April 20, 2009

Dear Colleagues,

I am writing to you today to share my experience with implementing a computerized anesthesia record and my vision of the future use of these systems. In 2004 my colleagues and I were asked to evaluate three computer systems for use in the operating suite. At the time we had no idea how we should evaluate these systems. We couldn’t have a demo model to use for a month. Nobody we knew of was using a computerized anesthesia record. We decided to choose the system that seemed to offer the greatest flexibility in designing the format of the anesthesia record. We thought that the hospital had forgotten about the whole project, as we heard nothing more about the computer for two years. Then in 2006 it was announced to us that our hospital had purchased the Picis system and planned to implement it. Initially, we did what most physicians do. We insisted that the program would distract us from patient care, and was a hazard to patient safety. Group members voiced concerns that erroneous vital sign values would be entered into the record whenever a surgeon leaned on a blood pressure cuff or a pulse oximeter was dislodged. There was fear that the record might demonstrate events that they would rather not see.

Despite these views we decided to move forward with the project with the assurance of the hospital administration that if the computer system proved to be truly detrimental to patient safety or a distraction to our care, it would be abandoned. Over a six month period, I and four other group members constructed the program to fit our practice with the assistance of our hospital IT department and a consultant that had been hired to organize the implementation process. Once the program was ready for implementation, I conducted a two month trial that I charted on both paper and on the computer. This was a very difficult period, but it allowed us to improve many aspects of the program making it faster and easier to use prior to rolling it out to the entire group. Once I felt that the program was working efficiently, we held two classes to show all of our group members the work flow pattern that seemed to work most efficiently for using the program as we had designed it. We allowed everyone to experiment with using the program over the next month and then chose a day to have everyone move away from the paper record to using only the computer.

We are now entering our third year of using only computerized anesthesia records. Despite many of our group members’ initial reluctance to use the computerized record, none of my colleagues would want to return to a paper record. We now realize many benefits to computerized anesthesia charting including:

1. The ability to quickly look up a patient’s previous airway management without sifting through disorganized paper charts. This is especially useful for patients who have difficult airways. The ability to copy forward portions of the patient’s previous preop record saves a great deal of time and man-hours by eliminating redundancy.
2. The ability to provide our quality assurance department with data on many parameters that are required by SCIP such as time from antibiotic dose to incision, documentation of appropriate sterile technique, use of beta-blocker, insulin use and glucose levels, use of intraop warming devices. This data can be used to justify improved contract rates for insurers that are willing to compensate for proof of improved quality of care.
3. The ability to document multiple data pieces simultaneously that would be near impossible to manually record…. continuous cardiac output, SVR, entropy values, cerebral oximetry values. This allows one to spend more time analyzing and acting on the data gathered rather than wasting time recording it. Providing anesthesia has moved from being analogous to flying a plane to flying the space shuttle.
4. The ability to quickly gather anesthesia utilization data that can be used to support stipend requests in the case of under utilized FTEs or used to justify the addition of additional manpower in the case of a high level of utilization.
5. The ability to completely eliminate paper from the OR suite including the use of the program to document patient follow-up notes for those discharged with continuous nerve block catheters. We have also transitioned to using the program to document PACU orders.
6. The program also enables my colleagues to track the progress of cases and determine who should be assigned add-on cases without making multiple telephone calls or pages thus reducing the work load and distractions for the OR coordinator.
7. We are able to review PACU records from the OR while anesthetizing subsequent patients. We can respond to PACU nurse problems with visual access to pertinent information on the patient in the PACU.
8. We have multiple clinically relevant emergency protocols such as the “lipid rescue protocol,” the malignant hyperthermia management protocol, insulin infusion protocols, CMS guidelines on antibiotic use, standards for regional anesthesia in the face of anticoagulation, and standardized TEE documentation protocols. These protocols are all immediately available in our add-in folders.
9. We have the ability to review the next patient’s medical history from PACU manager while working on the previous case. The preop nurses’ contribution to a common preop record eliminates redundancy and allows for faster turn over times.
10. The computerized anesthesia record provides a legible complete record of the entire case that would be far easier to defend in court than the majority of written records that I have audited. We tend not to correct or modify any of the data in the record and only occasionally provide a memo to explain aberrant BP, HR or SpO2 values as we feel that trends rather than isolated values are significant. An unaltered electronic record is much more defensible in the event of a poor outcome.

While we initially went through a 3-6 month period that some would argue made them focus more on charting than they were accustomed to doing, we now spend far less time than we used to with a written chart, and the final record is far more complete than a written record. We no longer print any of the records. There remain many challenges to fully capturing the capabilities of a computerized record. In cooperation with Anesthesia Business Consultants our next advance will be to implement a computer generated anesthesia bill directly from the data from our Picis anesthesia record. ABC’s F1RSTAnesthesia technology is Oracle- based and can thus integrate seamlessly with most electronic anesthesia records including Picis. This transition to computerized billing will result in immediate processing of the patient’s charges and will eliminate the need for a courier or data entry personnel to duplicate information that has already been recorded in the anesthesia record. The anesthesia record data will be mapped to the appropriate location on the computerized bill, and the data transmitted nightly to ABC. The computerized bill can be checked for accuracy to ensure that the anesthesiologist has chosen the correct ASA billing code. The billing journal can be made available to the anesthesiologist via web access to verify ABC’s receipt of the billing data and its completeness. Any changes that need to be made (for instance missing A-line or CVP) could be emailed to ABC for correction. Eliminating the courier service and the automated completion of a standardized insurance or Medicare claim directly from data entered on the anesthesia record should save significant processing manpower and time which should reduce a groups aged accounts receivable and save on the costs of processing these claims. The use of email to clarify non-computer anesthesia billing claims already significantly reduces processing time. It currently takes about a month to six weeks to verify charges and make sure there are no cases that are missing. The computerized process will ensure that no cases are missing and will likely significantly improve our cash flow and the time to from surgery to bill submission. We will no longer need to carry around envelopes of patient charges that are often misplaced and inconsistently submitted. This can be a major source of lost revenue in academic programs that may be counting on someone whose salary is not tied to their submission of billing claims. In a busy private practice group the rapid turnover times and movement from room to room can contribute to missing claims and lost revenue that the computerized billing system will capture.

A remaining area of improvement would include the use of patient web access to initiate their preoperative anesthesia record. Many outpatients could easily enter their own medications, prior surgical procedures, and run through a simple review of systems that could reduce the man-hours needed to prescreen patients. Dr. Peng and I have experimented with use of web access with our patient site www.AnesthesiaRisk.net. If the patient’s anesthesiologist were able to have web access to the patients prior anesthesia records and their partially (self-)completed preop record even more time could be saved preparing patients for surgery and the anesthesiologist could better plan his or her anesthetic technique in advance of meeting the patient. Invasive monitoring and needs for fiber optic intubation could be anticipated in advance. We currently are able to access much of this information from home using Citrix Metaframe Secure Access Manager and our hospitals Meditech system. The Picis preop manager should be similarly accessible. In addition if the surgeons’ offices had web access to the OR scheduling system, they could better utilize their time, and hospitals might be better able to fill their schedules in a more compressed efficient manner. Better utilization of the OR schedules will reduce evening add-ons when the hospital staff is being paid time and a half. Improvements in computerized medical records will result in marked savings in time and money.

Thank you for the opportunity to share my experience and views with you,

Sincerely,
John MacCarthy, MD
St. Jude Medical Center
Fullerton, California

Thank you, Dr. MacCarthy, for allowing us to publish your “Dear Colleague” letter – and for describing how you are working with ABC on implementing a computer generated anesthesia bill directly from the data in your anesthesia record.

Your description of your group’s initial qualms about computerized anesthesia records will resonate with many anesthesiologists. We hope that the significant and practical benefits, along with the potential of anesthesia information management systems, will become equally well recognized.

Sincerely,

Tony Mira
President and CEO