Are You Getting the Most Out of Your Anesthesia EMR?

The majority of our clients do not work in facilities that have an anesthesia electronic medical record (EMR). Despite some early trepidation about the transition from a paper record to an EMR, most installations have gone fairly smoothly. The majority of our clients report that they are reasonably happy with the new system. As is so often the case with new technology, younger physicians tended to embrace EMRs faster and more enthusiastically than their older colleagues. Although there was once a variety of companies offering an anesthesia EMR, the field has contracted considerably. Epic and Cerner now dominate the market for inpatient systems. Anesthesia Touch—a product we developed—is also a popular option for hospitals still on paper, as well as for outpatient facilities.

Vendors of EMR and anesthesia information management system (AIMS) solutions tout the significant advantages of an electronic record versus its hard-copy cousin. The question, though, is whether the average anesthesia practice is really maximizing the benefits of their new record-keeping technology.

One Size Fits All?

The implementation of an EMR is such a significant event for our clients' practices that we have created a separate EMR transition team that guides providers through the basic requirements of anesthesia billing and compliance. We ask that our clients let us know when they get wind of the first discussion of an EMR coming to their hospitals. We like to be involved in an advisory capacity, providing strategic support for clinical and IT staff. Just as important is input from the anesthesia group. For each EMR transition, there should be a group "champion" who is able to work with both our staff and the EMR programming team to ensure processes conform to group-specific needs.

The fact is that even now, after so many anesthesia installations, each vendor still offers a one-size-fits-all solution. However, because each practice is unique in its staffing and case mix, nuanced customization is often required for optimal effectiveness. We often joke that if you have seen one anesthesia EMR installation, you have seen one anesthesia EMR installation. It is a little-known fact that the national EMR vendors make a considerable amount of money programming the necessary modifications.

It's About Billing

So, what are we talking about here? Electronic records have the potential to remind providers of critical documentation requirements for appropriate billing. The following are just some common examples. Our implementation team has a much more extensive list.

• Supporting coding distinctions by capturing the location of the surgical site, such as upper versus lower abdomen or upper third of the femur versus lower two thirds.
• Ensuring that nerve blocks for post-operative pain management include a note that the block was performed for purposes of post-operative pain management at the request of the surgeon.
• Confirming whether the block was performed before or after induction of general anesthesia.
• Induction time and other time-stamped events.
• Justifying the use of ultrasonic guidance (USG).

While EMR vendors like to cite the potential for an electronic interface that would allow relevant details of each case to be uploaded to the billing software, this is more aspirational than reality. The fact is that many facilities are unwilling to spend sufficient resources to create an electronic interface for the billing staff or lack the expertise to do so. This means that, even with an electronic record, most coding decisions are made by certified coders reviewing pdf images. This might seem counter-intuitive, but it is the standard in the industry. Anesthesia billing algorithms are simply too arcane. Coders must be able to consider all aspects of each case to determine what is billable. For example, a nerve block is not separately billable unless the record indicates that the primary mode of anesthesia was general.

In theory, an electronic record will consistently capture more critical details of each case than a paper record. Anesthesia time is a good example of this. Our experience is that the EMR allows the provider to capture billable time more appropriately and without rounding up to the nearest five-minute increment.

In most environments, an EMR will ensure that all cases are captured for billing. The biggest challenge comes when the EMR is not used in all venues. Practices must clearly identify how cases will be captured, especially those performed out of the operating room—the so-called non-OR anesthesia (NORA) cases. It should also be noted that, in many cases, there is a lag built into case capture to allow for provider edits. EPIC, for example, often suggests a 3-to-7-day hold to allow providers to close/finalize their case records.

As a general rule, an EMR will enhance the billing process, but this cannot be taken for granted. Depending on the system, a number of tools may be available to ensure that a record has been received for every service provided, and these must be applied with assiduity to ensure that cases do not get lost in the system. One such tool is the activity report that compares the cases performed to the cases submitted. It is always appropriate to inspect and not expect the system to catch everything.

Practice Management Practicality

It used to be that it was enough to get paid well for the professional services provided by a practice. "Cash is king" was the old mantra. Now we are in a much more competitive and strategic phase of practice management. The real value of an anesthesia database is its wealth of management information. We often say that the anesthesia department should have more and better data about what actually happens in the operating rooms than any other stakeholder in the facility. The question is whether the department has clearly identified its management reporting needs and structured its data capture to ensure that it can make decisions based on timely and accurate data.

Billing requires the documentation of each provider's role in providing the care. Anesthesia is unique among medical specialties in the documentation of medical direction. That is a billing requirement. Knowing what anesthetizing location the case was performed in is a practice management requirement. Many clients dismiss the significance of tracking anesthetizing locations and yet OR utilization studies are often at the core of hospital contract negotiations. How can one evaluate the relative profitability of venues if utilization metrics cannot be normalized?

A concept that many groups are now starting to appreciate is profitability by lines of business. How does the profitability of the endoscopy center compare to the ASC? Having the ability to readily identify and compare lines of business can be an invaluable asset, especially if the question focuses on staffing and manpower requirements.

One of the inherent challenges to effective practice management is data validation. Misinformation is always worse than no information. If the practice is going to rely on the information from the EMR, then the data must be consistent and verifiable. It is certainly true that we don't always know today what data points will be critical tomorrow. That is why this dimension of an EMR implementation must be thought through so carefully. After all, today's EMR is no longer just a clinical record-keeping tool as the paper record used to be. Anesthesia practices no longer operate in a financial vacuum. Their value proposition must not only include their providers but the facilities they serve.

The Quality Question

Despite the fact that anesthesia has become an incredibly safe specialty--providers often tell their patients they are at greater risk driving to the hospital than undergoing general anesthesia—a focus on pay for performance measures are having a curious impact on the specialty. How do you make a service better that is already pretty good? The reality is that one cannot manage what one does not measure. Anesthesia practices are being hit with quality metrics from every direction. Quality has become a confusing soup of acronyms. Most groups are going through the motions of capturing and reporting quality metrics without really believing it will actually improve patient care. Unnecessary bureaucratic requirements are always viewed with a certain degree of disdain.

The problem is that quality metrics can only impact the quality of care provided if they are taken seriously and applied judiciously. As groups are faced with the challenge of reporting data that may or may not be viewed as improving quality of care for patients, but have been adopted by CMS or the societies, they are being asked to review and act on the data, and this may be creating an uncomfortable role of policing themselves. We suspect that few practices actually want to profile providers and hold them accountable using what many feel are questionable benchmarks for quality.

The days of peer review may have created a culture of acquiescence. In the past, a provider had to be seriously deficient to be reported. This having been said, as some of the nation's largest anesthesia entities grow, there is an increasing focus on quality and profiling using the published quality measures. With an EMR, the necessary data is available. There just has to be a commitment and a will to use it.

In Conclusion

EMRs definitely represent progress when it comes to anesthesia record-keeping, but they are no panacea. As is true of any tool, it is only as useful as you allow it to be. The automated record is just a springboard. It is the practice that has to decide how high they want to jump.

If you are in a facility that is scheduled to install an anesthesia EMR or if you have concerns about your current EMR solution, please contact your account executive or reach out to us at info@anesthesiallc.com.your text here ...