The ABCs of EMRs: Anesthesia in the Electronic Age
Summary
Increasingly, anesthesia practices are migrating from hard-copy anesthesia records to their electronic counterpart, i.e., EMRs. There are advantages and disadvantages to these systems. This article explores what groups can expect to encounter when moving to an electronic anesthesia record and how to ensure that the EMR appropriately captures all the data required for accurate claim submission.
I can remember when important documents were kept in a paper folder and stuck in a metal file cabinet. Those were the "good old days" when you had to keep folded maps in your glove compartment in order to navigate from state to state, and emergency communication from the road meant heading to the nearest gas station phone booth. My, how times have changed. Yes, in many ways, for the better. Convenience, immediacy, efficiency—that's what the digital age has brought us! It is no surprise, then, to see that companies, organizations and institutions have widely adopted the use of electronic data storage and transmission capabilities. That includes hospitals.
A Not-So-Subtle Suggestion
Over the last 20 years, we have seen a growing emphasis—spurred by both public and private interests—to move to a paperless environment in the healthcare space. The federal government, via HIPAA and other rules, has encouraged widespread adoption of electronic medical records (EMRs) by hospitals and other health-related entities. Their rationale for this agenda is two-fold: to facilitate more complete and accurate patient information, and to ensure the information is more readily available to other providers—especially in urgent or emergent circumstances.
Accordingly, the Centers for Medicare and Medicaid Services (CMS) over the last several years began adding its own "gentle persuasion" in this regard by implementing the "meaningful use" payment penalties for certain providers who abstain from "acceptable" EMR usage.
The Pros and Cons
Of course, the government has given several reasons for the priority it places on transitioning from paper records to electronic records. One government website actually lists the advantages of EMR use, which—in addition to the ones mentioned above—include the following:
- Securely sharing electronic information
- Enabling safer, more reliable prescribing
- Helping promote legible documentation
- Enhancing privacy and security of patient data
- Helping providers improve productivity and work-life balance
- Enabling providers to improve efficiency and meet their business goals
- Reducing costs through decreased paperwork and reduced duplication
These benefits do have a risk that needs to be appreciated by the facilities and providers. Some systems have been rushed to market without the appropriate levels of security and infrastructure, which can lead to major issues. A fractured market and failure to align goals of all the stakeholders can bring issues to bear on all involved. Steven J. Stack, MD, president of the American Medical Association, told WBUR in Boston:
"Imagine, in a world where a 2-year-old can operate an iPhone, you have graduate-educated physicians brought to their knees by electronic health records. When you have more than a quarter million physicians being penalized by the government, by a single program, I think that most people will understand the math. It's not the 250,000-plus physicians that are the problem, it's most likely the single program they're being punished by."
One of the keys to success with an EMR is an understanding of the specialties and technologies together. This alignment allows for a smooth transition and where a true partner is critical.
The Secret of Our Success
The MiraMed family of companies has been helping anesthesia groups make the move from paper records to EMRs for nearly two decades. We have a wealth of experience and protocols that typically facilitate a seamless and relatively painless transition. We understand the strengths and weaknesses of the various EMR systems that are prevalent within the market today, and we know how to take their general template programming and customize it so that it more effectively captures the data points required for anesthesia coding and billing.
If you are in a facility that has decided to install an EMR for the first time or is preparing to add an anesthesia module to their existing EMR, we encourage you to contact us so that we can help in the configuration of the system in that location. Each situation is different. In most, however, we are able to work with your group, hospital and EMR representatives to provide education as to what will be required from an anesthesia billing perspective. Since certain fields or functionalities may not be initially present within the system, we will provide a list of data point requirements. We will then follow up with multiple conference calls and template reviews throughout the transition process to ensure the system will function optimally with anesthesia in mind.
Who You Gonna Call?
No EMR system is perfect when it comes out of the box into a facility. There will be missing fields or premature case closings or an inability to attach associated records (e.g., pain note) or a myriad of other functionality misfires. The question is, when you find that you have these "ghosts in the machine," where can you turn to obtain some type of assistance, guidance or expertise? We have an entire department dedicated specifically to helping our clients with the EMR transition process. All you have to do is call!