was like before cell phones became so commonplace, I have difficulty conceptualizing how a surgery center could have operated without the precise and constant tracking on a system like Cerner’s.”
The EHR also stores all of the patient’s data in one location. Because the CHRIAS surgeons who operate in the center also use Cerner software as part of their contract with United Medical, patient records are seamlessly integrated and updated in real time, so that the private practice and the ambulatory surgery center always have the most up-to-date information.
“Although the Cerner system works best if all aspects of the patient’s care is monitored by the various Cerner software platforms, from the private practice to the surgical center, to the billing process, that’s not a requirement,” Erkan explained. “The platform can import EHRs from other software providers and export out to a format that can be used by other platforms.”
The first metric, and one of the most important when evaluating the return on investment of such a comprehensive overhaul, is money, Erkan said.
“We saw an improvement to our cash right from implementation of the Cerner software,” he reported. “This improvement was driven by improved revenue recognition and automated billing processes, which amounts to an overall increased cash collection of 12% per month.
“Another way the Cerner software saves us money is with automated inventory tracking,” he continued. “Prior to implementation, inventory was tracked by hand, and then entered into a custom inventory-tracking database so we could run reports on the numbers. Errors in tracking could be made in any number of steps using that system.”
The Cerner inventory management module tracks inventory in real time, removing risk of error, he added. The entire inventory is scanned in and monitored by the software so staff always know exactly what they have on hand. All supplies are scanned when used during procedures, making recordkeeping simple, inefficient and accurate, he said.
Then there is the precise data for making business decisions. The Cerner system tracks a variety of standard operating procedures digitally, which allows American Surgery Center staff to not only examine processes for any inefficiencies that it can improve on, but also use accurate data when making business decisions.
“For example, we now had precise data on the length of time patients were in surgery for a procedure,” Erkan reported. “All procedures of a particular type are allotted the same amount of time, and there’s an expectation for procedures to go over that.
“When we were tracking procedures by hand, procedures seemed to be going over by the allotted time by 35.8%,” he continued. “When the Cerner software was implemented, and we began tracking all aspects of patient care, this number dropped to 26.5%. We attribute this improvement to the Cerner software optimizing certain inefficiencies and to the system removing human error.”
Staff members know that when some of their nurse circulators would record time by hand, they did so haphazardly, sometimes noting procedure times after the procedure was over, going on what they remembered the times being. That kind of reporting cannot be accurate.
“Now that our process is automated – every piece of equipment used during a procedure is scanned at the time of use and then logged in the system – we know our records are precise,” Erkan said. “And we can make better business decisions around scheduling, and we can decrease patient and surgeon wait times.
“Having quality data like this allows us to maximize our daily caseload, as well as improve the overall experience for our patients.”
On another results front is improving surgery center efficiency. Doctors are infamous for running behind schedule. Everyone has had experiences of sitting in waiting rooms well beyond their scheduled appointment time.
“It’s annoying, to say the least, from the patient’s perspective,” Erkan said. “From the perspective of the surgery center, these delays are costly. They often start early, and then continue to compound through the day.
“It’s imperative for ambulatory surgery centers to pursue methods to narrow the gap between scheduled and actual procedure duration,” he continued. “The Cerner software helps optimize our efficiency to help keep our caseload on track and in alignment with the day’s schedule. For a procedure to be completed in the scheduled time, it has to start on time. One late start can cause upheaval for the entire schedule.”
In the first six months after the system was implemented, American Surgery Center data showed that 69% of the first cases of the day started on time; however, when cases started late, it was 45 minutes on average after the scheduled start time.
“As the staff adjusted to the system. The natural efficiencies the software provided were realized,” Erkan said. “We’re not tracking a 72% first-case-on-time start rate, which might not seem much better, but the average start time is down to only 15 minutes after the scheduled start, which is a significant improvement.”
ADVICE FOR OTHERS
Erkan’s advice to any small to midsize surgery centers is to upgrade to an EHR.
“It looks expensive on paper, but the value to efficiency and effectiveness of the entire surgery center’s workflow is worth the cost many times over,” he stated. “These systems improve not only staff performance, but also patient outcomes, by keeping patients on track and informed about their procedures.
“Bariatric patients in particular have to jump through so many hoops to have their procedures covered by insurance providers, and, by tracking these cases digitally, it’s much easier to keep patients on track and to help them stick with the program through all the rigmarole,” he said.
Therefore, by tracking all metrics in real time, it’s much easier to pull together any necessary reporting.
“Filing for Accreditation Association for Ambulatory Health Care accreditation is a momentous task,” he noted. “During our first filing, we had yet to switch to an EHR, and the entire process was an absolute nightmare.
“We were reliant upon one nurse who had been with the surgery center before we bought it,” he continued. “She was the only one with the experience and institutional knowledge to complete the necessary paperwork, but she was an angry, resentful person who made the entire experience an absolute nightmare for all of us. Our EHR removes that kind of roadblock and makes reporting much quicker and easier.”
But from more than just a business perspective, Erkan urges other ambulatory surgery centers to update and upgrade their systems to bolster the entire field.
“Ambulatory surgery centers help reduce healthcare costs and improve patient outcomes by competing with larger hospital systems,” he said. “And one thing the pandemic highlighted was that we’re too reliant on large, centralized healthcare providers, which can quickly get overrun and become hotbeds of sickness.
“But these centers are only able to compete if their technology and workflow processes stay abreast of hospital systems,” he concluded. “Upgrading and improving your technology doesn’t just help your surgical center. It improves the entire ambulatory surgery center field.”