Wrinkles in TimeWords

Wrinkles in Time in the OR:
A Call for Synchronized Clocks



Wrinkles in timekeeping can cost hospitals big bucks. Lawsuits and compliance issues are just two problems stemming from imprecise timestamps—a consequence of nurses, anesthesiologists, and other healthcare providers recording times from unsynchronized clocks.

“I’ve been in many medical institutions where all the clocks are different,” said anesthesiologist Michael Jopling, MD, Chairman of Anesthesiology at Mount Carmel St. Ann's Hospital in Columbus, Ohio, and President of the Society of Technology in Anesthesia (STA). “This is very frustrating. It creates a big problem for record keeping.”

But even synchronization of clocks—including those in computers and physiological monitors, as well as clocks on walls—wouldn’t iron every last wrinkle in the hospital timekeeping dilemma. There’s yet another fold.

This March, thanks to the Energy Policy Act of 2005, Daylight Saving Time (DST) will begin three weeks early—a move meant to reduce energy consumption. Unfortunately, the time change has unintended consequences. Devices with clocks not programmed to make the DST transition could supply incorrect timestamps for weeks.

Now, specialists at Geisinger Medical Center in Danville, Pennsylvania are teaming up to tackle both problems—starting with synchronization. Anesthesiologist Mark Poler, MD, is spearheading the movement. He has been instrumental in encouraging Geisinger to replace independent time pieces with those that are specially synchronized.

The devices, known as Primex radio-synchronized clocks, have base stations that acquire time from Global Positioning System (GPS) satellites in orbit. The base stations are positioned throughout the hospital and use a radio transmission on a licensed frequency to rebroadcast time to clocks equipped with special receivers.

Dr. Poler’s interest in bringing Primex clocks to Geisinger was spurred by troublesome trends he’s noticed in the operating room (OR). “People keep time by their wrist watches,” he said. “Others take times from clocks on the walls that don’t run at the same speed because nobody’s bothered to set them.”

This lack of synchronization means that a patient leaving the OR at 10:12 in the morning could magically arrive in the recovery room at 10:05am—a mysterious step back in time.

To further confuse matters, Dr. Poler explained that computers used to record the duration of medical procedures have clocks in them which may or may not be synchronized to each other either, let alone to clocks on the wall. This is also the case for physiological monitors that measure heart rate and blood pressure and .often do not have network ports or software to facilitate synchronization to a reference standard.

But what really got him thinking about the synchronization problem was a financial concern: the realization risk that Geisinger was overcharging Medicare due to erroneous calculations of elapsed time from unsynchronized clocks.

Determination of elapsed time in the OR affects billing; errors can have major financial consequences. In particular, underestimating time results in less time billed and lost hospital revenue, and overestimating chargeable time is a compliance issue punishable as fraud. All medical institutions walk a fine line between justifying charges based on time of rendered services versus taking great care not to overcharge.
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While reviewing the record books at Geisinger, Dr. Poler observed that certain short procedures occurring over midnight and lasting only 15 minutes were instead logged at 15 45 minutes and 23 hours. This happened because timekeeping operating room management software was unable to handle the transition to a new date at midnight. Subsequently, checks and procedures had to be put in place for the billing process.

Meanwhile, mistakes like these—which are due in part to lack of clock synching—could lead to billing thousands of additional dollars in one hospital.

“When hospitals bill time to Medicare or insurance companies, they do not want to bill for time that didn’t actually occur,” said Dr. Jopling. “This is a compliance issue, and it’s grounds for huge penalties.” Mistakes in timekeeping have lead to thousands of additional dollars being billed in one hospital.


Needless to say, compliance with medical regulations is a critical motivation, which Geisinger has actively pursued, for synchronizing clocks. A second major impetus is avoiding lawsuits.

“It’s interesting—the clock rarely causes problems for the actual patient, but discrepancies in timekeeping can provide a field day for lawyers who misinterpret records,” said Michael O’Reilly, MD, an anesthesiologist at The University of Michigan Health System in Ann Arbor.

Dr. O’Reilly explained that healthcare workers trying to reconstruct an operating room event for the medical record book write a timeline. “When the timeline reflects gaps or inconsistencies,” he said, “people can be sued.”

Random elements in timekeeping can be misconstrued as incompetence on the part of the physician. “If you’re talking about delivering a baby by emergency C-section,” said Dr. Poler, “and the delivery actually happened in 5 minutes, but according to the clocks it was 13, and then the baby isn’t born perfectly, the attorney could say the surgeons were slow and inept.” In fact, the procedure actually happened efficiently and there was nothing the surgeons could have done to make that baby’s outcome good.

Dr. Poler believes the cost of synchronizing clocks at hospitals could be trivial compared to the money hospitals save in lawsuits.

Meanwhile, it’s possible that the money Congress hoped to save in oil consumption by initiating the Energy of Act of 2005 could be paid to technology specialists called to update timekeeping devices, including devices at hospitals.

“The change in the dates for Daylight Saving Time is extremely sticky and has the potential to deliver some of the chaos that was predicted for Y2K,” said Robert Murcek, Director of Network Infrastructure and Support at Geisinger.

Employees unaware of the new legislation might not know the correct weekend to make the time change. In hospitals, this means that lab computers could be updated while OR clocks are forgotten, or vice versa. Time stamps could be misplaced by an hour on blood pressures and heart rates. Billing departments could charge for an extra hour of operating room care. The list goes on and on.

“The real consequence of the time change,” said Dr. Poler, “is that people must be aware that it will occur and that the clocks they have are either going to handle it correctly or not at all—and they probably all won’t do the same thing.” At the last Daylight Saving Time change, most Primex clocks made the expected adjustment. However some did not “fall back,” demonstrating that the system is not foolproof. Dr. Poler said that pairs of analog clocks within a foot of each other have been reported to show a one hour time difference. Meanwhile, digital clocks that lose the synchronization signal at a time change simply start to display dashes.

He is hopeful that the Primex clocks will handle the transition to the early DST, as the clock makers have promised.

Dave Thewlis, Executive Director of Calconnect—an IT consortium of calendaring and scheduling systems, vendors, and customers which is working towards interoperability between different systems—says the time change doesn’t have to be a headache if people prepare.

Most software vendors are publishing notices telling their customers whether or not there’s a problem with their individual programs. “My advice is to check with your software vendor about updates,” said Thewlis. “If an update has to happen, make sure it happens prior to March 11th—the first day of the new Daylight Saving Time. If a program doesn’t need an update, get it in writing. The last thing you’d want to do is have someone say you don’t have anything to worry about when you really do need to update the software, especially in the medical profession.”

Administrators at Geisinger are already checking with software vendors, according to Mr. Murcek, to ensure that applications receive necessary updates.

Meanwhile, all this watching of the clock is a headache for physicians. “We spend a lot of time doing clerical timekeeping work and we want to reduce that,” said Dr. Jopling. “We’d rather be engaged with the patient.”

This may be possible someday. There is talk of employing a tracking device that would instantaneously record everything from when a patient receives a drug to when he enters the recovery room. Until then, though, each tick of the clock must be carefully recorded.

“We’re really coming into a transition period right now,” said Dr. Jopling. “Some hospitals have a computerized, paperless process and others are more paper-based, but as we start to move forward, one thing’s for sure: we need all of our medical devices to be synchronized.”

.MGW.