The emergency department (ED) is live on HealthPort electronic document management system (EDMS) from SDS (formerly Smart Document Solutions) and now it's time to move to the next step of our phase one implementation: same-day surgery. As the title eludes, this department presented a whole new set of opportunities for me and my staff.

Dear Diary,

At one time or another, everyone feels like they're glimpsing another world for the first time. For some, it happened in a childhood move, facing a new classroom, playground and teacher. Others feel it when stepping off a plane in a foreign country. As professionals, we sometimes feel it when we begin a new job or even transfer to a new department. 

Last month, I talked about our success in the ED. Just 2 months after going live in the ED, we went live in the operating room (OR) for same-day surgery records. As with any incremental implementation, we borrowed from "lessons learned" in the ED. We quickly learned, though, that the OR is a completely new world. A few idiosyncrasies of the same-day surgery project, from planning to implementation, are definitely worth noting:

 Details, details and more details

Records for same-day surgery are more complex and therefore had to be indexed at a much more detailed level. Consequently, the planning and analysis phase was more intensive. Our indexing enabled clinicians and staff to go straight to the consent, history and physical, surgery chart or other key data - whatever they needed right then. In the long run, this extra up-front work saves time for everyone.

 As they say in real estate, location is everything

Generally speaking, HIM staffers aren't usually in the OR, unless we're having our tonsils removed. It's not as widely trafficked as the emergency department due to the sterile, more private environment. As a result, we weren't sure where to put PCs for HealthPort EDMS access. We didn't intuitively know the OR's workflow or how surgeons, anesthesiologists, nurses and staff used technology to manage and facilitate tasks. This situation called for more consulting and collaboration with key members of the OR team to ensure the new system was convenient and accessible to everyone who needed it.

 Cheerleaders - they're not just for football anymore

I mentioned during our ED implementation that the HIM staff was available "on demand" for training; we literally roamed the ED during the first few weeks helping physicians and nurses during the adoption phase. For obvious reasons, this wasn't as practical in the OR, but it was just as important. We asked the OR team to call our office when they needed help and would pay a visit to the OR and gown up if needed. Because the OR environment was so different, however, our project champions, or "cheerleaders," were an absolute necessity. Our cheerleaders were comfortable with technology, understood the many benefits of EDMS and most importantly, knew and lived in the OR environment. They were the key to our fast adoption and success, and the HIM department is thankful for their support!

Despite the fact that the OR truly is a different world than the ED, we had a successful and fast implementation. We planned for the differences, and we engaged the department as much as we could, with their busy schedule.

Next month we will begin our biggest step yet - planning for an inpatient record implementation. As HIM professionals, we spend every day working with inpatient records. But I'm sure the move from paper-based to electronic inpatient records will be a completely new world for me and my department. 

Traci Waugh is director of health information and compliance at North Valley Hospital, Whitefish, MT, and a client of SDS.