Anesthesia Quality Databases

Jody Locke, CPC
Vice President of Anesthesia and Pain Management Services, ABC

The focus on quality outcomes in healthcare has been long in coming. As the cost of health care continues to rise faster than the cost of living, the nation finds itself facing a dilemma. Perhaps a free market approach to healthcare is not the best approach after all. Economic incentives and ground breaking research have clearly provided significant advances in some areas, but what has been their impact on cost? As diverse and independent as the specialty of anesthesiology is, its practitioners have challenged the leadership to take the lead in finding ways to provide quality care more consistently so that anesthesia is not a contributor to the cost of healthcare but a regulator of spending.

While virtually all anesthesiologists and CRNAs have now become familiar with the current requirements of the Physician Quality Reporting System (PQRS), this is just one example of a public approach to ensuring consistency based on process rather than outcomes. As a rule, anesthesia practices have access to more and better data about what actually happens in operating rooms and delivery suites than any other single agent or source in a hospital. Deciding how to mine it from an outcomes perspective and how to apply the lessons learned is the question of the day. While the discussion may appear arcane and abstract to practitioners in the field, the fact is, the stakes are significant. For many, what is at stake is the independence and autonomy of the specialty: better to set standards for ourselves than to have them defined by others.

While CMS took the lead in capturing some rudimentary quality indicators, the Medicare requirement to report the pre-surgical administration of prophylactic antibiotics, active temperature management and the use of sterile techniques for placement of central venous catheters actually just represents the most obvious manifestation of what is becoming a proliferation of private quality initiatives. The process really started to take shape with the activities of the anesthesia subspecialties. The best known of these was undertaken by the Society for Ambulatory Anesthesia (SAMBA) which has been working on a list of clinical indicators and an outcomes database for many years now. The SAMBA Clinical Outcomes Registry (SCOR) currently includes indicators for about 10,000 patients. While other subspecialty societies are also focused on the formulation of a list of indicators and a database specifically relevant to their areas of focus, two organizations have taken the lead in the development of a national, specialty-wide approach to quality and outcomes data capture.

• The Anesthesia Business Group (ABG) represents 12 of the nation’s largest private anesthesia groups, which have been meeting four times a year to address issues of interest and special concern to the nation’s largest anesthesia practices, the so-called mega groups such as North American Partners in Anesthesia (NAPA) and Greater Houston Anesthesiology (GHA). Their membership is geographically diverse and especially significant with regard to volume of cases performed and variety of venues served. In 2002 the ABG established the ABG Anesthesia Data Safety Group, LLC (ADSG), which was intended to provide a vehicle and support for its efforts to capture clinical outcomes data from its member groups. As of June 2011 the participants had collected over 2 million clinical records and corresponding administrative data. Information about the Anesthesia Business group and its activities can be obtained via its website at www. Anesthesiabusinessgroup.com.
• The other organization that is forging a path in this arena is the American Society of Anesthesiologists (ASA). As the national specialty organization for anesthesiologists, the ASA brings its own clout and credibility to the challenges of defining a meaningful list of clinical indicators and capturing member data. The ASA’s quality Institute (AQI) efforts are being led by Richard P. Dutton, M.D. M.B.A. who is responsible for the development of the National Anesthesia Clinical Outcomes Registry (NACOR). The stated goals of the registry and its database are specifically relevant to all the strategic challenges facing today’s anesthesia practices: personal benchmarking, quality reporting, hospital credentialing, maintenance of licensure, maintenance of certification and clinical research. Dr. Dutton has written several articles for previous issues of the Communique (most recently, the Summer 2012 issue) describing AQI,NACOR and AIRS (Anesthesia Incident Reporting System) developments. While the data base is still in a state of evolution, subscription is growing, as is the number of ABC client practices that are participating.Questions about the AQI can be addressed via its website at www.aqihq.org.

Having access to data, however, is a mixed blessing; the opportunity to mine all the demographic and physiological data about all the surgeries that are performed in the country is huge but so are the challenges; the diversity of forms and systems is almost unfathomable. What to extract, how to validate it and where to store it and how to package the results so that the specialty can continue to improvequality, consistency and surgical outcomes requires focus, commitment, and leadership. Historically anesthesia practice management has tended to focus more on revenue opportunities and compliance risk reduction rather than cost savings; and so this new focus on outcomes requires some serious rethinking of budgetary priorities. The return on investment is not quite so clear or compelling, but as recent developments continue to highlight, no less necessary. The immediate focus of CMS policy is the automation of clinical record keeping and meaningful use but this is not just a governmental initiative. Defining pay for performance criteria is clearly the issue of the day.

In the meantime, both the ASA and the ABG are inviting all anesthesia practices to support their efforts by contributing data. Which is the best vehicle, given the ultimate objective of being able to bench mark practices and identify common risks and challenges? It probably does not matter (except for ABC clients, for whom arranging to participate in AQI-NACOR involves no changes in the data or formats sent to us). Since the objectives of both organizations are the same it would appear inevitable that they will come together and work in a unified or, at least, a coordinated manner.

Security and the integrity of clinical details is an issue, to be sure. If a practice shares information about reportable events and these are shown to be outliers what might the consequences be? Attachments are a serious issue. No alternative is without some risk. This is why the ABG and the ASA made it such a priority to be certified by the Anesthesia Patient Safety Foundation but this is only the beginning. As the development of national anesthesia quality databases progresses, special attention will have to be given to ensuring the protection and privacy of each practice’s contributions. Important precedents were established with the implementation of the Health Insurance Portability and Protection Act (HIPPA) in 1996 for the protection of individually identifiable health care information. If the intent of quality indicators is to identify and prosecute individual providers is will never succeed. The goal must be a feedback loop of quality trends for the advancement of all.

Self-reporting is another challenge. What is to motivate providers to report honestly? Legal precedent has been so punitive in this area. This is where the leadership of the practice must take a stand and reframe the issues. Anesthesiology has a long history of independence and autonomy. Its practitioners believe that the consistent quality of care they provide is a function of good training, timely and reliable monitoring data and the sound judgment that comes from years of practical experience. Why should they think more data or other people’s input would make it better? While not wrong, there is one piece most providers don’t consider and that is how the customer views the services they provide. The time has come to demonstrate just why and how anesthesia morbidity and mortality have fallen so dramatically in the past few decades.

The database will eventually contain both basic demographic data about the population of patients who undergo anesthesia across the country and the kinds of complications they may experience under anesthesia. Participation does not require the practice to have an Anesthesia Information Management System (AIMS). Encouraging participation has become a priority of the ASA, which has supported its development.

The ABG began collecting data from its member groups but is now encouraging other non-member practices to contribute. Like the AQI, it has paid staff who are dedicated to data evaluation and statistical analysis. The organization has dedicated considerable time and resources to ensuring the accuracy and reliability of all its data elements.

Recognizing that quality reporting is the next wave of anesthesia practice management all of the nation’s billing companies are looking at ways to serve as a vehicle for their clients to participate. ABC has made this a special priority. Ultimately, the nation’s billing industry will no doubt play an invaluable role in resolving many of the technical and logistical questions that practices will have about what data elements to track and how to capture them. These efforts will give all practices that outsource their billing a tactical advantage with regard to these national clinical initiatives but it is certainly not to say that those which chose to do their billing themselves cannot find other ways to participate.

In other words, concerns about how to capture data can be readily addressed by a variety of options currently available to all groups. The real question each practice must come to terms with is their appreciation of what is at stake here. This is one of those longer term strategic questions, the kind that has more to do with how members see the role of their specialty in the future and what they are prepared to do to redefine their practice value proposition.

Change is never easy and the requirement that individual anesthesia providers start sharing more details about the care they provide is being viewed in many quarters with great concern and no small amount of skepticism; the Orwellian overtones of such initiatives can often lead to considerable paranoia, especially among those not willing to change the way they practice. As is so often the case, in anesthesiology the real challenge may have less to do with contributing data and more to do with convincing partners that the business of healthcare really has changed the specialty that much. To those who think effective anesthesia practice management is just about effective billing and accounts receivable management, welcome to a future in which you must be able to sell your services to get paid for your services.

Jody Locke, CPC, serves as Vice President of Pain and Anesthesia Management for ABC. Mr. Locke is responsible for the scope and focus of services provided to ABC’s largest clients. He is also responsible for oversight and management of the company’s pain management billing team. He will be a key executive contact for the group should it enter into a contract for services with ABC. He can be reached at Jody.Locke@AnesthesiaLLC.com.