A matrix model for valuing anesthesia service with the resource-based relative value system.

BACKGROUND: The purpose of this study was to propose a new crosswalk using the resource-based relative value system (RBRVS) that preserves the time unit component of the anesthesia service and disaggregates anesthesia billing into component parts (preoperative evaluation, intraoperative management, and postoperative evaluation). The study was designed as an observational chart and billing data review of current and proposed payments, in the setting of a preoperative holing area, intraoperative suite, and post anesthesia care unit. In total, 1,195 charts of American Society of Anesthesiology (ASA) physical status 1 through 5 patients were reviewed. No direct patient interventions were undertaken. RESULTS: Spearman correlations between the proposed RBRVS billing matrix payments and the current ASA relative value guide methodology payments were strong (r=0.94-0.96, P<0.001 for training, test, and overall). The proposed RBRVS-based billing matrix yielded payments that were 3.0%±1.34% less than would have been expected from commercial insurers, using standard rates for commercial ASA relative value units and RBRVS relative value units. Compared with current Medicare reimbursement under the ASA relative value guide, reimbursement would almost double when converting to an RBRVS billing model. The greatest increases in Medicare reimbursement between the current system and proposed billing model occurred as anesthetic management complexity increased. CONCLUSION: The new crosswalk correlates with existing evaluation and management and intensive care medicine codes in an essentially revenue neutral manner when applied to the market-based rates of commercial insurers. The new system more highly values delivery of care to more complex patients undergoing more complex surgery and better represents the true value of anesthetic case management.

Knowledge-assisted sequential pattern analysis with heuristic parameter tuning for labor contraction prediction.

The optimal dosing regimen of remifentanil for relieving labor pain should achieve maximal efficacy during contractions and little effect between contractions. Toward such a need, we propose a knowledge-assisted sequential pattern analysis with heuristic parameter tuning to predict the changes in intrauterine pressure,which indicates the occurrence of labor contractions. This enables giving the drug shortly before each contraction starts. Asequential association rule mining based patient selection strategy is designed to dynamically select data for training regression models. A novel heuristic parameter tuning method is proposed to decide the appropriate value ranges and searching strategies for both the regularization factor and the Gaussian kernel parameter of leastsquares support vector machine with radial basis function (RBF) kernel, which is used as the regression model for time series prediction. The parameter tuning method utilizes information extracted from the training dataset, and it is adaptive to the characteristics of time series. The promising experimental results show that the proposed framework is able to achieve the lowest prediction errors as compared to some existing methods.

Transition to a novel advanced integrated vitrectomy platform: comparison of the surgical impact of moving from the Accurus vitrectomy platform to the Constellation Vision System for microincisional vitrectomy surgery.

BACKGROUND: Microincisional vitrectomy surgery (MIVS) is the current standard surgical approach for pars plana vitrectomy. Historically, the most common surgical platform for vitrectomy surgery, since its introduction in 1997, has been the Accurus vitrectomy system. Recent introduction of the next generation of vitrectomy platforms has generated concerns associated with transitioning to new technology in the operating room environment. This study compared, in a matched fashion, surgical use of the Accurus vitrectomy system and the next generation Constellation Vision System to evaluate surgical efficiencies, complications, and user perceptions of this transition. METHODS: Electronic health records were abstracted as a hospital quality assurance activity and included all vitreoretinal surgical procedures at the Bascom Palmer Eye Institute, Anne Bates Leach Eye Hospital, during two discrete 12-month time periods. These two periods reflected dedicated usage of the Accurus (June 2008-May 2009) and Constellation Vision (July 2009-June 2010) systems. Data were limited to a single surgeon and evaluated for operating room (OR) total time usage/day, OR case time/case, and OR surgical time/case. Further analysis evaluated all patients undergoing combined MIVS and clear cornea phacoemulsification/intraocular lens (IOL) implantation during each individual time period to determine the impact of the instrumentation on these parameters. All records were evaluated for intraoperative complications. RESULTS: Five hundred and fourteen eligible patients underwent MIVS during the 2-year study windows, with 281 patients undergoing surgery with the Accurus system and 233 patients undergoing surgery with the Constellation system. Combined MIVS and phacoemulsification with IOL implantation was performed 141 times during this period with the Accurus and 158 times during the second study period with the Constellation. Total number of patients operated per day increased from 7.55 with Accurus to 8.53 with Constellation. Surgical room time decreased from 56 minutes with Accurus to 52 minutes with Constellation, and procedure time decreased from 35 minutes with Accurus to 31 minutes with Constellation (P < 0.004). Combined MIVS/phacoemulsification surgery saw similar declines in surgical room time and procedure time (P < 0.001). Subset analysis of procedures limited by case number per day (eg, four cases/day, five cases/day, six cases/day, and seven or more cases/day) showed similar outcomes with a decrease in surgical room time and procedure time. No increases in surgery-related complications were noted by quality assurance review during these time periods. DISCUSSION: Transitioning to advanced surgical technology is a complex issue for the surgeon, the hospital team, and the hospital administration. This study documents improvement in three significant measures of surgical efficiency: operative number of patients per day, operative room time, and surgical procedure time that reflect the positive impact of the novel, combined, integrated, posterior and anterior, ophthalmologic surgical platform of the Constellation Vision System. These data are imperative to evaluate the impact of transition from one surgical platform to another. During this transition, hospital quality assurance review and surgeon evaluation of operative complications showed no increased concerns for the shift from the Accurus to the Constellation Vision System surgical platform. Further, both operative staff and surgeons felt that the transition to the Constellation was not associated with increases in difficulty with setup, turnover, or use and that the Constellation decreased safety concerns for surgical usage. Ultimately, in this case, new technology benefited the surgeon, the patient, and the hospital.

Prediction of uterine contractions using knowledge-assisted sequential pattern analysis.

The usage of the systemic opioid remifentanil in relieving the labor pain has attracted much attention recently. An optimal dosing regimen for administration of remifentanil during labor relies on anticipating the timing of uterine contractions. These predictions should be made early enough to maximize analgesia efficacy during contractions and minimize the impact of the medication between contractions. We have designed a knowledge-assisted sequential pattern analysis framework to 1) predict the intrauterine pressure in real time; 2) anticipate the next contraction; and 3) develop a sequential association rule mining approach to identify the patterns of the contractions from historical patient tracings (HT).

Future of electronic health records: implications for decision support.

The potential benefits of the electronic health record over traditional paper are many, including cost containment, reductions in errors, and improved compliance by utilizing real-time data. The highest functional level of the electronic health record (EHR) is clinical decision support (CDS) and process automation, which are expected to enhance patient health and healthcare. The authors provide an overview of the progress in using patient data more efficiently and effectively through clinical decision support to improve health care delivery, how decision support impacts anesthesia practice, and how some are leading the way using these systems to solve need-specific issues. Clinical decision support uses passive or active decision support to modify clinician behavior through recommendations of specific actions. Recommendations may reduce medication errors, which would result in considerable savings by avoiding adverse drug events. In selected studies, clinical decision support has been shown to decrease the time to follow-up actions, and prediction has proved useful in forecasting patient outcomes, avoiding costs, and correctly prompting treatment plan modifications by clinicians before engaging in decision-making. Clinical documentation accuracy and completeness is improved by an electronic health record and greater relevance of care data is delivered. Clinical decision support may increase clinician adherence to clinical guidelines, but educational workshops may be equally effective. Unintentional consequences of clinical decision support, such as alert desensitization, can decrease the effectiveness of a system. Current anesthesia clinical decision support use includes antibiotic administration timing, improved documentation, more timely billing, and postoperative nausea and vomiting prophylaxis. Electronic health record implementation offers data-mining opportunities to improve operational, financial, and clinical processes. Using electronic health record data in real-time for decision support and process automation has the potential to both reduce costs and improve the quality of patient care.

Perioperative cardiac evaluation of simulated patients by practicing anesthesiologists is not consistent with 2007 ACC/AHA guidelines.

STUDY OBJECTIVE: To determine if practicing anesthesiologists recommend preoperative evaluations consistent with the 2007 ACC/AHA guidelines on perioperative care. DESIGN: Survey instrument. SETTING: Academic medical center. SUBJECTS: ASA membership. MEASUREMENTS: In this Web-based survey, participants were presented with 6 clinical scenarios characterized by surgical procedure and the patient's clinical condition (ie, clinical risk factors and functional capacity). Scenarios and possible recommendations were presented randomly. Participants were asked to select the recommendation they considered to be most consistent with the Guidelines. The percentage of participants selecting the recommendation most consistent with the 2007 Guidelines was recorded. MAIN RESULTS: Of the 22,504 actively practicing members of the ASA who were sent a survey, 1,595 actively practicing self-selected anesthesiologists responded. For one of 6 scenarios, patients with an active cardiac condition, the upper 95% confidence bound for the percent selecting a recommendation consistent with the Guidelines was 82%. For the remaining 5 scenarios, the upper 95% confidence bound for the percent of anesthesiologists with an appropriate recommendation did not exceed 40%. With the exception of the scenario describing a patient with an active cardiac condition, respondents were more likely to provide recommendations consistent with the Guidelines if they had been in practice less than 5 years or worked in a teaching environment. CONCLUSION: When evaluating simulated patients, practicing anesthesiologists who are ASA members did not recommend preoperative evaluations that were consistent with the 2007 ACC/AHA Guidelines.

Shortcomings and challenges of information system adoption.

The number of institutions implementing AIMS is increasing. Shortcomings in the design and implementation of EMRs have been associated with unanticipated consequences, including changes in workflow. These have often resulted from the carryover of paper-based documentation practices into an electronic environment. The new generation of mobile devices allows providers to have situational awareness of multiple care sites simultaneously, possibly allowing for improved proactive decision making. Although potentially facilitating safer anesthetic supervision, technologic and cultural barriers remain. Security, quality of information delivery, regulatory issues, and return on investment will continue as challenges in implementing and maintaining this new technology.

Can children undergoing ophthalmologic examinations under anesthesia be safely anesthetized without using an IV line?

PURPOSE: To document that with proper patient and procedure selection, children undergoing general inhalational anesthesia for ophthalmologic exams (with or without photos, ultrasound, laser treatment, peri-ocular injection of chemotherapy, suture removal, and/or replacement of ocular prosthesis) can be safely anesthetized without the use of an intravenous (IV) line. Children are rarely anesthetized without IV access placement. We performed a retrospective study to determine our incidence of IV access placement during examinations under anesthesia (EUA) and the incidence of adverse events that required intraoperative IV access placement. METHODS: Data collected from our operating room (OR) information system includes but is not limited to diagnosis, anesthesiologist, surgeon, and location of IV catheter (if applicable), patient's date of birth, actual procedure, and anesthesia/procedure times. We reviewed the OR and anesthetic records of children (>1 month and <10 years) who underwent EUAs between January 1, 2003 and May 31, 2009. We determined the percentage of children who were anesthetized without IV access placement, as well as the incidence of any adverse events that required IV access placement, intraoperatively. RESULTS: We analyzed data from 3196 procedures performed during a 77-month period. Patients' ages ranged from 1 month to 9 years. Overall, 92% of procedures were performed without IV access placement. Procedure duration ranged from 1-39 minutes. Reasons for IV access placement included parental preference for antinausea medication and/or attending preference for IV access placement. No child who underwent anesthesia without an IV line had an intraoperative adverse event requiring insertion of an IV line. CONCLUSION: Our data suggest that for children undergoing general anesthesia for ophthalmologic exams (with or without photos, ultrasound, laser treatment, intraocular injection of chemotherapy, suture removal, and/or replacement of ocular prosthesis), anesthesia can be safely conducted without placement of an IV line.

2007 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on perioperative cardiac evaluation are usually incorrectly applied by anesthesiology residents evaluating simulated patients.

BACKGROUND: The 2007 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on Perioperative Cardiac Evaluation and Care for Noncardiac Surgery is the accepted standard for perioperative cardiac evaluation. Anesthesiology training programs are required to teach these algorithms. We estimated the percentage of residents nationwide who correctly applied suggested testing algorithms from the ACC/AHA guidelines when they evaluated simulated patients in common clinical scenarios. METHODS: Anesthesiology resident volunteers at 24 training programs were presented with 6 scenarios characterized by surgical procedure, patient's risk factors, and patient's functional capacity. Scenarios and 5 possible recommendations per scenario were both presented in randomized orders. Senior anesthesiologists at 24 different United States training programs along with the first author of the 2007 ACC/AHA guidelines validated the appropriate recommendation to this web-based survey before distribution. RESULTS: The 548 resident participants, representing 12% of anesthesiology trainees in the United States, included 48 PGY-1s (preliminary year before anesthesia training), 166 Clinical Anesthesia Year 1 (CA-1) residents, 161 CA-2s, and 173 CA-3s. For patients with an active cardiac condition, the upper 95% confidence bound for the percent of residents who recommended evaluations consistent with the guidelines was 78%. However, for the remaining 5 scenarios, the upper 95% confidence bound for the percent of residents with an appropriate recommendation was 46%. CONCLUSIONS: The results show that fewer than half of anesthesiology residents nationwide correctly demonstrate the approach considered the standard of care for preoperative cardiac evaluation. Further study is necessary to elucidate the correct intervention(s), such as use of decision support tools, increased clarity of guidelines for routine use, adjustment in educational programs, and/or greater familiarity of responsible faculty with the material.

Intravitreal injection analysis at the Bascom Palmer Eye Institute: evaluation of clinical indications for the treatment and incidence rates of endophthalmitis.

OBJECTIVE: To report the incidence of endophthalmitis, in addition to its clinical and microbiological aspects, after intravitreal injection of vascular-targeting agents. METHODS: A retrospective review of a consecutive series of 10,142 intravitreal injections of vascular targeting agents (bevacizumab, ranibizumab, triamcinolone acetonide, and preservative-free triamcinolone acetonide) between June 1, 2007 and January 31, 2010, performed by a single service (TGM) at the Bascom Palmer Eye Institute. RESULTS: One case of clinically-suspected endophthalmitis was identified out of a total of 10,142 injections (0.009%), presenting within three days of injection of bevacizumab. The case was culture-positive for Staphylococcus epidermidis. Final visual acuity was 20/40 after pars plana vitrectomy surgery. CONCLUSIONS: In this series, the incidence of culture-positive endophthalmitis after intravitreal injection of vascular agents in an outpatient setting was very low. We believe that following a standardized injection protocol, adherence to sterile techniques and proper patient follow-up are determining factors for low incidence rates.

Is the immediate reversal of diastolic dysfunction of cirrhotic cardiomyopathy after liver transplantation a sign of the metabolic etiology?

Cirrhotic cardiomyopathy currently is believed to be a multifactorial entity. This communication describes a case of immediate intraoperative recovery of diastolic function following liver transplantation. This suggests that an underlying metabolic inhibition of myocardial metabolism is an important factor in the development of cardiomyopathy in end-stage liver disease. Liver Transpl 15:1417-1419, 2009. (c) 2009 AASLD.

Anesthesia information management system implementation: a practical guide.

Anesthesia Information Management Systems (AIMS) display and archive perioperative physiological data and patient information. Although currently in limited use, the potential benefits of an AIMS with regard to enhancement of patient safety, clinical effectiveness and quality improvement, charge capture and professional fee billing, regulatory compliance, and anesthesia outcomes research are great. The processes and precautions appropriate for AIMS selection, installation, and implementation are complex, however, and have been learned at each site by trial and error. This collaborative effort summarizes essential considerations for successful AIMS implementation, including product evaluation, assessment of information technology needs, resource availability, leadership roles, and training.

Targeting operating room inefficiencies in the complex management of vision-threatening diseases in children.

OBJECTIVE: To review the effect of interventions designed to decrease turnover time in infants and children (median age, 2.6 years; range, 1 month to 10 years) who required examinations under anesthesia. METHODS: Five efficiency interventions (3 anesthesia providers for 2 rooms, digital remote communication, change in patient scheduling, standardization of case order, and streamlining administration of preoperative medications) were implemented during a 4(1/2)-year period from January 2003 to July 2007. Using data from our in-house operating room information system, we analyzed turnover times (time it took 1 patient to leave the operating room and the next to enter). RESULTS: The mean turnover times decreased from 12.1 minutes to 3.8 minutes. The 90th percentile of longest turnover times decreased from 14.5 minutes in 2003 to 5.8 minutes in 2007, despite a progressive increase in the number of cases per day. CONCLUSION: Caring for children who require extensive examinations under anesthesia can be efficiently achieved in nonpediatric environments.

The use of an anesthesia information system to identify and trend gender disparities in outpatient medical management of patients with coronary artery disease.

BACKGROUND: Previous anesthesia information management systems-based studies have focused on intraoperative data analysis. Reviewing preoperative data could provide insight into the outpatient treatment of patients presenting for surgical procedures. As gender-based disparities have been demonstrated in the treatment of patients with cardiac disease, we hypothesized that there would be gender disparities in the outpatient pharmacologic management of patients with coronary artery disease (CAD) scheduled for elective noncardiac surgery. METHODS: We analyzed electronic medical records of ambulatory patients with CAD (prior myocardial infarction [MI], coronary artery bypass surgery, and angioplasty with or without stenting, angina) presenting for elective noncardiac surgery between 1/2004 and 6/2006 (30 mo) at an inner city hospital. RESULTS: Of 21,039 ambulatory patients seen in the preanesthesia clinic, 6.4% (1346) had CAD. Patients with CAD: Men were more likely to be taking beta-blockers (P < 0.002), statins (P < 0.0001), aspirin (P < 0.0001), and antiplatelet medications (P < 0.04), although there was a trend of increased use of aspirin (P < 0.01) by women over the course of the study. Patients with history of prior MI: Men with a prior MI were more likely to be taking beta-blockers (P < 0.0001) and statins (P < 0.02), although there was a trend of increased use of beta-blockers (P < 0.0005) and aspirin (P < 0.03) by women over the course of the study. Quarterly prevalence rates for outpatient medication use were greatest for beta-blockers and least for aspirin. Patients were more likely to be taking a statin, aspirin, or oral antiplatelet medication if they were receiving chronic beta-blocker therapy (P < 0.0001 for each medication). CONCLUSION: Aggregating anesthesia management information systems data provides an epidemiological perspective of community care of patients presenting for surgery. We found that gender disparities in outpatient medical treatment of patients with CAD, which previously favored men, have diminished primarily as a result of increased use of these medications in women. Nonetheless, despite evidence supporting the use of risk-reduction strategies, our patients are undertreated with standard medical therapies.

Discrepancies in medication entries between anesthetic and pharmacy records using electronic databases.

BACKGROUND: Accurate recording of disposition of controlled substances is required by regulatory agencies. Linking anesthesia information management systems (AIMS) with medication dispensing systems may facilitate automated reconciliation of medication discrepancies. METHODS: In this retrospective investigation at a large academic hospital, we reviewed 11,603 cases (spanning an 8-mo period) comparing records of medications (i.e., narcotics, benzodiazepines, ketamine, and thiopental) recorded as removed from our automated medication dispensing system with medications recorded as administered in our AIMS. RESULTS: In 15% of cases, we found discrepancies between dispensed versus administered medications. Discrepancies occurred in both the AIMS (8% cases) and the medication dispensing system (10% cases). Although there were many different types of user errors, nearly 75% of them resulted from either an error in the amount of drug waste documented in the medication dispensing system (35%); or an error in documenting the medication in the AIMS (40%). CONCLUSIONS: A significant percentage of cases contained data entry errors in both the automated dispensing and AIMS. This error rate limits the current practicality of automating the necessary reconciliation. An electronic interface between an AIMS and a medication dispensing system could alert users of medication entry errors prior to finalizing a case, thus reducing the time (and cost) of reconciling discrepancies.

Anesthesia information management systems: a survey of current implementation policies and practices.

BACKGROUND: Anesthesia information management systems (AIMS) implementation is increasing, but there are no published recommendations from anesthesia professional societies to guide configuration and policy decisions that affect billing, security, medical-legal, and compliance issues. METHODS: A 45-question structured survey was developed by a committee of the Society for Technology in Anesthesia and was sent to the clinical administrator at 18 separate institutions, comprising six different installed AIMS systems. The primary goal of the survey was to establish a baseline of current policies and practices. RESULTS: There was more than two-third agreement among respondents for only 25% of questions. A number of configurations reported may increase exposure to billing denial, Medicare and Medicaid noncompliance, security breeches, and medical-legal defense difficulties. CONCLUSIONS: Developing guidelines by anesthesia professional organizations such as Society for Technology in Anesthesia to assist in the configuration of AIMS is recommended to help anesthesia departments avoid problems that may result in significant financial and legal risk.

Evidence-based management assessment of return on investment from anesthesia information management systems.

A systematic and comprehensive review of the scientific literature revealed 4 evidence-based methods that contribute to a positive return on investment from anesthesia information management systems (AIMS): reducing anesthetic-related drug costs, improving staff scheduling and reducing staffing costs, increasing anesthesia billing and capture of anesthesia-related charges, and increased hospital reimbursement through improved hospital coding. There were common features to these interventions. Whereas an AIMS may be the ideal choice to achieve these cost reductions and revenue increases, alternative existing systems may be satisfactory for the studied applications (i.e., the incremental advantage to the AIMS may be less than predicted from applying each study to each facility). Savings are likely heterogeneous among institutions, making an internal survey using standard accounting methods necessary to perform a valid return on investment analysis. Financial advantages can be marked for the anesthesia providers, although hospitals are more likely to purchase the AIMS.

Changing medical group behaviors: increasing the rate of documentation of quality assurance events using an anesthesia information system.

In the United States, quality assurance (QA) documentation is required by numerous agencies for each anesthetic performed. The goal of this study was to determine the effect of several interventions on the voluntary completion rate of QA documentation. We hypothesized that optimizing workflow integration would increase both QA completion rates and complication capture rates and promote long-term successful changes in reporting behavior. Whereas electronic scanning of anesthetic records may automate some aspects of QA, there will continue to be a need for anesthesiologists to enter QA documentation that cannot be automated. Starting from a baseline completion rate of 48%, we instituted a series of interventions. We successively increased the completion rate to 55% (education), 68% (workflow integration), and 78% (individual feedback). Each intervention increased the completion rate from the previous intervention (P < 0.001). The increased completion rate suggests better overall data capture, because the percentage of "no complication" entries decreased. After the study period, the completion rate increased to 94%, principally because of the improved workflow integration. As implementation of anesthesia information systems increases, attention to user interface design may be a key component in the functionality and utility of these systems.

The medicolegal importance of enhancing timeliness of documentation when using an anesthesia information system and the response to automated feedback in an academic practice.

Documentation should ideally occur in real time immediately after completion of a service. Although electronic records often do not print the time that documentation notes were entered on the medical record, automated anesthesia record keeping systems store an audit trail that time stamps events entered by all anesthesia providers. As more lawyers become aware of this fact and requisition audit trails, prospective charting of necessary documentation may undermine the integrity of an anesthesia care team accused of malpractice, with potentially significant medicolegal consequences. We changed existing documentation practices of a large academic practice via a three-step process. Educational sessions increased the percentage of cases with correct timing of emergence documentation from 25% to 60% over a 2-mo period. Automated email performance feedback further increased correct note timing to 70%. When combined with personal contact by a member of the billing office and email copy notification of the chair, the percentage increased to >99.5%. The behavioral change was seen in all individuals, as 95% of attendings had < or = 2 records/mo with untimely documentation at the end of the study period. Once the habits were ingrained, further input was rarely necessary over the next 9 mo. This suggests physician behavioral change related to work process flow, unlike that related to patient care, is easily sustained.

Failure to recognize loss of incoming data in an anesthesia record-keeping system may have increased medical liability.

Automated anesthesia record-keeping systems (AARKs) are increasingly being used. There is a perception that AARKs may limit medical liability. We report a case in which our AARK may have increased our medical liability exposure. Nine months after a patient suffered a serious intraoperative complication, the anesthesiologist was named (as one of several defendants) in a claim alleging failure to properly monitor anesthetic care. One reason why the anesthesiologist was named related to a gap of 93 min in which no vital signs were documented in the anesthesia record. Relying on the physiological monitors to assess the patient's condition, the anesthesiologist did not recognize the interruption of data transmission, because the "active" medication window obscured the graphical display of the vital sign window.