The Tipping Point for Anesthesia Information Management Systems
Teecie Cozad Vice President, Product Management, DocuSys, Inc., Atlanta, GA
Although Anesthesia Record Keepers have been available for nearly 30 years, it has only been in the last decade that broadly featured Anesthesia Information Management Systems (AIMS) have been available. In this comparison, I have defined an Anesthesia Record Keeper as an electronic system that produces a paper printout of a legible, complete anesthesia record at the end of a case; my definition of an AIMS gets closer to the ideal – an electronic anesthesia medical record that maintains integrated communication with other hospital and provider systems throughout the perioperative period (such as clinical information systems used by nurses, clinical data repositories used by hospitals and professional fee billing systems in place for the group).
As AIMS mature to the stature of information systems, they are gaining acceptance. Yet, market penetration for this product is still, by nearly all estimates, less than 10%. Ultimately, one of the most limiting factors of widespread adoption has been the requirement to win over two groups to purchase and implement an AIMS: facility administrators who typically provide the budget, and physicians, who need to use the technology. A confluence of factors aimed at both potential buyers, however, is moving the AIMS industry to the tipping point of widespread adoption.
First, a national emphasis on health IT through the federal economic stimulus package, although not directed to specialty systems such as AIMS, will likely leave such specialty groups as lone users of paper records in an electronic environment – a situation that will hasten conversion. A secondary push toward health IT has been proposed through the national health care reform proposal recently introduced by Senator Baucus and others, encouraging health providers to use IT to coordinate care, curb Medicare abuse and fraud, improve care quality and reduce duplicate tests.
Second, in the national debate surrounding healthcare reform, reducing costs through the elimination of Medicare abuse and fraud is a primary focus when discussions turn to paying for such proposals. Those discussions generally lead to scrutiny of health providers who bill for their services and the RAC (Recovery Audit Contractor) program is the latest permutation of that examination. As advised by Pendleton and Gustafson in ABC’s Summer 2009 Communiqué (“What Anesthesiologists and Pain Management Physicians Need to Know About the RAC Program”), improved demonstration of medical compliance and documentation of start and end times, invasive lines, post-operative pain services, medical necessity for monitored anesthesia care cases and chronic pain management are wise. The case completeness checks provided by a robust AIMS such as DocuSys® will perform real time concurrency checks and prevent a provider from closing a case until all billing requirements are complete.
Safety and Quality – Hand in Hand
The continued emphasis on patient safety and quality embodied by CMS’s Physician Quality Reporting Initiative (PQRI) will also drive AIMS adoption. The more anesthesiology quality measures are adopted by payers, the more technology will play a role in prompting the clinician to document their evaluations and actions and to report their performance effectively. While relatively small bonuses are held out to stimulate participation in these measurement programs now, the general consensus is that physician payments will go the route of hospital payments where bonuses for reporting became bonuses for performance before becoming reductions in payments for non-reporting. A good AIMS should have a decision support engine that allows the anesthesiology group to design prompts to achieve 100% compliance with both performance and reporting on quality measures. It should assist the anesthesiologist by selectively prompting at the appropriate time for an appropriate subset of patients to avoid message fatigue.
Wrong site surgery is another instance where one can imagine the anesthesia provider with a widening downside potential. Although surgeons and anesthesiologists are still getting paid when “never” events such as this occur, Bierstein suggested in the Winter 2009 issue of the Communiqué (Health Care Quality and Measuring Performance), ...”it is not hard to imagine…[a system that allocates] a pro rata share of responsibility for perioperative injury.”1 An AIMS can offer checklists to the user that assist in documenting anesthesiology’s part in the important “Time Out” for confirmation of patient demographics and surgical site.
Other safety measures that can be enhanced with an AIMS include verification and reporting of adverse medication reactions. Utilizing an AIMS that incorporates a drug information database can standardize allergy and home medication documentation, eliminate duplicate documentation through inbound integration of codified allergy and drug information from nursing information systems and can enable selective decision support at the point of care around allergy alerting and potential drug-to-drug interactions.
Capturing postoperative complications is a required and necessary part of the provision of anesthesia. A feature-rich AIMS of today should allow the provider to document any events that are noted during or after the case and track them for Quality Improvement purposes. Some AIMS, such as DocuSys, permit the separation of Quality Improvement documentation from the generally available Anesthesia Record. Additionally, there are active projects aimed at building multi-institutional clinical anesthesia databases for benchmarking and outcomes research to which groups may wish to contribute. These databases are built on the output of various AIMS. Enterprise-level reporting databases may contain the clinical data repositories of related information systems as well as AIMS data.
An important benefit of technology highlighted by the advent of Personal Health Records (PHRs) is a concept that the Cleveland Clinic and others implemented a decade ago – that of having the patient participate in their preoperative care by completing a computerized health questionnaire. An AIMS that can incorporate a triage methodology for presurgical testing and pre-anesthesia evaluation based on the patient’s health history can provide extensive patient safety benefits by communicating the patient’s surgical risk to the entire medical team for optimization well in advance of the day of surgery. Using technology in this way permits the primary care provider, surgeon, anesthesiologist, preoperative nurse and the patient to work in concert to improve care and eliminate duplicate testing – additional goals of national health care reform proposals.
An AIMS at the Point of Care
Adoption of an AIMS is dependent on two buyers and both have to be convinced of the value of an AIMS for a purchase decision to be made. Let’s start with the problems that an AIMS can solve for the provider at the point of care.
First, after years of development and feedback from the anesthesiology market, it is understood by AIMS manufacturers that systems have to be easy to learn and easy to use. No one in the fast paced arena of anesthesia delivery has time to grapple with a user interface that is not intuitive. Some systems require less handling than others to thoroughly document a case, but a primary requirement of any successful AIMS implementation is that the anesthesia providers must be able to focus on the patient and not on the tasks of using a computer or documenting physiologic data. Some systems, like DocuSys, have minimized the work involved in supply and drug utilization by accepting bar code scanning to replace drop down lists, and by sending utilization data to materials management and pharmacy systems automatically so that anesthesia providers do not have to manage charge forms.
Second, the fear on the part of anesthesia providers that erroneous vital signs will be entered into the record has largely receded as more and more clinicians have gained the understanding that a legible, complete record is far easier to defend in court than an incomplete hand-written record. Most providers utilizing AIMS now enter a quick note to explain aberrant physiologic data recordings.
The federal Drug Enforcement Agency (DEA) has made additional functionality of some AIMS, like DocuSys, a real benefit. With requirements for anesthesia providers to document narcotic use and wasting, the AIMS that can provide complete electronic narcotic reconciliation can save significant time for anesthesia providers as well as hospital pharmacists, both of whom are in short supply. Many hospitals have implemented dedicated medication dispensing carts in each operating room because of the difficulties encountered and the resources consumed in reconciling anesthetic narcotic usage. A comprehensive AIMS should eliminate the duplicate documentation required to dispense the medication from the cart and document its administration in the record by communicating bi-directionally with the cart and with pharmacy.
Other efficiencies can be brought to the point of care by a well designed AIMS. Access to previous medical records in a manual world can be slow and inefficient. Immediate access to AIMS records means that the anesthesiologist can quickly review a patient’s previous airway management techniques in preop to assist in planning. A strong AIMS should automatically post complications during a case to the patient’s future PreAnesthesia Evaluation record to extend safety to upcoming visits and maintain links to images of the airway, if available.
For those anesthesiologists who serve as managers of the OR, an AIMS system can help to streamline traffic through the OR with the use of patient and provider tracking systems. Most AIMS utilize the work station monitor and/or plasma screens to provide boards that document a patient’s progress through the perioperative process. The best AIMS also provide tools that allow the anesthesia manager to assign anesthesia providers to add on cases without phone calls and pages. The OR/Anesthesia utilization reports available in an AIMS can permit anesthesia managers to gather data for underutilized FTEs that can successfully result in needed stipends or produce the proof sources for additional manpower when there is high utilization.
Those with departmental responsibilities to support professional fee billing and physician compensation recognize manual systems as inherent sources of errors and omissions. A primary benefit of an AIMS is the elimination of missing charge sheets and the automatic transmission of billing data – either in image or data formats – at the close of each case. A good AIMS will provide reports to verify that all cases made it to the billing destination, reporting on closed, opened but not completed, and cancelled cases. Those who have successfully implemented AIMS with billing support have seen their “Days to Bill Drop” decrease by 10 or more days.
The Bottom Line is Still the Bottom Line
Finally, returning to the second buyer for an AIMS, it is the hospital or facility executive who makes the final purchasing decision. For the anesthesia group who desires to implement an AIMS, the group needs to operate at a strategic level to accomplish their wish. Hospitals lose millions of dollars every year because many co-existing diseases are not adequately documented. No other physician group is better positioned to provide the documentation that can result in accurate identification of co-morbidities for surgical patients than anesthesiologists. Using an AIMS that can separate the healthy from sick patients; start a PreAnesthesia Evaluation with a patient’s personal health record, and bring in preoperative nursing documentation to validate it, allows the anesthesiologist to spend a couple of minutes on identifying co-morbidities on a subset of surgical patients. This strategic use of an anesthesia resource can significantly improve the financial status of the hospital. More accurately capturing charges on all items used for a particular patient and providing information that allows the hospital to more accurately track inventories of drugs and supplies provides even more ammunition in convincing hospital executives that an Anesthesia Information Management System is an investment that cannot wait.