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Fall 2014

Making Meaningful Use More Meaningful

Danielle Reicher, MD
Anesthesiologist, San Diego, CA

Using a cloud-based Meaningful Use Electronic Health Record (EHR) like F1RSTUse enables anesthesiologists to participate in either the Medicare or Medicaid EHR Incentive Programs. For those of us who have been doing this for the last few years, the incentive payments have been quite substantial. While data entry does require some time and commitment, the process is straightforward and provides additional non-financial rewards to the physician and patient. As physicians, we have the ability to document patient encounters, review patient records, generate patient lists and securely message our patients. In addition, there is now technology to securely message the growing number of other healthcare providers in the Direct Protocol messaging trust bundle.

Historically, anesthesiologists have been the unseen doctors behind the mask. Patients may be grateful for good care, but they may not remember much about the experience due to the amnestic effects of our medications and the fact that much of their attention is on their surgical outcome. However, it is not that unusual for patients to have particular questions or concerns about their anesthesia care. Here are some of the common patient concerns:

  1. History of unusual sensitivity or resistance to anesthetic agents
  2. Severe postoperative nausea in the past
  3. History of difficult airway
  4. Unusual reaction to a medication in the past
  5. Fear of anesthesia
  6. Desire to know what anesthetic agents are given

Using a Meaningful Use product like F1RSTUse, we can efficiently respond to any of the concerns by communicating with our patients through the “visit notes” or similar feature. If my patients have an unremarkable anesthetic and do not seem particularly interested in extra details, I may leave this blank or simply thank them for the privilege of being their anesthesiologist that day. On the other hand, I can respond to any of the concerns above in a concise and accurate fashion. I can state which medications and doses they received if the concern is about their sensitivity to agents. If indeed there was increased or decreased sensitivity, I can document this. I can tell them what antiemetics they were given. I can tell them about their airway management, emergence pattern or unusual medication reactions. All of this information can be accessed on the patient side via Health Companion®, a secure free personal health record. [Note: the author is a cofounder of Health Companion.]

If the patient does not have any specific questions preoperatively, it is not unusual for the anesthesiologist to have particular concerns after giving an anesthetic. Here are some examples:

  1. Difficult airway
  2. Adverse medication reaction
  3. Unusual sensitivity or resistance to anesthetic agents
  4. Previously undiagnosed hypertension
  5. Wheezing or secretions in patient who denied pulmonary symptoms preoperatively
  6. Difficult intravenous access
  7. Emergence delirium
  8. Electrocardiographic abnormality not previously noted

In the past, these issues might be noted in a progress note or explained verbally to the patient or family member, or even provided in writing to the patient. However, communicating this information in a secure way and ensuring a permanent electronic record allows the patient and physician a more reliable method of transmitting valuable information. The patients will be able to access this information anytime, anywhere in the future or share it with future caregivers. This is not to say that I would not explain any of this to patient and family in person. I will always make every effort to convey useful and important information face to face. But so often, when patients leave a healthcare facility, these conversations are not well remembered.

I recently had a patient who cautioned me that she was a real “lightweight” when it comes to anesthesia. She was extremely concerned about this. I administered sedation for her colonoscopy and she required a very average dose of midazolam and propofol. She awakened immediately after the procedure. I was able to tell her that she responded quite typically to the medications and she was very relieved to hear this. I also put this information in her visit notes and included the doses. She was very pleased when I told her I would include that information so she could have it for future reference.

If I have a patient with a known difficult airway who safely undergoes anesthesia with a laryngeal mask airway (LMA), I am able to explain in the visit notes that the case went well. I can further explain that the airway device used often works well even with patients who have a difficult airway and that this does not guarantee future success.

When considering adverse medication reactions, anesthesiologists may observe hives or anaphylaxis after giving a combination of medications. We know that the most common allergic reactions are due to antibiotics or muscle relaxants. We also know that other medications can be responsible. We may need to refer the patient to an allergist and we certainly want them to be aware of all the medications they received. All of this information can be recorded in the electronic record after a thorough discussion with the patient.

Some may be skeptical of the added time required to document this. However, the incidence of adverse events is not that high and having the electronic record is actually more efficient and timesaving than trying to scribble out an unofficial note for patients to take home.

Improved patient communication is not only advocated by the federal government, but it is also supported by our professional societies. The ASA Practice Guidelines for Management of the Difficult Airway published in Anesthesiology 2013: 118: 251-270 state that anesthesiologists should:

“inform the patient (or responsible person) of the airway difficulty that was encountered. The intent of this communication is to provide the patient (or responsible person) with a role in guiding and facilitating the delivery of future care. The information conveyed may include (but is not limited to) the presence of a difficult airway, the apparent reasons for difficulty, how the intubation was accomplished, and the implications for future care. Notification systems, such as a written report or letter to the patient, a written report in the medical chart, communication with the patient’s surgeon or primary caregiver, a notification bracelet or equivalent identification device, or chart flags, may be considered.”

Specific templates have been recommended for documentation and are available online at diffairway.htm. This data can all be incorporated into the visit notes of the F1RSTUse EHR.

Unfortunately, the position that anesthesiologists may be exempt from future Meaningful Use penalties has reinforced the belief that anesthesiologists play a limited role in patient care and need not participate in such programs. We should not abandon this excellent opportunity to become more engaged with our patients and the healthcare system in general. While we may not be a daily fixture in the medical lives of our patients, our role is critical and the information we gather can be extremely vital to the electronic medical record. Let’s make Meaningful Use even more meaningful!

Danielle Reicher, MD is an anesthesiologist in private practice in the San Diego area. She has a longstanding interest in health information technology and preventive health care. She can be reached at