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  • Anesthesiologists Targeted in CMS’ Review of Existing Rules

    Neda Mirafzali, Esq.
    The Health Law Partners, PC, Southfield, MI

    On August 22, 2011, as a result of a directive from President Obama, the US Department of Health and Human Services (“HHS”) issued its Plan for Retrospective Review of Existing Rules (“Plan”). The Plan includes a review from all HHS operating and staff divisions (e.g., the Centers for Medicare and Medicaid Services (“CMS”)) that establish, administer and/or enforce regulation. HHS’ Plan aims to review “existing significant regulations to identify those rules that can be eliminated as obsolete, unnecessary, burdensome, or counterproductive or that can be modified to be more effective, efficient, flexible, and streamlined.” While, on its face, a review of unnecessary regulations appears to be beneficial, looking below the surface reveals that the review may create fundamental changes in medical and anesthesia practice. CMS is contemplating reviewing the conditions of participation (“CoPs”) for anesthesia services (42 CFR 482.52) to eliminate the certified registered nurse anesthetist (“CRNA”) supervision requirement, which could significantly impact anesthesiologists, CRNAs, their practices and their patients.

    Current Hospital CoPs For Anesthesia Services

    As a preliminary matter, it should be noted that for the purposes of the hospital CoPs for anesthesia services, CMS considers the areas where anesthesia services are furnished and may include operating room suite(s), both inpatient and outpatient; obstetrical suite(s); radiology departments; clinics; emergency departments; psychiatry departments; outpatient surgery areas and special procedure areas (e.g., endoscopy suites, pain management clinics, etc.). Moreover, administering anesthesia must only be by:

    1. A qualified anesthesiologist;
    2. A non-anesthesiologist MD or DO;
    3. A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under State law;
    4. A CRNA who is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed; or
    5. An anesthesiologist’s assistant who is under the supervision of an anesthesiologist who is immediately available if needed.

    These requirements concerning who may administer anesthesia do not apply to the administration of topical or local anesthetics, minimal sedation, or moderate sedation.

    The CRNA supervision requirement (number (iv), above) applies in States that have not opted out of the requirement. States may opt out of the CRNA supervision requirement by sending a letter, signed by the State’s governor, to CMS concluding that it is in the best interest of the State’s citizens to opt out of the physician supervision requirement (42 CFR 482.52(c))1. According to CMS, as of October 2010, sixteen (16) states have chosen to opt out: California, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, South Dakota, Wisconsin, Montana and Colorado. Notably, this rule does not require hospitals to allow CRNAs to practice unsupervised; this rule merely exempts those States that have opted out from requiring supervision of CRNAs as a condition to Medicare reimbursement.

    For those remaining thirty-four (34) states that have not opted out, the requirement that the operating practitioner or anesthesiologist be “immediately available” is satisfied if the operating practitioner or anesthesiologist is “physically located within the same area as the CRNA, e.g., in the same operative/ procedural suite, or in the same labor and delivery unit, and not otherwise occupied in a way that prevents him/her from immediately conducting hands-on intervention, if needed.” This supervision requirement is intended to ensure the safety of the patients while also allowing the anesthesiologists to simultaneously tend to multiple patients, thus providing for more efficient delivery of care.

    HHS’ Plan for Retrospective Review of Existing Rules Targets Anesthesia

    However, these rules may change with HHS’ and CMS’ upcoming review. As part of its Plan, HHS agencies identified regulations that that will be reviewed over the next two years. One of CMS’ areas of review includes the hospital CoPs. Specifically, CMS will be reviewing the CoPs for anesthesia services (42 CFR 482.52) in response to the following comment:

    Many regulations requiring a “physician” to perform procedures or at least supervise them are called unnecessary by commenters because oftentimes the work can be done just as easily by Certified Registered Nurse Anesthetists (CRNAs) and other Advanced Practice Registered Nurses (APRNs). Similarly, this commenter wrote that current regulations, 42 CFR part 482.52(a)(4) require unnecessary supervision by an “operating practitioner or an anesthesiologist” upping costs by increasing staff members but not safety. This commenter summed up these particular concerns by, “suggest[ing] that all regulations and interpretive guidelines issued by CMS be reviewed with the intent of removing restrictions concerning anesthesia services provided by nurse anesthetists.”

    CMS argues that the purpose of reviewing the hospital CoPs would be to “remove or revise multiple requirements that are inconsistent with other requirements or impose unnecessary burdens to increase flexibility.” CMS indicates that the review of the hospital CoPs would result in an estimated $600 million in savings, annually.

    According to the American Society of Anesthesiologists (“ASA”), while CRNAs are certainly valuable, they are only qualified to perform some anesthesia services and are not qualified to perform all anesthesia services. In other words, a CRNA does not equal an anesthesiologist. The ASA contends that CRNAs should supplement an anesthesiologist’s practice by performing services under that anesthesiologist’s supervision, pursuant to the current regulations. The AANA categorically disagrees.

    The ASA also takes the position that when anesthesiologists are involved in procedures, the anesthesiologist plays the role of the perioperative physician in which s/he is solely responsible for providing comprehensive care to the patient during the entirety of the procedure. Moreover, the ASA states that it is because of the anesthesiologist’s over twelve (12) years of formal training that s/he is knowledgeable enough to evaluate all aspects of a patient’s condition, taking into account all of the potential risks. A 2000 study published in Anesthesiology found that death and failure-to-rescue deaths were greater when care was not directed by anesthesiologists.

    Last year, however, an article appeared in Health Affairs that marshaled data to show that there were no differences in outcomes between anesthesiologists and CRNAs.

    As stated above, lifting the requirement that CRNAs be supervised when performing anesthesia services would affect Medicare Part B payment policies, but lifting the requirement does not necessarily imply that CRNAs will immediately begin providing services independently. CRNAs can only perform services independently if the hospital in which they perform those services embraces a supervision-free environment. The ASA urges anesthesiologists to continue working with their local and national anesthesia associations and lobbying organizations to encourage CMS to reject the commenter’s suggestion. The American Association of Nurse Anesthetists has worked long and hard to eliminate the supervision requirement, and it will also urge its members to use the HHS-CMS review of the CoPs to further its professional goals. No one can predict the outcome, but everyone who wishes will have a chance to be heard, directly or indirectly.

    Neda Mirafzali, Esq., is an associate attorney with the Health Law Partners, PC and practices in all areas of health care law, assisting clients with transactional and corporate matters; representing providers and suppliers in health care litigation matters; providing counsel regarding compliance and reimbursement matters; and representing providers and suppliers in third party payor audit appeals. She can be reached at (248) 996-8510 or at

    [1] The CoPs for ambulatory surgery centers (“ASCs”) (42 CFR 416.42) and critical access hospital (“CAHs”) (42 CFR 485.639) provide that CRNAs can administer anesthesia services when under the supervision of an operating physician. These CoPs likewise allow States to opt out of this requirement.

  • Putting Your Anesthesiology Practice on Wheels

    Shawn Michael DeRemer, MD
    Gregg M. White, CRNA, MS
    Anesthesia Associates Northwest, LLC (AANW), Portland, OR

    Health care delivery has gradually shifted from in-hospital to outpatient settings, most recently to physicians’ offices. In fact, in 2009 the number of office-based procedures in the United States numbered 12 million. Nevertheless, though outpatient surgery may be more convenient and financially beneficial for both doctors and patients, many physicians are not taking advantage of the full realm of possible procedures that could be offered in an office setting.

    In 2010, we decided to expand our own anesthesia management and staffing services business by helping physicians expand their practices. Our idea was to bring the surgical suite to physicians’ offices via a fully equipped van that would deliver all necessary resources — and also foster a “culture of safety.”

    What We Needed

    We went to task outfitting a slick- looking van with everything a physician might need to ensure efficiency and safety during the delivery of anesthesia for office-based surgery. After months of labor pains, the AANW mobile anesthesia van service was born in January 2011.

    The process of purchasing and equipping a van started by identifying our requirements, choosing a vehicle manufacturer and comparison-shopping for vans. We also worked closely with vendors to get the best deal on equipment. In addition to monitoring equipment, oxygen, supplies and drugs, we bought battery back-ups to cover power outages. We also drew up a safety checklist and maintenance schedules for the van and equipment. Lastly, we procured a parking space, with special lights and camera surveillance, outside our business office.

    Altogether the start-up costs totaled well beyond the six-figure mark.

    What We Provide

    Sticker shock aside, we ended up with a sleek Mercedes Sprinter van with state- of-the-art anesthesia equipment. The intent is to bring all-inclusive anesthesia resources/equipment/supplies, along with pharmaceuticals and anesthesia clinicians. This eliminates all financial and many of the legal burdens on the surgeon/physician. Additionally, the surgeon can do what he does best. Instead of monitoring the patient before, during and after receiving anesthesia, the doctor can concentrate on the procedure at hand.

    We work flexibly with our client medical practices to provide a staffing model that suits their needs — whether an MD-only model, a CRNA-only model, or a combination of the two. Our Quality Assurance/Safety Director and our Director of Practice Management collaborate with the medical team to ensure best business and safety practices and provide recommendations when needed.

    Some of our regular clients have blocked days where they schedule and then notify us of the cases. Others call to check for availability and we coordinate times with their offices. Paperwork is faxed over and folders are prepared, which our anesthesia providers collect the day of the procedure for transport.

    Appointments are confirmed one business day prior to the scheduled time. We arrive approximately one hour prior to the procedure to set up and do intake with the patient, including pre-anesthesia evaluation, vital signs, answering questions, etc. The average case time is one to two hours, and we remain with the patient until he/she is fully recovered (approximately 20 to 25 minutes).

    All equipment and supplies are removed and returned to the office for documentation and are cleaned and checked for the next scheduled case.

    All mobile cases are billed by time to the physician’s office. The physician collects from the patient. If the patient has insurance they can submit the invoice for reimbursement.

    Safety First

    Highly publicized fatalities such as the death of Kanye West’s mother have drawn attention to the safety of office-based procedures, which are unregulated in all but 23 states. Moreover, a vast majority of medical practices lack accreditation by one of the major accrediting agencies (AAAHC, AAAASF, JCAHO). With or without an anesthesia care team such as the one we provide, safety is a critical issue we knew we had to address.

    With this in mind, we collaborate with office-based practices to create a “culture of safety.” (We use a safety checklist similar to the one developed by the Institute for Safety in Office-Based Surgery, which appears on page 8 of this issue of the Communique?.)

    The safety checklist gives our clients details on what to expect and familiarizes them with our specialized anesthesia service, including perioperative management; complications and recovery; medications and sedation. We assess the facility itself to ensure it is up to par and help with patient and procedure selection. Before surgery we also contact the patient by phone to answer questions and further assess suitability.

    Monitoring during the recovery period is perhaps the most important service we provide. One study showed that 46% of adverse office-based incidents leading to an ASA claim were deemed preventable by better monitoring—e.g., by pulse oximetry in the postoperative setting. (Source: Domino KB. Office- based anesthesia: lessons learned from the Closed Claims Project. ASA Newsletter 2001;65(6):9-11, 15)

    Whom We Work With

    When we launched our mobile service, the majority of our cases were at small dental/endodontic offices and orthopedic practices. Today, we are working with all types of practices (ophthalmologists, podiatrists, dermatologists, endoscopists, cosmetic and plastic surgeons, and others), and we are called on to provide anesthesia for a wide variety of office-based procedures, including hysteroscopies, LEEP procedures and sterilization, cone biopsy, endometrial ablations, etc.

    Marketing 101

    In developing the marketing materials for our mobile services, we focused on several messages and how these messages can be translated to the patient, including:

    • We’re there so the doctor can do what he does best. Few patients really warm up to the thought that their surgeon is multi-tasking during an operation. The presence of an anesthesia clinician allows the doctor to do the procedure in the office and make himself or herself look good at the same time. It also enables the surgeons to focus on what they do best.
    • More revenue for the doctor; less cost for the patient. In today’s economy, all of us are trying to find ways to increase revenue. This is one way a doctor or dentist can do so while also saving the patient and/or insurance company money. (By the way, cost containment for the patient is a significant, though often overlooked, benefit. Many patients pay 20% of medical costs out of pocket, and many procedures (dental, cosmetic) aren’t covered by insurance at all. Eliminating the hospital facility fee greatly reduces the patient’s bill.)
    • The advantages of our mobile service also centers on convenience and efficiency, both for the surgeon and for the patient. By using our services, the surgeon has the potential to see patients in between procedures. There’s no time wasted driving offsite to a hospital or surgical facility. And, patients enjoy the safety and convenience of a hospital in a familiar office setting with experienced board certified anesthesiologists or AANA-certified nurse anesthetists by their side.
    • Up-to-date equipment and knowledge benefits everyone. In the past two years anesthesia has evolved; huge technological advances have been made. Surgeons can’t be expected to keep up. Those practices that have purchased anesthesiology equipment often have an outdated, hodge-podge solution that won’t meet the needs of all patients and all procedures. A mobile anesthesia service like ours mitigates all these factors.

    Lessons Learned

    From a service provider’s perspective, under-utilization is the biggest risk and a lesson we quickly learned. Our van is in service an average of 3.5 days a week (with an average of 2 cases per day), which means it is parked in our garage at our facility, not earning any revenue for the rest of the week.

    To ensure the van doesn’t break down on the way to a procedure, we purchased full service maintenance contracts from the van manufacturer, and we follow preventive maintenance cycles to minimize wear and tear and reduce the risk of breakdowns.

    In addition to the up-front costs of establishing a mobile anesthesia service, a provider has to bear the ongoing costs of doing business. Vehicle maintenance and equipment refurbishing costs are a major expense, and there are other ongoing costs that are unique to a mobile service. For example, we need medical and equipment-related insurance, as well as insurance on the vehicle, both for the van and the contents inside.

    Though it’s too early to project profitability, the mobile anesthesia service has grown steadily since its inception in January 2011. It has expanded our customer base into places we never could have serviced had we maintained only our outsourced labor services.

    Even with less than maximum utilization, the bottom line in terms of community response and customer satisfaction has been positive for us. Doctors and patients alike appreciate the convenience of having the equipment and technical staff come to them. It has given us a leg up on competition and an image that is helpful in branding ourselves.

    In summary, there is definitely a market and need for mobile services such as ours, but start-up costs are high and profitability won’t be immediate. Nonetheless, we believe this is an opportunity to be in on the ground floor of an industry that is just beginning to take shape.

    Shawn Michael DeRemer, MD, is a board-certified anesthesiologist and Executive Medical Director of Anesthesia Associates Northwest, LLC (AANW) in Portland, Oregon, providing anesthesia management and staffing services to hospitals, surgery centers, and physicians’ offices. Dr. DeRemer also maintains a part-time clinical practice at several hospitals and surgery centers in the Portland metropolitan region. He can be reached at 503-201-1166 or at

    Gregg M. White, CRNA, MS, Executive Operational Director for Anesthesia Associates Northwest, LLC (AANW). Mr. White provides full-time administrative and operational support to AANW, while maintaining a part-time inpatient and ambulatory clinical practice at several Portland area hospitals and clinics. He can be reached at 503-577-4941 or at

  • Anesthesia Leadership in the Preoperative Clinic

    Bart Edwards, MBA, MHS
    Vice President of Client Services, ABC

    Anesthesia practices looking to optimize their value proposition at their respective facilities have sought a greater role in the preoperative preparation of their patients. The emphasis on efficiency and the continuity of care in recently suggested models of healthcare reimbursement, including Accountable Care Organizations, have drawn renewed attention to opportunities within the preoperative clinic. The economic reality is that providers and facilities are not getting paid to provide those services under current reimbursement rules. Preoperative clinics can provide benefits in quality of care and cost reduction, in addition to the significance of improving patient and surgeon satisfaction. Anesthesia practices are in a unique position to develop the preoperative clinic into a valuable resource.

    The expenses of a poorly performed preoperative assessment are borne by both the surgical department and anesthesia provider (as well as by the patient) in the form of poor utilization. Patient satisfaction and outcomes are affected by delays and improper risk minimization strategies. The increased costs of surgical setup, sterilization, and vacant room time for each delay or cancellation are measurable and significant. Reduced productivity for ancillary staff, surgeons and anesthesia providers may be the most painful financial consequence of poor preoperative preparation.

    Parish Management Consultants’ Preanesthesia Clearance and Evaluation (PACE) Clinic

    Parish Management Consultants, LLC is one of many anesthesia practices that are seizing the opportunity to improve the surgical care experience for its surgeons and patients. Several Louisiana hospitals have approached Parish for assistance in reducing same day cancellations and improvement in on-time starts by initiating or improving preop clinics. Parish has partnered with multiple facilities in Baton Rouge, Lafayette and New Orleans to establish a Preanesthesia Clearance and Evaluation (PACE) Clinic.

    Al Patin, RN, MBA, Regional Vice President for Parish Management Consultants admits, “We had a huge issue getting patients to the room on time.” The facility at which the first PACE was developed and the practice set to work. They selected increasing the number of on time starts as the primary metric to monitor progress. Other indicators include surgeon satisfaction surveys and cancellation rates. Mr. Patin indicates, “The goal is to keep patients and surgeons happy, and efficiency does that.”

    There is some debate regarding the type of provider to staff the PACE clinic. While an RN can perform many of the necessary functions, Parish recommends a nurse practitioner as the manager of its PACE clinic. Parish Management Consultants signs a Collaborative Practice Agreement, accepting the opportunity along with its hospital partner to guide the nurse practitioner in this role. Another Parish facility is considering a CRNA in that position, which is higher from a cost perspective. “Some facilities will pay the premium to place a CRNA in that role, either as an employee or out of subsidized dollars.” The benefits of increased efficiency and increased user satisfaction are not hard dollars, but the cost of the provider is black and white. This is compounded by decreasing reimbursement opportunities overall, and for preoperative evaluation services in particular.

    Most facilities will provide surgical schedulers with a telephone guideline to select the patients who must present for personal preop screening prior to the day of surgery, often based on ASA Physical Status. Other practices have triaged the scheduled patients into tiers based on co- morbidity, age and planned procedure. At one facility, one hundred percent of the surgical patients come through its PACE clinic. “All patients come through the PACE, but anesthesia does not touch them all.” The Parish doctors set up an algorithm based on the ASA guidelines for the preoperative assessment. The nurse practitioner calls in an anesthesiologist for sicker patients, but the hope is that even this can be reduced with greater experience.

    With the training and process in place, “We let her go,” said Mr. Patin. In many cases, the nurse practitioner is able to provide a more detailed history and physical to supplement that provided by the surgeon. This is of significant value to the anesthesia provider. Evidence-based algorithms for necessary preoperative testing are used instead of standing orders for routine exams to tamp down overutilization and expenses. The results of the assessment are recorded in the patient’s electronic medical record (EMR).

    The long list of items that needs to be coordinated prior to surgery can include evidence-based lab testing, EKG, radiology study, informed consent, and patient education. Further challenges for preoperative assessment include risk identification, stratification and reduction. The PACE clinic collects and maintains these results and reviews them in a single location prior to the schedule procedure date. The complete preop workup is then made available on the day of surgery to the assigned anesthesia provider and the entire perioperative team within the EMR.

    The impact of the increased attention to the preop clinic has been positive. In the first three months one Parish facility has seen the percentage of its on time starts improve 25%. In fact, most delays are now surgeon driven. “We learned that we had trained our surgeons to be late,” said Mr. Patin. The clinic is a first step, “it starts with the process – not people or supplies.” The hospital performs annual surveys, and it is expected that the increased efficiency will yield higher surgeon satisfaction scores. Regarding the goal of the program, Mr. Patin stated “Ultimately efficiency dictates whether the surgeon will be comfortable coming back.”

    Increased anesthesia direction in the preoperative clinic can reduce stress and provide a more streamlined experience for patients. The better trained and monitored clinic providers can correctly identify and accommodate co-morbidity in advance of the scheduled procedure.

    For the anesthesia practice, fewer delays and cancellations decrease the unused operating room time and drive up utilization. More work can be done by each scheduled provider, with higher efficiency and a better return per hour worked. The increased responsibility and integration through the clinic strengthens the relationship with the facility. The further benefit will be to demonstrate anesthesia’s added value in the preoperative clinic when discussing non fee-for-service reimbursement models.

    Bart Edwards, MBA, MHS serves as Vice President of Client Services for ABC clients in the Eastern US. After receiving an MBA and MHS from the University of Florida, Mr. Edwards spent twelve years providing management expertise to hospital based physician practices. Since joining ABC, he has worked with anesthesia practices to demonstrate their value in and outside the operating room. Mr. Edwards gratefully acknowleges the expertise shared by Al Patin of Parish Management Consultants in this article. He can be reached at

  • The Institute For Safety in Office-Based Surgery (ISOBS)

    Fred E. Shapiro, D.O.
    Assistant Professor of Anesthesia, Harvard Medical School, Boston - ISOBS Founder

    In recent years, the economic pressures of medicine have incited a paradigm shift in health care delivery, such that surgical procedures are moving from the hospital to the office-based setting. Often called the “wild west of health care,” office- based procedures continue to increase at a rapid pace, with an estimated more than 10 million procedures performed in 2010. A growing body of literature calls for greater leadership in the field of office-based surgery, and for leaders who are educated in all facets of quality improvement. In addition, a recent study found that a comprehensive checklist used in an interdisciplinary, team-based setting resulted in a reduction in surgical complications as well as cost savings.

    Development of such a checklist and education of practitioners, patients, and office personnel is the mission of the Institute for Safety in Office-Based Surgery. An independent, non-profit 501(c)(3) organization, ISOBS has developed a safety checklist for use in the office-based setting. The checklist, shown in Figure 1, calls on engagement from RNs, MAs, PAs and physicians to ensure safe care. Perhaps most important, the checklist is fully customizable to a variety of office-based settings, from elective plastic surgery to ophthalmology. ISOBS recently completed a retrospective chart review using the checklist, and is now proceeding to the prospective phase of checklist deployment. In addition, ISOBS is developing web-based educational modules for practitioners on using the checklist.

    The need for leadership in office- based procedure performance is clear. Without tools to aid patient safety, neither practitioners nor patients will have the security they deserve. Using a comprehensive safety checklist as well as associated educational modules, ISOBS aims to fill this void and supply practitioners with innovative yet common sense tools to protect their patients.

    For further information, see Shapiro FE, Durman RD. Office-Based Anesthesia and Surgery: Creating a Culture of Safety. ASA Newsl. 2011; 75(8);10-12. ISOBS also publishes a complimentary electronic newsletter to which you may subscribe through the organization’s website,

    ISOBS will host a reception at the ASA Annual Meeting in Chicago on Friday, Oct. 14, 2011 honoring Atul Gawande, MD and Mark Warner, MD, for their contributions to the field of patient safety.

    Fred E. Shapiro, DO, is Assistant Professor of Anesthesia, Harvard Medical School, Beth Israel Deaconess Medical Center Department of Anesthesia Critical Care and Pain Medicine, Boston, MA. He is Co-Founder of The Institute for Safety in Office-Based Surgery (ISOBS), Immediate Past President of the Massachusetts Society of Anesthesiologists and member of ASA Committees on Patient Safety and Education, Quality Management and Departmental Administration (QMDA), Governmental Affairs, and Ambulatory Surgical Services. He can be reached at

  • Pre- and Post-Anesthesia Assessment: Role of the AQI

    Richard P. Dutton, MD, MBA
    Executive Director, Anesthesia Quality Institute, Park Ridge, IL

    Electronic capture of patient information before and after surgery is an essential component of an effective anesthesia quality management program.

    • Postoperative data are the outcomes of our work. These include rare safety issues related to intraoperative care, but not always apparent in the OR or PACU: events like neurologic injury, myocardial infarction, aspiration pneumonia or complications of pain management. More common, and increasing in importance, are the “patient-centered” outcomes which will be used by external regulators to judge us: the occurrence of nausea and vomiting, the adequacy of pain management, and overall patient satisfaction.
    • Preoperative information, on the other hand, is the substrate for understanding anesthesia risks. Comparison of outcomes across institutions will require careful risk adjustment, and electronic capture of pre-existing conditions, chronic medications and pertinent diagnostic studies will enable this process. Even information as simple as the ASA physical status can be a powerful tool for understanding anesthesia outcomes across broad populations.

    As proprietor of the National Anesthesia Clinical Outcomes Registry, the Anesthesia Quality Institute is a strong proponent of electronic data capture in all phases of anesthesia care. The more practices can make preoperative and postoperative data available, the sooner we will have robust national benchmarks for anesthesia performance. The good news is that there are a number of companies and products emerging to fill this need, as well as a variety of innovative solutions. Many vendors of Anesthesia Information Management Systems (AIMS) have been offering PACU record keeping for years, often including a Quality Management form to capture outcomes and complications. Many of these forms now follow the categories and definitions established by the ASA Committee on Performance and Outcome Measures, and freely available on the AQI website ( The 26 adverse outcomes established by this committee appear in Table 1. A sample definition from the same committee report is in Figure 1.

    The more foresighted AIMS vendors are expanding even further, to include modules that can be used by anesthesiologists and their facilities to record post-discharge follow-up. Traditional barriers to this effort are slowly eroding. Concern with legal discovery has led to systems that route QM forms to a different database from the AIMS medical record; the need to submit requests for reimbursement promptly has led to partition of postoperative records within the global EMR, so that the case can still be “closed out” in a timely fashion. And the difficulty of interfacing the AIMS with the institutional EMR is moderating with the general growth in interoperability across healthcare information technology, and with the evolution of local data repositories that aggregate information from multiple platforms.

    For practices not yet using an AIMS, there now exist a variety of stand-alone preoperative and postoperative data capture systems. Notable among these is ePreop, which draws on the AQI schema and definitions to provide a “one-stop shop” for coordinating the care of perioperative patients. ePreop software now extends to cover the capture of outcome and satisfaction information as well. Other programs, such as Fides, are designed to make it easy to enter patient feedback from postoperative phone calls into a database that links to the original case. No one technical solution will be right for every practice situation, but it is encouraging that software now exists to enable the basic steps of: 1) gathering outcomes from patients, 2) linking those outcomes to records of the surgery itself, and 3) reporting that data in digital form on both the local and national level.

    Every anesthesia practice needs to understand the outcomes it achieves, and that AQI exists to aggregate those outcomes and create national benchmarks. Eighty-three percent of AQI participants collect and report some outcomes from their cases, and already benefit from an improved understanding of their own practice. ABC and ePreop are committed to facilitating this advance in care, and to the general improvement of safety.

    ABC is proud to be an AQI Preferred Vendor and a partner of ePreop.

    Richard P. Dutton, MD, MBA is Visiting Professor of Anesthesiology, University of Maryland School of Medicine and AQI Executive Director. To contact Dr. Dutton or the AQI, visit