eAlerts
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Operating Room Utilization Data Management
Jody Locke, CPC
Vice President for Practice Management, ABCThe database of an anesthesia billing system should contain invaluable data with regard to all that takes place in a hospital’s operating rooms and delivery suites. Because there is a charge created for each and every anesthetic, the level of detail captured by an anesthesia department should rival that of the hospital information system itself. While the file layouts of many anesthesia billing systems are defined by the information necessary to generate a claim, we are starting to see the emergence of a new generation of software that seeks to capture not only what will be necessary to get paid for anesthesia but also data that will allow the anesthesia practice not only to manage itself more effectively, but to provide the hospital administration productivity and performance indicators and metrics that underscore the potential role of anesthesia in more effective operating room management.
Despite the potential of an anesthesia practice database to enhance operating room efficiency this aspect of practice management is in its infancy. The most common use of productivity data continues to be the evaluation of potential stipend requirements. Anesthesia practice managers are coming to understand the correlation between operating room utilization and the need for financial support. The financial analysis seeks to assess whether the revenue potential of each location covers the cost of providing the care. Having a reliable handle on the profitability of each location covered has been proven to be a consistently effective means of both justifying stipend requests and encouraging administrators to reconsider adjusting coverage requirements. The key, of course, is the ability to produce and present the data and calculations in a manner that is both clear and compelling.Forward-looking practices also use similar types of productivity metrics to evaluate each line of business on a regular basis. Such forms of analysis provide an important means of assessing the reasonableness of continued coverage. The result of such service-line specific review may result in requests for additional financial support or they may inspire creative thinking about alternative ways of providing coverage more cost effectively. A classic example involves a practice that had believed it was important to tie up every surgery center in town to keep out the competition; once the group assessed its actual yield per location day, however, it quickly realized that a number of the coverage contracts were significantly impacting the compensation of the average shareholder. A careful assessment of the data led to the elimination of some of the less productive contracts and a much more realistic book of business.
Rare is the anesthesia practice that is not challenged by the economics of coverage and reimbursement. The conventional approach to the enhancement of practice profitability tends to focus on revenue enhancement, either through more aggressive contracting or accounts receivable management. The fact is that such efforts have limited ability to resolve significant profitability shortfalls. Typically, the only real solution involves matching staffing to revenue, which may involve adjusting coverage. It is one thing to work on ways on increasing the size of the revenue pie, but if the pie is divided too many ways then none of the slices will support the income expectations of the providers.
The use of productivity data and metrics to assess the profitability of coverage is leading to a view that an even better strategy would be to use the same kinds of information more pro-actively to actually help hospitals and surgi-centers manage rooms more effectively on a prospective basis. This is opening doors of opportunity for anesthesia practices to be seen more as problem-solvers in the tricky business of operating room management. Some practices have been so successful in their education of hospital administration that key stakeholders have come to rely on the anesthesia metrics and scorecards as the most reliable means of measuring operating room efficiency.Key to all of these strategies is the ability to produce normalized productivity metrics by anesthetizing location. The value of being able to drill down to the specific anesthetizing location is becoming increasingly clear. To this end developers of billing software are making the necessary modifications to file layouts. Having the capability to capture such data and actually being able to generate reliable reports on demand, however, are two quite different issues. Not only must forms be designed to encourage the practitioner to indicate where the case was performed, but there must be a clear logic and structure to the labeling. Minor inconsistencies in provider labeling can greatly impact the quality of the information reported. Operating Room #1 must be reported and entered the same way for every case or the performance indicators will not make sense. It does not matter what the labeling convention is, so long as it is consistent.
Once this is accomplished the results can be invaluable. ABC’s F1RSTAnesthesia allows for performance data to be tracked in a variety of ways. Standard performance metrics are a very useful starting point. It is especially useful to be able to track average case production, units billed, hours of anesthesia time and actual collections by operating room. Even more useful is the ability to look at these same metrics by shift or time of day. Perhaps the best mechanism for monitoring utilization is the ability to plot activity by hour of day. Four typical examples of utilization data are included in the tables accompanying this article. These represent actual report data for two ABC clients.
Table 1 presents key performance metrics in summary for calendar 2008. This table allows for the assessment of comparative productivity among locations as compared to standard benchmarks. Most practices try to achieve an average productivity of 50 ASA units per location day, which should be sufficient to cover the cost of coverage given a reasonable payor mix. Ideally, each location should generate at least 7 hours of billable anesthesia time. This is considered a sustainable level of production.
Table 2 compares activity by shift for the same locations. Here the view is historical. Conventional wisdom holds that in an 8 hour shift there should be 6 hours of billable anesthesia time. It is also true that 75-80% of the revenue per anesthetizing location should be generated during the day shift.
Table 3 shows the number of locations in use by hour of the day. Here production data is aggregated and averaged for eight months. Most observers are interested in the point at which the level of activity starts to drop off. This type of graph also allows for the comparison of activity by day of week.
The last chart, Table 4, presents productivity metrics for day shift versus overall productivity over time and allows for the identification of downward trends or seasonal variations in productivity. This type of analysis is especially useful for the assessment of staffing needs and will sometimes be incorporated into a staffing budget.
Anesthesiologists intuitively recognize the value of timely and accurate data in the management of their activities. There is no question that the use of high tech digital monitors has greatly enhanced the quality of care provided in the operating room. There is no reason to believe the same concept will not prove equally as valuable in the management of the operating rooms themselves. Anesthesia providers just need to get over the preconceived notion that they are captive to the system. There is no question that the possession of such data and the ability to use it effectively in the education of the hospital administration represents a new role for many practices. The case for a more active role for anesthesia in the management of operating rooms is being made daily across the country. It will not be a wholesale transformation of the specialty but a gradual evolution from quiet observer to active participant. As in so many things, the best advice is to identify opportunities to demonstrate small examples of process improvement and build on successes one by one.
It is easy to look at these types of charts and graphs and to say, that is interesting but it would not be too useful in my hospital. Such an attitude, however, will inevitably be a self-fulfilling proposition. There is a reason why so many of the largest anesthesia practices are investing in technology and data capture devices to be able to reliably measure and monitor patterns of operating utilization. They have long since learned that having the tools to manage manpower and staffing more effectively is the key to their cost-competitiveness and survival. This may not be the kind of technological application that captures the imagination with its sophistication or innovation but it is clearly one that ensures profitability.While there is no one best way to capture and present operating room utilization data there are clearly systems that are more user-friendly and flexible than others. ABC is especially proud of its F1RSTAnesthesia software and the various ways clients have been able to use its data to manage their practices more effectively and to provide unexpected value added service to their hospitals.
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The Pace Picks Up in the Development of Health Information Technology
ABC is very proud to be the exclusive sponsor of a major new event at the Annual Meeting of the American Society of Anesthesiologists: A Celebration of Advocacy, the opening session of the 2010 meeting which will be held in at the Morial Convention Center in New Orleans, Louisiana from October 17th through October 21st.
One theme common to all the different proposals for healthcare reform in this season of intense advocacy is the need to increase both the capabilities and the installed bases of health information technology. David Blumenthal, MD, MPP, National Coordinator for Health Information Technology in the Department of Health & Human Services recently noted that:
It would be hard for any health professional today to escape the conclusion that the antiquated, paper-dominated system we now have in place isn’t working well for patients, creates added costs and inefficiencies, and isn’t sustainable. As we look at our nation’s annual health care expenditures of approximately $2.5 trillion, there are many ways our current system fails both patients and providers. It is clear that change is necessary.
The need for change from our “antiquated, paper-dominated systems” to powerful and flexible information technology has been clear for quite some time. We generate and depend on a massive amount of information, to which we add more data every day. Managing all the information that we record and using it to its maximum capabilities are major challenges for anesthesiologists and other professionals.
ABC invested in powerful custom-built anesthesia practice management software, F1RSTAnesthesia™, several years ago. This system goes far beyond claims and revenue cycle management, of course. Jody Locke illustrates the use of data on the time and units billed and the actual collections per anesthetizing location, by hour, to analyze utilization and identify opportunities for increases in productivity in his article “Operating Room Utilization Data Management.” While Jody’s graphs and charts come from F1RSTAnesthesia™, which he helped to shape, he acknowledges that “there is no one best way to capture and present operating room utilization data.”
To look at some of the ways in which other developers and organizations manage data, we invited several such developers to describe their systems in this issue of the Communiqué. The digital pen-and-paper method of completing an anesthesia record marketed under the name Shareable Ink Anesthesia Record™ represents brand-new technology about which we are very excited—so much so that we have entered into an exclusive agreement with the company that developed the system under which, for a certain time, we will be the sole anesthesia billing company to sell the digital pen under the F1RSTAnesthesia™ Record.
Several third party systems represented in this issue are already quite familiar to most anesthesiologists. Readers will immediately recognize the name Docusys®. Teecie Covad, VP for Product Management at Docusys, Inc. has written a comprehensive description of the features and benefits of a true AIMS in “The Tipping Point for Anesthesia Information Management Systems.” Picis® Anesthesia Manager is another system used by many anesthesiologists every day. It has a large installed base in hospitals across the country. Dr. Carlos Nunez, Chief Physician Executive for Picis, gives an excellent historical overview of the changing industry needs and adaptations, and the Picis® solution, including a synopsis of the federal Stimulus Package that will reward hospitals for demonstrating the “meaningful use” of information technology starting in 2011.
The nearly $20 billion in Stimulus funds to promote the adoption of electronic health records was one aspect of the American Recovery and Reinvestment Act of 2009 (“ARRA”). Another part of ARRA significantly alters and supplements HIPAA privacy and security provisions. Abby Pendleton, Esq. and Jessica Gustafson, Esq. review the HITECH (Health Information Technology for Economic and Clinical Health Acts) provisions of ARRA pertaining to patients’ privacy rights, breach notification, and the consequences of breaching private information.
ASA has created a new organization, the Anesthesia Quality Institute (AQI), to develop a national data registry for anesthesia. To achieve similar goals of collecting data from multiple operating rooms to support benchmarking and quality improvement initiatives, SouthEast Anesthesiology Consultants of Charlotte, NC, launched its own Quantum Clinical Navigation System™ in the 1990s and reports that Quantum is now installed in 25 hospitals. John Kunysz, Quantum’s chief operating officer, describes the system and its value in his article “The Cost-Cutting Approach to Healthcare Reform.”
Joe Laden, a name very familiar to participants in the MGMA-Anesthesia Administration Assembly (AAA) and other members of the anesthesiology community, has synthesized everything he learned from studying and comparing multiple examples in his write-up entitled “Anesthesiology Practice Web Sites.” His checklists and brief descriptions will be invaluable to readers contemplating creating or expanding their own websites.
Having read of the amazing capabilities of anesthesia information management systems in the first half of this issue, do not miss the wonderful warning “13 Steps to a Disastrous Anesthesia Information System Implementation” by AAA officer and VIP Phil Mesisca.
The changes that have taken place in anesthesia practice since I founded ABC thirty years ago are staggering—and the constants are equally amazing. We are all privileged to work in an area that asks us to learn new technologies and new practices, or at the very least, new approaches, all the time. As with every quarterly issue of the Communiqué, I am most grateful for the willingness of experts like those noted above to share their knowledge with us.
With best wishes,
Tony Mira,
President & CEO -
Is Your Concurrency Software Compliant?
Hal Nelson, CPC
Director of Compliance and Client Services, ABC
As part of our desire to keep both clients and readers up to date, the Communiqué has been printing compliance information since its inception. In the Compliance Corner, we will now formally keep you abreast of the various compliance issues and/or pick out a topic that would be of interest to most of our readers.
Anesthesia groups that practice in a “care team” setting use concurrency software to calculate the maximum number of cases that an anesthesiologist is medically directing at any given time. This software ultimately assigns concurrency modifiers to each claim being billed, thus influencing the expected allowable that an insurance company will pay. The biggest flaw with such concurrency programs is their inability to properly handle intra-operative handoffs, or relief.
For example, Anesthesiologist A begins medically directing a case at 2:00pm. Anesthesiologist B takes over the case at 3:00pm and the case ends at 3:30pm. Unless your concurrency software has the ability to input multiple anesthesiologists with multiple start/stop times on the same case, the software is not giving you accurate data.
From a billing standpoint, relief cases are billed under one anesthesiologist’s name with the total case time. This anesthesiologist’s name billed is typically the physician with the greatest amount of time in the case. However, from a compliance perspective, each physician’s start/stop times need to be analyzed for concurrency in order to properly select the correct medical direction or medical supervision modifier.
In the example given above, Anesthesiologist A may have a maximum concurrency ratio of three CRNA rooms from 2:00-2:59pm. Anesthesiologist B may have a maximum concurrency ratio of five rooms from 3:00-3:30. If the concurrency analysis is run only on Anesthesiologist A from 2:00-3:30pm, the concurrency modifier assigned will be incorrect, which will result in a potential overpayment from the payer, as shown in Figure 1.
In conclusion, intra-operative handoffs should be well documented on the anesthesia record and concurrency should be run on each anesthesiologist’s individual times in order to properly calculate the modifier assigned on the claim form. Since Medicare medical direction (1-4 concurrent CRNA rooms) pays 50% of the allowable to anesthesiologist, while medical supervision (5+ rooms) pays a maximum of only 4 units to the anesthesiologist, it is crucial that your concurrency reports be able to substantiate the modifier billed on each case.
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The Anesthesia Record™ Powered by Shareable Ink®: A Dialogue with the Inventor
Vernon Huang, MD, Founder and Chief Medical Officer of Shareable Ink and inventor of Anesthesia Record™
San Francisco, CAIn this issue, Communiqué interviews Dr. Vernon Huang, Founder and Chief Medical Officer of Shareable Ink and inventor of their Anesthesia Record™ product. The Shareable Ink Anesthesia Record allows immediate capture of information written on paper anesthesia records. Dr. Huang is also a practicing anesthesiologist in the San Francisco Bay Area with an extensive background in medical informatics and technology. Dr. Huang can be reached at vhuang@shareableink.com. ABC will market the product under the name F1rstAnesthesia Record™.
Question: Dr. Huang, what is the Shareable Ink Anesthesia Record?The Shareable Ink Anesthesia Record is a product that enables anesthesiologists and CRNAs to take advantage of the benefits of electronic medical records without disrupting their workflow. Using the system, anesthesia providers fill out a paper form — that is nearly identical to their current anesthesia record — using a “digital” ballpoint pen. Essentially, they chart on a paper anesthesia record just as they have always done.
But now, when they drop off the patient in the PACU, they simply dock their pen in a cradle, and all the information is immediately and securely transmitted to our servers. Then, the Shareable Ink system creates actual computerized data from the pen strokes — capturing times, signatures, diagnoses, procedures, and anything else written on the form. All the information in the pen is encrypted and transmitted to our secure servers where all the computing is done.
The Shareable Ink system can even automatically conduct rule checks and immediately notify providers if they forget to provide required information, such as a signature or anesthesia end time. Alerts can be sent via pagers, text messages or emails — before the anesthesiologist has even left the PACU. An immediate notification means that a provider can fix the record while it’s still in front of him or her, resubmit the record by docking the pen, and avoid callbacks and rework.
Question: The system’s simplicity is intriguing. How is the data utilized after it’s captured?*
After the data is captured from the paper record, it is immediately “electronic” and we can do all sorts of useful things with it. This is a key capability of the Shareable Ink Anesthesia Record.
We can “slice and dice” the data and push it out to various stakeholders of the anesthesia record. For example, information required for billing can be sent to the billing company without the delay and cost associated with scanning or mailing. Because our system conducts rule checking and can immediately notify the provider about errors, we can eliminate sending the chart back to the provider for rework that would normally add weeks to the A/R cycle.
We can also send information about narcotics used during the case to the pharmacy. Sometimes, we take the data from many forms and build “dashboards,” web pages that give a view into data aggregated from many cases. Institutions can use these dashboards to monitor SCIP measures such as antibiotic administration time and patient temperature on PACU arrival.
As another example, my group has always recorded anesthesia ready time in addition to surgery start time. This way, we can measure how efficiently the OR is running. If the hospital asks us to provide an extra anesthesiologist to staff a room, we may be able demonstrate that another room is not necessary by bringing attention to this OR “downtime.” If there is sufficient downtime, the resource issue can be addressed by scheduling existing rooms more efficiently.
Unfortunately, my group never had an easy mechanism for collecting and analyzing the data. The exercise would have been too tedious to retrospectively enter that data from all the paper charts. But now, using the Shareable Ink system, the data is available electronically and anyone with a spreadsheet can analyze it. The system can even attach time stamps to checkboxes, signatures, or any other data collected from the form. This allows groups using the Shareable Ink Anesthesia Record to do detailed data analysis with regard to CRNA supervision.Question: How does the technology by Shareable Ink compare to scanning?
First, information is immediate and actionable with the Anesthesia Record. Scanning is not as timely because the process requires someone – usually not the anesthesiologist – to physically obtain the record, put it in a work queue, and then scan it. Scanned information is also less actionable. For example, if someone scans a record with no anesthesia end time or no signature, and then, submits it for payment, days or weeks would pass before the anesthesiologist is notified about the missing information.
Second, all you get is a “picture” of the record with scanning. You don’t really obtain any discrete data. You can’t easily answer questions like, “what percentage of my patients are ASA 4E?” or “how many central lines did I put in last year?” from an archive of scanned records.
Question: What made you come up with the Shareable Ink Anesthesia Record?
I’ve always been fascinated with technology. That’s probably why I chose anesthesia as a specialty. I took a break from clinical medicine before residency to manage the healthcare market for a division within Apple Computer. I remember giving a talk in 1993 in which I predicted that someday all doctors would be carrying PDAs. Since medical school, I’ve known that healthcare providers were mobile professionals with their own specific computing needs.
The digital pen is the ultimate extension of mobile computing. Finally, we have a technology that fits our workflow. Previously, in order to use an EHR, we had to modify our workflow to fit decades-old technology. With the Shareable Ink technology, we just do our jobs as we have for years. Only now, we seamlessly capture our information digitally in the background.
Question: How did you start Shareable Ink?
During residency, in the middle of the “dotcom” boom, I took a sabbatical to join a start-up company called PatientKeeper. PatientKeeper was one of the first companies to allow clinicians to use PDAs and smartphones in their workflow. The company has grown tremendously over the years, and now, they have signed contracts with about 12% of US hospitals.
I reached out to my friend Steve Hau, the founder of PatientKeeper, and was able to convince him to become the CEO and a co-founder of Shareable Ink. Steve has a proven track record of building new companies in healthcare IT and making customers successful. He quickly assembled a terrific team of industry veterans.
Question: Who is using the Shareable Ink Anesthesia Record?
Anesthesiologists from coast to coast are using our system, and we are also working with physicians in other specialties, in both the inpatient and outpatient settings. Our anesthesiologist clients aren’t limited to any particular location or sub-specialty. We can take any existing anesthesia record and make it work with our system.
Question: What are the benefits of using the Shareable Ink Anesthesia Record?
There are numerous benefits that accrue to both the individual anesthesiologists as well as to the institutions at which they practice. The main benefit to the providers is that they get almost all of the advantages of having an EHR – but without the hassles associated with changing workflow.
With our system, there is virtually no learning curve or training involved; everyone already knows how to fill out an anesthesia record with a pen. Because of immediate rule checks, anesthesiologists know that they are filling out their records completely and won’t be asked weeks later to recall, for a particular case, what time they transferred care in the PACU. Taken together, this positively impacts job satisfaction and the bottom line.The benefit to the institution is that they get access to data that they have always wanted but never had before —and without having to scan or key enter the records. Also, there is essentially no burden on the IT staff. No Shareable Ink software is installed on site. All the information from the pen is encrypted and transmitted to our servers where all the computing is done. Administration and providers can optionally access the data using a standard web browser and the data is always owned by the client.
Question: What benefits does it bring to the anesthesia provider?
The benefits are multiple. From an administrative and workflow perspective, the Shareable Ink Anesthesia Record eliminates lost records, cuts down on the number of records that need to be reworked and decreases days in A/R. Providers no longer have to fill out billing tickets and carry around anesthesia records until they reach some critical mass that reminds them to do their billing and send in their paperwork.
From a clinical perspective, it encourages more complete and accurate charting since it can notify us if we’ve submitted a record with a required element missing, such as an unsigned CRNA compliance statement or missing signature.
From a practice management standpoint, the Shareable Ink Anesthesia Record allows you to capture all sorts of new data that was never easily available before. One of the first things my group implemented was recording our position on the call schedule on our records. With the Shareable Ink system, it’s easy to collect all this data so we can actually analyze how much a particular position on the call schedule works over time. This will allow us to staff more efficiently.
Finally, from a financial perspective, we now have all the data we need in order to qualify for pay by performance or to report a new PQRI measure. If a new performance measure is initiated, we don’t have to do a lot of computer and data entry work, we just have to introduce a new field on a form.
Question: How does Shareable Ink technology compare to current Anesthesia Information Management Systems (AIMS)?
Anesthesia Information Management Systems have been commercially available for over a decade yet they have been installed in less than five percent of the marketplace. I believe this lack of adoption is due to two primary factors: cost and difficulty of use.
The Shareable Ink Anesthesia Record costs only a fraction of the amount an AIMS costs, and we can capture all of the salient data that the institutions that pay for these AIMS want. The Shareable Ink Anesthesia Record is also incredibly easy to use. Training is minimal and the workflow of the user doesn’t change.
In addition, AIMS require providers to use a keyboard, mouse, or other data entry device, and thus modify the way they work in order to accommodate data entry. I think this is the main reason that there has not been more widespread adoption of these systems. The approach that we’ve taken with Shareable Ink allows providers to practice the way they do now, input data in a way that is natural and familiar, and still get the benefits of an electronic system.
Question: How does the cost compare to AIMS?
Current AIMS systems require new computer hardware to be installed in every operating room, sometimes even requiring the replacement of anesthesia machines! The Shareable Ink Anesthesia Record not only costs a fraction of the cost of an AIMS in implementation, it also saves the institution ongoing costs related to training and support. Our physicians report that they require about half an hour of training. CRNA users, who don’t need to take advantage of the alerting or reporting functions, report that their training took just five minutes! On the support side, we’re not asking the providers to do anything new other than place the pen in a cradle. There’s not much that can go wrong so ongoing support costs are miniscule.
Question: What about automated vitals signs capture?
We don’t automatically capture vitals signs, and I believe that that is one of our strengths. Using the Shareable Ink Anesthesia Record, providers are still engaged with the case and record the vital signs every five minutes. This means that every five minutes the vitals have to go from our eyes, through our brains, and then be written on the anesthesia record.
It’s been suggested that while using an AIMS, providers have a tendency to let the record go on “autopilot,” and they can actually be less vigilant to the vital signs. I know some controversy surrounds this.
What we know for a fact is that cases have been litigated where the automated anesthesia record failed to record the vital signs for extended periods. Also, many providers are concerned about AIMS systems capturing spurious data, such as recording an abnormally high pulse because the cautery is in use. They fear that these data might increase their liability and lead to increased documentation burdens to edit the readings. The Shareable Ink approach still allows for the human filtering of inaccurate vital signs so that the record reflects what actually happened during the case.
Question: What are the challenges of implementing the technology?
The main challenge is in educating the institution. Hospitals are often reluctant to start new IT projects because of their history of being over budget and behind schedule. Normally, once we show the parties involved how little training is involved and how minimally disruptive it is to their workflow, things go very fast.
The only requirement to deploy the system is that the location have an Internet connection. As I mentioned, we don’t install any software on site. All we leave behind is a docking cradle for the pen and a driver to allow that cradle to communicate with our servers. Computing is done securely and remotely by Shareable Ink’s servers.
Another challenge is interfacing to the wide range of hospital IT and OR information systems that exist. Fortunately, the interface work isn’t required to get started. And the team at Shareable Ink has a deep knowledge and significant experience at this task.
Question: How does the Shareable Ink Anesthesia Record work with OR information systems?
We can interface into the OR information system. Often, the anesthesiologist keeps the most accurate and up to date record. This is especially true if the circulating nurse is expected to enter data into an OR system while performing clinical duties. By extracting data from the anesthesia record, powered by Shareable Ink and uploading it into the existing OR information system, Shareable Ink relieves physicians and nurses from the mundane, distracting and expensive task of data entry. The Shareable Ink Anesthesia Record is very complementary to traditional information systems because it draws on their strengths of storing, retrieving, and displaying data. Data entry is a limiting factor on all existing systems, and now, we’ve made that process a part of the existing workflow nearly effortless.Question: Why did you choose ABC to be your partner?
I’ve been an ABC customer from within two busy anesthesia practices. Every few years, we re-evaluate the marketplace and consider changing billing vendors and every time, we return to ABC for our business.
We chose ABC to be Shareable Ink’s reseller in the anesthesia marketplace because of their market share, focus on the anesthesia market, their expertise in anesthesia billing and practice management, and their willingness to embrace new technologies.
Reference: Vigoda, M.M., Lubarsky, D.A. Failure to Recognize Loss of Incoming Data in an Anesthesia Record-Keeping System May Have Increased Medical Liability. Anesth Analg 2006;102:1798-1802
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The State of AIMS Adoption
Carlos M. Nunez, M.D.
Chief Physician Executive, Picis®, Wakefield, MAAlthough still far from achieving mainstream adoption, anesthesia information management systems (AIMS) have made significant strides in market penetration over the last five years. Commercially viable AIMS solutions have been available for more than two decades, but it is only recently that the notion of implementing an automated anesthesia record has become widespread within the practice of anesthesiology. Perhaps the federal government’s push to increase the adoption of electronic health records (EHRs) as a part of the recently passed “stimulus package” will lead to near universal acceptance of AIMS, but there are other forces at work that have moved AIMS from being an interesting experiment to a vital tool for the management of anesthesia patient information.
First and foremost, the leading AIMS solutions have matured in ways that reflect not only the progress of technology, but also the realities of modern clinical practice. Even the most basic systems can recreate the paper anesthesia record; capturing data from monitors and anesthesia machines, as well as input from the user to document things such as medications, fluids and clinical notes. However, more advanced systems such as Picis® Anesthesia Manager have moved beyond simple record keeping, and now offer decision support tools and remote access that extend the usefulness of the electronic record. There have also been advances in configurability, usability and stability that have made AIMS easier to implement and more transparent to the workflow of the average user. Probably the most significant technological advance that has directly increased adoption of AIMS has been the integration and interoperability of these systems with the information infrastructure of the hospital.The most successful AIMS solutions are those that allow the electronic anesthesia record to operate seamlessly with the other information systems installed in the hospital. The interoperability begins in the operating room and extends as far as the outpatient areas. In fact, the event that led to the largest market expansion of AIMS was the availability of the first commercially viable suite of perioperative automation solutions, Picis CareSuite, in 2003. By combining a traditional operating room management system (ORMS) with the clinical solutions for preoperative evaluation, anesthesia automation, and recovery room (PACU) documentation, AIMS adoption in the United States jumped in one single year from a handful of systems to almost 100. Vendors offering stand-alone systems began to suffer and in some cases disappear, while the traditional hospital information system (HIS) vendors attempted to enter the market.
While interoperability of AIMS solutions was a welcome development for the IT management of the hospital, it was the gains in usability that began to turn the tide with anesthesia providers in terms of user acceptance. For example, the availability of patient data from outside the perioperative period, such as allergies, medications, lab and other test results, has helped drive the acceptance of anesthesia automation and streamline workflow. One of the most important immediate benefits is the ability to quickly access a patient’s previous anesthesia management details without sifting through paper charts. This is especially useful for patients who have difficult airways or other notable pathology that could affect the delivery of anesthesia. The ability to copy forward portions of the patient’s previous pre-anesthesia evaluation(s) also saves a great deal of time and eliminates redundancy. As a result, the pre-anesthesia evaluation and immediate preoperative preparation of the patient became less of a paper chase and improvements in the reliability of data captured from medical devices helped make anesthesia providers more comfortable with the automation of clinical record keeping. Advanced user interface design and flexible configuration options pushed the acceptance of AIMS even further. The evidence is clear in the marketplace: those AIMS solutions that offer comprehensive interoperability beyond the four walls of the OR and integrate well into the unique workflow of anesthesia have established themselves as the leaders.The final inherent trait of AIMS that provides tremendous incentives to hospitals is the ability to use their collected data to facilitate both clinical and administrative functions. The growing use of decision support is an excellent example of how vast amounts of data collected across the perioperative period can be available to the end users of AIMS, at the point of care. AIMS-based decision support systems enable users to create their own rules, providing clinicians with timely notifications based on patient data that can help the clinician guide the course of care. Imagine the AIMS screen displaying a colored icon or sending a text message to an anesthesiologist when a patient with a history of Malignant Hyperthermia has a recorded body temperature that is rising. The collection of data at the point of care also makes remote access to the anesthesia record possible, so that clinicians have access to patient information from any OR or PACU bed, anywhere they happen to be. Then, after the episode of care is complete, all of that data is available to generate billing (professional fees, supplies, pharmacy, etc.) as well as research and quality reporting. The ability to generate reports with AIMS data, as required by the Surgical Care Improvement Project (SCIP), is vital in today’s healthcare environment. The information that is documented in an AIMS, such as time from antibiotic dose to incision, appropriate sterile technique, use of beta-blockers, insulin use and glucose levels, and the use of intraoperative warming devices, can also be used to justify improved contract rates for insurers that are willing to compensate for proof of improved quality of care.
The American Recovery and Reinvestment Act of 2009 (ARRA) included nearly $20 billion to stimulate the adoption of electronic health records. Beginning in 2011, the federal government will reward hospitals with incentive payments for demonstrating the “meaningful use” of information technology. After 2015, the incentive payments go away; they replaced with financial penalties for those hospitals that do not meet the government’s goals. A large part of the meaningful use criteria center around the established and growing requirements for quality reporting as mandated by the Centers for Medicare and Medicaid Services (CMS). The perioperative care areas of the hospital are where a great deal of the data that CMS requires for its quality measures reporting program are collected, such as SCIP. ARRA may provide the final push necessary to arrive at near universal adoption of AIMS in the coming years. For more information on getting to meaningful use in high acuity areas of the hospital, such as the perioperative suite, Picis invites you to visit http://www.picis.com/Picis-Advocacy and download our position papers.
Carlos Nunez, MD, is Picis’s Chief Physician Executive. He can be reached at Carlosnunez@picis.com.
Despite the potential of an anesthesia practice database to enhance operating room efficiency this aspect of practice management is in its infancy. The most common use of productivity data continues to be the evaluation of potential stipend requirements. Anesthesia practice managers are coming to understand the correlation between operating room utilization and the need for financial support. The financial analysis seeks to assess whether the revenue potential of each location covers the cost of providing the care. Having a reliable handle on the profitability of each location covered has been proven to be a consistently effective means of both justifying stipend requests and encouraging administrators to reconsider adjusting coverage requirements. The key, of course, is the ability to produce and present the data and calculations in a manner that is both clear and compelling.
The use of productivity data and metrics to assess the profitability of coverage is leading to a view that an even better strategy would be to use the same kinds of information more pro-actively to actually help hospitals and surgi-centers manage rooms more effectively on a prospective basis. This is opening doors of opportunity for anesthesia practices to be seen more as problem-solvers in the tricky business of operating room management. Some practices have been so successful in their education of hospital administration that key stakeholders have come to rely on the anesthesia metrics and scorecards as the most reliable means of measuring operating room efficiency.
It is easy to look at these types of charts and graphs and to say, that is interesting but it would not be too useful in my hospital. Such an attitude, however, will inevitably be a self-fulfilling proposition. There is a reason why so many of the largest anesthesia practices are investing in technology and data capture devices to be able to reliably measure and monitor patterns of operating utilization. They have long since learned that having the tools to manage manpower and staffing more effectively is the key to their cost-competitiveness and survival. This may not be the kind of technological application that captures the imagination with its sophistication or innovation but it is clearly one that ensures profitability.
Question: Dr. Huang, what is the Shareable Ink Anesthesia Record?
Unfortunately, my group never had an easy mechanism for collecting and analyzing the data. The exercise would have been too tedious to retrospectively enter that data from all the paper charts. But now, using the Shareable Ink system, the data is available electronically and anyone with a spreadsheet can analyze it. The system can even attach time stamps to checkboxes, signatures, or any other data collected from the form. This allows groups using the Shareable Ink Anesthesia Record to do detailed data analysis with regard to CRNA supervision.
With our system, there is virtually no learning curve or training involved; everyone already knows how to fill out an anesthesia record with a pen. Because of immediate rule checks, anesthesiologists know that they are filling out their records completely and won’t be asked weeks later to recall, for a particular case, what time they transferred care in the PACU. Taken together, this positively impacts job satisfaction and the bottom line.
We can interface into the OR information system. Often, the anesthesiologist keeps the most accurate and up to date record. This is especially true if the circulating nurse is expected to enter data into an OR system while performing clinical duties. By extracting data from the anesthesia record, powered by Shareable Ink and uploading it into the existing OR information system, Shareable Ink relieves physicians and nurses from the mundane, distracting and expensive task of data entry. The Shareable Ink Anesthesia Record is very complementary to traditional information systems because it draws on their strengths of storing, retrieving, and displaying data. Data entry is a limiting factor on all existing systems, and now, we’ve made that process a part of the existing workflow nearly effortless.
First and foremost, the leading AIMS solutions have matured in ways that reflect not only the progress of technology, but also the realities of modern clinical practice. Even the most basic systems can recreate the paper anesthesia record; capturing data from monitors and anesthesia machines, as well as input from the user to document things such as medications, fluids and clinical notes. However, more advanced systems such as Picis® Anesthesia Manager have moved beyond simple record keeping, and now offer decision support tools and remote access that extend the usefulness of the electronic record. There have also been advances in configurability, usability and stability that have made AIMS easier to implement and more transparent to the workflow of the average user. Probably the most significant technological advance that has directly increased adoption of AIMS has been the integration and interoperability of these systems with the information infrastructure of the hospital.
While interoperability of AIMS solutions was a welcome development for the IT management of the hospital, it was the gains in usability that began to turn the tide with anesthesia providers in terms of user acceptance. For example, the availability of patient data from outside the perioperative period, such as allergies, medications, lab and other test results, has helped drive the acceptance of anesthesia automation and streamline workflow. One of the most important immediate benefits is the ability to quickly access a patient’s previous anesthesia management details without sifting through paper charts. This is especially useful for patients who have difficult airways or other notable pathology that could affect the delivery of anesthesia. The ability to copy forward portions of the patient’s previous pre-anesthesia evaluation(s) also saves a great deal of time and eliminates redundancy. As a result, the pre-anesthesia evaluation and immediate preoperative preparation of the patient became less of a paper chase and improvements in the reliability of data captured from medical devices helped make anesthesia providers more comfortable with the automation of clinical record keeping. Advanced user interface design and flexible configuration options pushed the acceptance of AIMS even further. The evidence is clear in the marketplace: those AIMS solutions that offer comprehensive interoperability beyond the four walls of the OR and integrate well into the unique workflow of anesthesia have established themselves as the leaders.