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Getting the HIM perspective on OpNote

This survey has been authorized by AHIMA but does not reflect a product endorsement by AHIMA

OpNote, mTuitive's postoperative reporting software for surgeons, has been released and is being used in several ASC's. Our past surveys focused on ease of use, efficiency and content for the surgeon. These efforts have proven extremely beneficial. We have yet to show the software to a surgeon who does not agree that OpNote is a more efficient reporting method than dictation. Their responses typically fall into one of two categories. "Dictation-transcription is an outdated methodology that adds no value" or "I realize that I am going to have to adopt an electronic system; this is the easiest and most comprehensive product I have seen." Our challenge has been to gain the attention of HIM managers who control the transcription budget. We are now reaching out to HIM professionals to gain their perspective and build the business case. If you are unfamiliar with the design of OpNote, please follow the link below for an example of a completed report. OpNote's goals are to make better use of transcription resources, streamline the reporting process and capture discrete data for use in disease registries, outcomes analysis and quality reporting initiatives. Here is an example of a report generated by OpNote. Thank you.
100%
1.Which answer best describes the facility where you work?
2.Type of Facility: What is the approximate volume of surgeries performed at your facility annually?
3.Of the following methods used to create an report, can you estimate percentage used at your facility?
4.OpNote is a synoptic or structured reporting system. Specific questions and answers are provided to yield discrete data for use in analysis, research and performance measurement (think of cancer registries and pathology checklists). In addition to elimination of transcription, OpNote hopes to provide improved documentation for coding, compliance, quality measures and risk management. The following questions pertain to these goals.
Yes
No
Maybe
OpNote guides the surgeon through the selection of the appropriate procedure(s) and diagnoses. ICD and CPT coding is assigned as a byproduct to ensure proper billing for the professional component. Would this help the coding process for your facility component?
Specific questions and answers can be required. Will this improve content for documentation, compliance or risk management purposes?
Do you understand the difference between discrete (structured data) and free text (unstructured data) and its use is data analysis?
Does your facility allow the use of defaulted reports?
Are you ever asked to abstract or search for data for outcomes analysis or quality measures?
Does your facility use speech recognition for dictation (anywhere)?
Do you ever outsource transcription?
Could savings on transcription be used for other functions?
Is the revenue cycle ever delayed by backlogged transcription?
Is the revenue cycle ever delayed by unsigned surgical reports?
5.What is your opinion?
Yes
No
No opinion or equal
Do you expect your budget to increase (over the normal cost of living) next year?
Do you consider yourself an early adopter of technology or business solutions?
Do you consider your facilty to be an early adopter?
Do you know if your surgeons' (professional component) coding and billing is consistent with your facility's?
Do you consider transcription to be a value added service?
Is abstraction a value added service.
Is the quality of data analysis more important than quality of data capture?
6.Which departments would be most interested in the following benefits? You may select more than one.
Rev. Cycle/ Finance
Surgery
HIM (Med.Rec.)
Qual. Mgt.
Compliance/ legal
Transcription cost savings
Consistent coding between surgeon and facility
Collection of quality data statistics
Report turn around time
Outcomes analysis
Performance measures
Revenue cycle acceleration
Required documentation for risk management
Surgical accreditation programs
7.Which of the following people or departments would be involved in the evaluation/ approval process at your facility?
Decision Maker
Evaluator/Influencer
Not Involved
HIM Director (medical records director)
Revenue Cycle Manager
Surgical Services Manager
CIO or IT management
CFO or Finance department
Quality Assurance Director
Compliance Officer or Risk Manager
Executive management (CEO, COO, Chief of Staff)
Chief of Surgery
Surgical staff (surgeons)
8.The following questions refer to an expanding Medicare review program known as RAC (Recovery Audit Contractor).
Yes
No
N/A
Prior to reading this, had you ever heard of RAC?
Did you know that Medicare intermediaries (MACs) as well as the RACs are now checking for consistency in coding between the facility and the surgeon?
Has anyone ever checked to see if your professional component billing is consistent with the hospital or surgicenter coding?
Have any of your facilities been audited by RACs?
9.How often do the following events ever happen at your facilities?
Never
Seldom
Occasionally
Frequently
Surgeons are requested to provide improved documentation to justify the level of care and/or reimbursement
Medical staff (particularly surgeons) are threatened with suspension of privileges due to incomplete or unsigned medical records
Surgeons are asked to provide data for quality indicators or pay for performance measures
10.The following questions relate to your facility and surgical staff.
Yes
No
Not sure/ no opinion
Does your facility have a similar reporting product already?
Do you believe a majority of your surgeons would use a product like OpNote?
Would surgeons prefer to use a touch screen (like a kiosk) for data entry?
Would they want speech recognition?
Working on an iPad or similar device a good idea?
Do you believe a single operative report to combine the circulating nurse's notes with the surgeon's is good idea?
Do you know of legal or compliance reasons why the reports have to be separate?
11.If you would like a copy of the survey results, please provide your email address.
If you would like to use the OpNote Savings Calculator to estimate the savings for your facility, go to the following link: mTuitive ROI Calculator