Tony Mira, Chairman and Chief Executive Officer of MiraMed
Harnessing Technology to Improve Anesthesia Quality: Stories from PRACTICE MANAGEMENT™ 2019
Though it is far from perfect, health information technology can be used in anesthesia to improve quality in a multitude of ways. We summarize some of the examples presented in a presentation by Mark A. Deshur, MD, MBA, of NorthShore University Health System at PRACTICE MANAGEMENT™ 2019.
Anesthesia providers typically think of anesthesia information management systems (AIMS) and electronic health records (EHR) when they think of health information technology (HIT) in anesthesia, but HIT's potential uses in the specialty reach much farther. HIT can be harnessed to ensure appropriate documentation, drive smarter clinical decisions, boost provider satisfaction, bolster financial performance, promote medication safety and more.
As long as anesthesia providers remain vigilant and don't fall prey to the common but mistaken assumption that HIT systems are fail-safe, technology can fuel important efficiencies and improvements in anesthesia quality, Mark A. Deshur, MD, MBA, of NorthShore University Health System, said in a presentation at the ASA's PRACTICE MANAGEMENT™ 2019 in Las Vegas.
"Quality has to be more than a promise," Dr. Deshur said, referring to Ford Motor Company's past motto, 'Quality is Job 1'. "It's easy to make a promise. It's much harder to actually deliver on that promise," he said.
Still, if properly implemented, technology can be a powerful quality improvement tool, said Dr. Deshur, whose talk included several successful examples at his institution and others that we'll highlight this week and in future eAlerts.
Harvest AIMS data to identify problems. After spotting an instance of failure to document placement of an arterial line in their practice, Dr. Deshur and his colleagues at NorthShore University Health System used data gathered from their AIMS dashboard to identify how often practitioners had failed to document placement of A-lines and central lines during the previous 10 months, discovering that "this was not an isolated incident; this was a much bigger problem." They built functionality into the AIMS that looks for invasive A-line or C-line data and sends a reminder to the anesthesia provider if documentation is still missing 30 minutes after line placement.
When clinicians click the reminder, they're taken to a place in the AIMS that allows them to easily document line placement. During the previous 10 months, the department had identified 16 A-line documentation failures per month and a total of six C-line documentation failures during that time. By using a dashboard to identify and track the problem, the department was able to implement a successful practice change that has yielded $15,000 in additional revenue annually.
Reduce excess fresh gas flow usage. Anesthesiologists at the University of Washington, Seattle, used a clinical decision support tool to notify clinicians when fresh gas flows (FGF) exceeded 1 liter/minute. If sevoflurane usage reached 2 minimum alveolar concentration-hours under low flow anesthesia (FGF<2 l/min), a second reminder was sent to increase FGF to 2 l/min to comply with Food and Drug Administration guidelines.
Mean FGF between incision and end of procedure were compared 1) at baseline; 2) when decision support to reduce FGF was applied; 3) when the decision rule was deliberately inactivated; and 4) when the decision rule was reactivated. The simple real-time reminder to lower fresh gas flow resulted in an annual cost savings of $100,000. After implementing a similar FGF reminder at their institution, NorthShore Health System is saving an estimated $25,000 per year, Dr. Deshur reports.
Lower labor epidural re-dose rates. The access to discrete data made possible by some HIT systems can make it easier to retrieve and analyze that data to highlight different practice patterns and enable clinicians to improve their practices in ways that they never could before. A review of data on labor epidural re-dose rates at NorthShore "opened our eyes to the fact that we could do better," Dr. Deshur said. Data showing re-dose rates ranging from 17 percent to 41 percent among the group's 45 anesthesiologists allowed the department to identify that it had a problem and start diving into it to identify what it could do better.
After a literature review to identify best practices, the department adopted patient-controlled epidural analgesia for labor at both of its hospitals, changed infusions to be consistent at both facilities and encouraged providers to switch to combined spinal epidurals from straight epidurals.
A review of the data since implementing these changes revealed an average re-dose rate of 15 percent across the department, "a substantial improvement we never would have even thought to make if we didn't see these types of trends," said Dr. Deshur.
Dr. Deshur highlighted some of the inherent challenges and potential pitfalls of technology in his talk as well. Among these is the very real risk of distraction that comes with HIT, which means that the need for "vigilance rings true now more than ever," he said. Another is complexity. "As our systems become more automated and complex, the assumption is that they're foolproof, except that every system has limitations, and it's not always clear what those limitations are and how the system will perform if those limitations are exceeded," he said, citing reports that the Tesla Model S has driven into fire trucks stopped on highways because the electric car's semiautonomous system could not detect the obstacles and the drivers had become complacent. "What happens if you have increasingly automated systems that lead to decreased vigilance?"
Still, though technology is far from perfect, Dr. Deshur said that with an understanding of the nuances and challenges, "HIT can help ensure we document appropriately, offer clinical decision support tools that allow us to make smarter decisions, enhance our bottom line through improved charge capture and lower costs," and improve the practice of anesthesia in countless other ways.
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With best wishes,
Tony Mira President and CEO