Perioperative medicine score developed by Kaiser Permanente researchers allows clinicians to schedule longer appointments for specific patients
Kaiser Permanente researchers have developed and implemented an automated tool that can predict the length of time a patient scheduled for surgery will require for a comprehensive preoperative appointment. By blocking out the appropriate amount of time on the doctor’s and patient’s schedules, Kaiser Permanente Northern California (KPNC) is able to provide optimal care to every patient and keep schedules running smoothly, the study’s authors said.
The findings were reported in Anesthesiology.
“Not all patients who are having surgery are the same,” said study co-author Bradley Cohn, MD, an anesthesiologist and the chair of perioperative medicine for KPNC.
“Some are fit, healthy, and active and are having a relatively low-risk surgery,” Cohn explained. “Others may be having a high-risk surgery or have many other medical conditions they are managing. And others are anywhere in between. Our goal was to figure out how you objectively evaluate this huge population of patients, determine which ones are which, and then schedule each patient appropriately.”
A focus on perioperative medicine
About 250,000 surgeries are performed at KPNC each year, and members of the hospital’s multidisciplinary perioperative medicine (POM) team meet with each patient prior to surgery. At that visit, the patient’s medical record is reviewed, and steps are taken to reduce surgical and anesthesia risk.
The new tool, called TimEHR, is embedded in a patient’s electronic health record. It uses information about the type of surgery and its risks as well as the patient’s health history to establish a TimEHR score. The score is used to determine whether a patient’s preoperative appointment should be scheduled for 20, 40, or 60 minutes, and if the appointment can be virtual or should be in-person.
“Our clinicians and teams want to provide the very best care for our patients preparing for surgery,” said senior author Vincent Liu, MD, MSc, a research scientist with the Kaiser Permanente Division of Research (DOR) and chief data officer for The Permanente Medical Group (TPMG). “By using data available within the EHR to determine the length of POM appointments we ensure patients receive personalized care leading up to these procedures.”
Using data to improve care
To develop the TimEHR score, the research team mined information contained in KPNC’s audit log, which automatically records when a nurse, doctor, pharmacist, or other care provider opens and closes a patient’s electronic health record. Federal HIPAA regulations mandate that these time-stamped audit logs be part of any comprehensive electronic health record system used in the U.S.
“This data is a new frontier in health data analysis,” said first author Sidney Le, MD, a DOR research scientist and surgeon with TPMG. “The audit-log data shows the amount of time providers spend in the electronic medical record — such as before, with, or after seeing a patient, checking on a patient’s medications, following up on test results, or reviewing the medical record. We were able to quantify that data and then use it to predict how long patients would need for their preoperative appointment.”
TimEHR was developed on a data set that included 65,800 patients who had presurgical appointments with a POM team within 30 days of an elective surgery. It was validated in a study that included 94 physicians and advanced practitioners. The final model uses 129 of 397 potential patient factors to predict the time needed for a preoperative appointment. The most important factors are age, presence of other health issues, coronary artery disease, heart failure, need for an interpreter, and use of blood thinners. The tool is now used routinely throughout KPNC.
TimEHR improves on a prior tool the team developed called CAST [Comorbidity Assessment and Surgical Triage], which predicts appointment time length based on a patient’s risk of experiencing a complication. The CAST tool was integrated into the EHR in 2021.
“Surgical risk, which we used in CAST, helped us predict appointment time but we realized there were other unique aspects of the patient that contribute to how long an appointment will need to be,” said Cohn. “The new tool takes that into account.”
Cohn said the data they used is similar in some ways to what companies use to determine if their websites or advertisements are reaching the people they want reach. “Websites and marketing people pay a lot of attention to how much time someone spends on a web page and then try to develop ways to keep people on a page longer,” explained Cohn. “What our team did is convert this concept to how much time providers are spending in a patient’s EHR prior to surgery and then use that information to develop better scheduling procedures for our patients and physicians.”
Next, the researchers intend to look for ways to use audit log data to schedule time-specific appointments in other outpatient settings, such as primary care. “The work this team has done is actually very generalizable,” said Cohn. “This study is focused on perioperative medicine, but it’s really about how you right-size clinics and match patients with the right appointment, with the right provider, for the right amount of time.”
The study was funded by the National Institute on Aging, the National Institutes of Health, and The Permanente Medical Group Delivery Science Fellowship Program.
Co-authors include Brian Lawson, PhD, Yun Lu, MD, MPH, and Patricia Kipnis, PhD, from the Division of Research, and Andrea M. Gochi, MD, of the University of California, San Francisco.
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes, and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. KPDOR seeks to understand the determinants of illness and well-being and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 720-plus staff, including 73 research and staff scientists, are working on nearly 630 epidemiological and health services research projects. For more information, visit divisionofresearch.kp.org or follow us @KPDOR
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