July 31, 2017

Peruse the most recent graph showing electronic health record (EHR) adoption rates among hospitals, and you’ll see a curve sloping steadily and optimistically upward.  In 2015, nearly all reported hospitals (96 percent) possessed certified EHR technology, and 84 percent had adopted EHRs with advanced functionality.  In addition, more than 80 percent of non-federal acute care hospitals had adopted all of the functionalities of a basic EHR—a nine-fold increase since 2008, before passage of the HITECH act of 2009, according to the Office of the National Coordinator for Health Information Technology.

Though anesthesia has been somewhat slower to climb on board, the implementation of electronic anesthesia medical records (EMRs) or anesthesia information management systems (AIMS) rose 400 percent from 2007 to 2010, according to an ASA Monitor article by Joseph W. Szokol, MD, JD, MBA, and Mark A. Deshur, MD, MBA.  In 2014, an estimated 45 percent of anesthesia practices were using electronic anesthesia records.

Though these statistics show progress, plot the individual EHR and AIMS implementation stories behind the numbers and you will see a lot of zigzags.  It’s not that the nirvana of a seamless and efficient EHR or AIMS that improves patient care and supports regulatory compliance is unreachable; it’s just that getting there can be a long, bumpy ride.

“Adopting an AIMS has the potential to be one of the most important, yet potentially psychologically traumatic, changes in your anesthesia department in recent or distant memory,” Drs. Szokol and Deshur contend.  The process of digitization can take a toll.  The Medscape 2017 Lifestyle Report, a survey of 14,000 physicians across specialties, found “increasing computerization (EHRs)” to be the fourth leading cause of physician burnout.

Still, EMRs and AIMS are here to stay.  “The complexity of clinical care and need to more effectively coordinate perioperative care mandate more robust integration of documentation systems to optimize care,” states Neal H. Cohen, MD, MPH, of the University of California, San Francisco, School of Medicine.  “Robust electronic records are an essential requirement if anesthesiologists are going to be in a position to report on quality measures and clinical outcomes to support value-based payment strategies.”

Get Involved

For anesthesia providers, some of the “trauma” related to the shift from paper comes from the fact that they often have little input in the selection, build and implementation of the AIMS in their institutions, says Jessica Kovash, CHTS-PW, of Coratek Perioperative Consulting, in an article in the Fall 2015 issue of ABC’s quarterly newsletter, Communique.  This despite the fact that “input from anesthesia providers and practice managers is essential in order to get optimal use and benefits out of a system, regardless of the organization’s stage of adoption,” she says.

Hospitals, health systems, anesthesia care providers and practice and health information management professionals have learned a few things over the past several years.  There are strategies anesthesia groups can use to ease the transition to an AIMS.

According to Drs. Szokol and Deshur, one of the fundamentals is preparing by visiting other institutions in order to learn from their successes and failures.  “We learned a lot of valuable lessons from some of our visits, many of which we successfully applied toward our implementation,” they report.

Another is coming to grips with the realities of what an EMR can and cannot do, notes Jody Locke, vice president of anesthesia and pain practice management services at ABC.  The widespread assumption that well-established firms such as Epic and Cerner have a solution that can easily accommodate anesthesia is simply not true.  “Despite the systems’ features and functionality, few installations do not involve considerable modification,” he says.

Another fallacy is the notion that an EMR will expedite charge submission—that you will go live and that everything will automatically fall into place.  In reality, “the implementation of most Epic anesthesia systems, for example, requires a three- or four-day hold on charges to ensure completeness of batches,” Mr. Locke says.  Although this may change in the future, currently, no anesthesia practice with an EMR is able to rely on an electronic interface to transmit all cases from the facility to the billing system.  “Most coding for practices using EMRs is done based on a manual review of a digital pdf of the anesthesia record,” he says.

This uniqueness points to the need for anesthesia practitioners and practice management professionals to become involved in the EMR planning and implementation process early on, according to Karen Gehne, director of EMR integration at ABC.  “The electronic anesthesia record implementations that go the best are those that have a lot of anesthesia provider and practice management team involvement,” she says.

Though Ms. Gehne is referring specifically to the aspect of EMR implementation that involves creating an interface between the AIMS and the systems used by the anesthesia department’s billing vendor, she says participation in all aspects of an implementation benefits anesthesia groups.  Be involved, and involve your colleagues and staff from planning to go live and ongoing support, she advises.

Partner With Your Billing Vendor

In a paper published by the Anesthesia Quality Institute, Implementing an AIMS as Part of an Enterprise EHR, James Moore, MD, and Emily R. Richardson, MD, stress the importance of including the information necessary to support billing in the system build, noting that billing and compliance requirements should be delineated early in the design.  “The billing service should review whatever output will be used as the basis for billing,” they write.  In addition, “records, data and billing service access should be tested and validated before going live with the new system to avoid costly disruptions in the revenue cycle.” 

Here again, direct involvement plays an important role, Ms. Gehne notes.  That involvement includes communicating closely with your billing partner as early in the process as possible.  “Connect your billing vendor with your health information technology team at your clinical venue so they can work to set up the transfer of records and offer guidance on what needs to be captured to facilitate timely billing and coding,” she says.

She encourages anesthesia practices to let their billing vendors know as soon as they hear their facility is even looking to get a new EMR.  For ABC clients, Ms. Gehne will then ask for contact information and send those contacts specifications regarding the key data elements, including patient demographic information and billing information, that ABC requests for all EMR implementations.

N. Martin Giesecke, MD, editor of ASA Monitor, echoes Ms. Gehne’s sentiments regarding anesthesia provider involvement, pointing to the value of having a system champion as well, “a colleague who is given the time, and has the energy, to commit to the planning process.  The dividend will be a program that has the appropriate workflow for the group it is intending to serve.”  Like Ms. Gehne, he also recommends seeking input from everyone in the group.  “As these computerized records become more complex, sometimes it takes the suggestion of an iconoclast (luddite?) to actually create a functional product,” he says.  He also recommends ensuring that live support personnel are available for every anesthesiologist, around the clock, at the go live date.

Involving your billing partner and introducing them to your project team early on allows the vendor to provide information on the data elements needed and to be on hand to walk through the group’s workflow and billing and answer any billing-related questions as the process moves along, says Ms. Gehne. It also allows your billing partner to test a variety of reports and scenarios prior to go live to ensure that, at go live, the documentation will be transferred successfully for billing.  “EMR implementations that have the best preparation have an easier time capturing all of the services,” Ms. Gehne says.  “This reduces the chances of a significant drop in accounts receivables in the post-go live period.” 

Hold Timeouts, Use Shadow-Charting

Some providers believe that they will pull a switch, go live and that nothing will be impacted, Ms. Gehne observes.  “But you are asking providers to document things differently, and if they can’t get to the information they need, or it doesn’t go to their billing vendor, or they can’t get the record closed to do the billing, that will impact accounts receivables.  Of course, the goal is to have as few accounts receivables hills and valleys as possible.”

One of the most common difficulties encountered as anesthesia groups move to a new EMR is the workflow related to documenting the postoperative diagnosis and the postoperative procedure, notes Ms. Gehne.  In the paper world, the anesthesia provider writes the diagnosis and the procedure on the paper record.  In the EMR world, standard practice is for the surgeon to be responsible for the postoperative diagnosis and procedure.  The issue there is that surgeons typically have 48 hours to close their record, but anesthesia providers typically close the anesthesia record after the PACU handoff on the day of surgery.

To ensure that the postoperative diagnosis and procedure flow into the anesthesia record before the provider closes the record, Ms. Gehne recommends requesting a timeout at the end of the procedure to allow the surgeon and anesthesia provider to discuss the postoperative diagnosis and procedure so that the circulating nurse can enter that information into the EMR in a timely fashion.

Ms. Gehne encourages anesthesia groups to use shadow charting—a process of simultaneously documenting a case on paper and in the EMR—for about two weeks before go-live.  “Some providers don’t feel they have the time, but taking the time to understand the EMR screens and documentation ensures that clinicians will be confident at go-live,” she says.  Shadow charting also helps to ensure that more information will be readily available for billing and coding and reduces the chances of a negative impact on accounts receivables.

There is no question that EMRs and AIMS have found a permanent place in the specialty.  The next steps are to begin analyzing, applying and sharing the data in more sophisticated ways to enhance the quality, safety and cost effectiveness of anesthesia care.

With best wishes,

Tony Mira
President and CEO