Anesthesia Business Consultants: Communique fall09


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Communiqué features articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators.

Communique is created by Anesthesia Business Consultants (ABC), the largest physician billing and practice management company specializing exclusively in the practice of anesthesia and pain management.

ABC serves several thousand anesthesiologists and CRNAs nationwide with anesthesia billing software solutions.

Please send your email address to info [at] anesthesiallc [dot] com if you would like to join the Communique mailing list!

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Anesthesia Business Consultants: Communique fall09

  1. 1. FALL2009 VOLUME14,ISSUE4 ANESTHESIA BUSINESSCONSULTANTS The database of an anesthesia billing system should contain invaluable data with regard to all that takes place in a hospital’s operating rooms and delivery suites. Because there is a charge created for each and every anesthetic, the level of detail captured by an anesthesia department should rival that of the hospital information system itself. While the file layouts of many anesthesia billing systems are defined by the information necessary to generate a claim, we are starting to see the emergence of a new generation of software that seeks to capture not only what will be necessary to get paid for anesthesia but also data that will allow the anesthesia practice not only to manage itself more effectively, but to provide the hospital administration productivity and performance indicators and metrics that underscore the potential role of anesthesia in more effective operating room management. ABC offers The Communiqué in electronic format Anesthesia Business Consultants, LLC (ABC) is happy to announce that The Communiqué will be available through a state-of-the-art electronic format as well as the regular printed version. The Communiqué continues to feature articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators. We look forward to providing you with many more years of compliance, coding and practice management news through The Communiqué and our Monday e-mail alerts. Please log on to ABC’s web site at and click the link to view the electronic version of The Communiqué online. To be put on the automated email notification list please send your email address to ➤ INSIDE THIS ISSUE: Operating Room Utilization Data Management . . . . . . . . . . . . 1 The Anesthesia Record Powered by Shareable Ink ® : A Dialogue with the Inventor . . . . . . . . . . . . . . . . . . . . . . 3 Is your Concurrency Software Compliant? . . . . . . . . . . . . . . 7 The State of AIMS Adoption . . . . . . . . . . . . . . . . . . . . . . . . 12 The Tipping Point for Anesthesia Information Management Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 The Cost-Cutting Approach To Healthcare Reform . . . . . . . . 18 13 Steps to a Disastrous Anesthesia Information System Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Anesthesiology Practice Web Sites . . . . . . . . . . . . . . . . . . . 22 HITECH in a High Tech Era . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Event Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Continued on page 4 Operating Room Utilization Data Management Jody Locke, CPC ABC Vice President for Practice Management
  2. 2. The Communiqué Fall 2009 Page 2 The Pace Picks Up in the Development of Health Information Technology One theme common to all the different proposals for healthcare reform in this season of intense advocacy is the need to increase both the capabilities and the installed bases of health information technology. David Blumenthal, MD, MPP, National Coordinator for Health Information Technology in the Department of Health & Human Services recently noted that: It would be hard for any health professional today to escape the conclusion that the an- tiquated, paper-dominated system we now have in place isn’t working well for patients, creates added costs and inefficiencies, and isn’t sustainable. As we look at our na- tion’s annual health care expenditures of approximately $2.5 trillion, there are many ways our current system fails both patients and providers. It is clear that change is necessary. The need for change from our “antiquat- ed, paper-dominated systems” to powerful and flexible information technology has been clear for quite some time. We generate and depend on a massive amount of informa- tion, to which we add more data every day. Managing all the information that we record and using it to its maximum capabilities are major challenges for anesthesiologists and other professionals. ABC invested in powerful custom- built anesthesia practice management software, F1RSTAnesthesia™, several years ago. This system goes far beyond claims and revenue cycle management, of course. Jody Locke illustrates the use of data on the time and units billed and the actual collections per anesthetizing location, by hour, to analyze utilization and identify opportunities for increases in productivity in his article “Operating Room Utilization Data Management.” While Jody’s graphs and charts come from F1RSTAnesthesia™, which he helped to shape, he acknowledges that “there is no one best way to capture and present operating room utilization data.” To look at some of the ways in which other developers and organizations manage data, we invited several such developers to describe their systems in this issue of the Communiqué.  The digital pen-and-paper method of completing an anesthesia record marketed under the name Shareable Ink Anesthesia Record™ represents brand-new technology about which we are very excit- ed – so much so that we have entered into an exclusive agreement with the company that developed the system under which, for a certain time, we will be the sole anesthesia billing company to sell the digital pen under the F1RSTAnesthesia™ Record.  Several third party systems represented in this issue are already quite familiar to most anesthesiologists. Readers will immediately recognize the name Docusys®. Teecie Covad, VP for Product Management at Docusys, Inc. has written a comprehensive descrip- tion of the features and benefits of a true AIMS in “The Tipping Point for Anesthesia Information Management Systems.” Picis® Anesthesia Manager is another system used by many anesthesiologists every day. It has a large installed base in hospitals across the country. Dr. Carlos Nunez, Chief Physician Executive for Picis®, gives an excellent his- torical overview of the changing industry needs and adaptations, and the Picis® so- lution, including a synopsis of the federal Stimulus Package that will reward hospitals for demonstrating the “meaningful use” of in- formation technology starting in 2011. The nearly $20 billion in Stimulus funds to promote the adoption of elec- tronic health records was one aspect of the American Recovery and Reinvestment Act of 2009 (“ARRA”). Another part of ARRA significantly alters and supplements HIPAA privacy and security provisions. Abby Pendleton, Esq. and Jessica Gustafson, Esq. review the HITECH (Health Information Technology for Economic and Clinical Health Acts) provisions of ARRA per- taining to patients’ privacy rights, breach notification, and the consequences of breach- ing private information. ASA has created a new organization, the Anesthesia Quality Institute (AQI), to develop a national data registry for anesthesia. To achieve similar goals of collecting data from multiple operating rooms to support benchmarking and quality improvement initiatives, SouthEast Anesthesiology Consultants of Charlotte, NC, launched its own Quantum Clinical Navigation System™ in the 1990s and reports that Quantum is now installed in 25 hospitals. John Kunysz, Quantum’s chief operating officer, describes the system and its value in his article “The Cost-Cutting Approach to Healthcare Reform.” Joe Laden, a name very familiar to participants in the MGMA-Anesthesia Administration Assembly (AAA) and other members of the anesthesiology community, has synthesized everything he learned from studying and comparing multiple exam- ples in his write-up entitled “Anesthesiology Practice Web Sites.” His checklists and brief descriptions will be invaluable to readers contemplating creating or expanding their own websites. Having read of the amazing capabili- ties of anesthesia information management systems in the first half of this issue, do not miss the wonderful warning “13 Steps to a Disastrous Anesthesia Information System Implementation” by AAA officer and VIP Phil Mesisca. The changes that have taken place in anesthesia practice since I founded ABC thirty years ago are staggering — and the constants are equally amazing. We are all privileged to work in an area that asks us to learn new technologies and new practices, or at the very least, new approaches, all the time. As with every quarterly issue of the Communiqué, I am most grateful for the willingness of experts like those noted above to share their knowledge with us. With best wishes, Tony Mira President and CEO ABC is very proud to be the exclusive sponsor of a major new event at the Annual Meeting of the American Society of Anesthesiologists: A Celebration of Advocacy, the opening session of the 2010 meeting which will be held in at the Morial Convention Center in New Orleans, Louisiana from October 17th through October 21st.
  3. 3. The Communiqué Fall 2009 Page 3 In this issue, Communiqué interviews Dr. Vernon Huang, Founder and Chief Medical Officer of Shareable Ink and inventor of their Anesthesia Record prod- uct. The Shareable Ink Anesthesia Record allows immediate capture of information written on paper anesthesia records. Dr. Huang is also a practicing anesthesiologist in the San Francisco Bay Area with an ex- tensive background in medical informatics and technology. Dr. Huang can be reached at ABC will market the product under the name F1RSTAnesthesia Record™.  Question: Dr. Huang, what is the Shareable Ink Anesthesia Record? The Shareable Ink Anesthesia Record is a product that enables anesthesiolo- gists and CRNAs to take advantage of the benefits of electronic medical records without disrupting their workflow. Using the system, anesthesia providers fill out a paper form — that is nearly identical to their current anesthesia record — using a “digital” ballpoint pen. Essentially, they chart on a paper anesthesia record just as they have always done. But now, when they drop off the pa- tient in the PACU, they simply dock their pen in a cradle, and all the information is immediately and securely transmitted to our servers. Then, the Shareable Ink system creates actual computerized data from the pen strokes — capturing times, signatures, diagnoses, procedures, and anything else written on the form. All the information in the pen is encrypted and transmitted to our secure servers where all the computing is done. The Shareable Ink system can even automatically conduct rule checks and immediately notify providers if they forget to provide required informa- tion, such as a signature or anesthesia end time. Alerts can be sent via pagers, text messages or emails — before the anesthesiologist has even left the PACU. An immediate notification means that a provider can fix the record while it’s still in front of him or her, resubmit the record by docking the pen, and avoid callbacks and rework. Question: The system’s simplicity is intriguing. How is the data utilized after it’s captured? After the data is captured from the paper record, it is immediately “elec- tronic” and we can do all sorts of useful The Anesthesia Record TM Powered by Shareable Ink® : A Dialogue with the Inventor Vernon Huang, MD San Francisco, CA Continued on page 8 Shareable Ink® Anesthesia Record™
  4. 4. The Communiqué Fall 2009 Page 4 Operating Room Utilization Data Management Despite the potential of an anesthesia practice database to enhance operating room efficiency this aspect of practice management is in its infancy. The most common use of productivity data con- tinues to be the evaluation of potential stipend requirements. Anesthesia prac- tice managers are coming to understand the correlation between operating room utilization and the need for financial support. The financial analysis seeks to assess whether the revenue potential of each location covers the cost of provid- ing the care. Having a reliable handle on the profitability of each location covered has been proven to be a consistently ef- fective means of both justifying stipend requests and encouraging administrators to reconsider adjusting coverage require- ments. The key, of course, is the ability to produce and present the data and calcu- lations in a manner that is both clear and compelling. Forward-looking practices also use similar types of productivity metrics to evaluate each line of business on a regu- lar basis. Such forms of analysis provide an important means of assessing the rea- sonableness of continued coverage. The result of such service-line specific review may result in requests for additional financial support or they may inspire cre- ative thinking about alternative ways of providing coverage more cost effectively. A classic example involves a practice that had believed it was important to tie up every surgery center in town to keep out the competition; once the group assessed its actual yield per location day, however, it quickly realized that a number of the coverage contracts were significantly im- pacting the compensation of the average shareholder. A careful assessment of the data led to the elimination of some of the less productive contracts and a much more realistic book of business. Rare is the anesthesia practice that is not challenged by the economics of coverage and reimbursement. The con- ventional approach to the enhancement of practice profitability tends to focus on revenue enhancement, either through more aggressive contracting or accounts receivable management. The fact is that such efforts have limited ability to re- solve significant profitability shortfalls. Typically, the only real solution involves matching staffing to revenue, which may involve adjusting coverage. It is one thing to work on ways on increasing the size of the revenue pie, but if the pie is divided too many ways then none of the slices will support the income expectations of the providers. The use of productivity data and metrics to assess the profitability of cov- erage is leading to a view that an even better strategy would be to use the same kinds of information more pro-actively to actually help hospitals and surgi-cen- ters manage rooms more effectively on a prospective basis. This is opening doors of opportunity for anesthesia practices to be seen more as problem-solvers in the tricky business of operating room man- agement. Some practices have been so successful in their education of hospital Continued from page 1 Table 1: An example of Operating Room Production Metrics by Room
  5. 5. administration that key stakeholders have come to rely on the anesthesia metrics and scorecards as the most reliable means of measuring operating room efficiency. Key to all of these strategies is the ability to produce normalized produc- tivity metrics by anesthetizing location. The value of being able to drill down to the specific anesthetizing location is be- coming increasingly clear. To this end developers of billing software are making the necessary modifications to file layouts. Having the capability to capture such data and actually being able to gener- ate reliable reports on demand, however, are two quite different issues. Not only must forms be designed to encourage the practitioner to indicate where the case was performed, but there must be a clear logic and structure to the labeling. Minor inconsistencies in provider labeling can greatly impact the quality of the informa- tion reported. Operating Room #1 must be reported and entered the same way for every case or the performance indicators will not make sense. It does not matter what the labeling convention is, so long as it is consistent. Once this is accomplished the results can be invaluable. ABC’s F1RSTAnesthesia allows for perfor- mance data to be tracked in a variety of ways. Standard performance metrics are a very useful starting point. It is espe- cially useful to be able to track average case production, units billed, hours of anesthesia time and actual collections by operating room. Even more useful is the ability to look at these same metrics by shift or time of day. Perhaps the best mechanism for monitoring utilization is the ability to plot activity by hour of day. Four typical examples of utilization data are included in the tables accompanying this article. These represent actual report data for two ABC clients. Table 1 presents key performance metrics in summary for calendar 2008. This table allows for the assessment of comparative productivity among locations as compared to standard bench- marks. Most practices try to achieve an average productivity of 50 ASA units per location day, which should be sufficient to cover the cost of coverage given a rea- sonable payor mix. Ideally, each location should generate at least 7 hours of bill- able anesthesia time. This is considered a sustainable level of production. Table 2 compares activity by shift for the same locations. Here the view is his- torical. Conventional wisdom holds that in an 8 hour shift there should be 6 hours of billable anesthesia time. It is also true that 75-80% of the revenue per anes- thetizing location should be generated during the day shift. Table 3 shows the number of loca- tions in use by hour of the day. Here production data is aggregated and aver- aged for eight months. Most observers are interested in the point at which the level of activity starts to drop off. This The Communiqué Fall 2009 Page 5 Continued on page 6 Table 2: An example of a typical shift utilization assessment Table 3: An example of a typical Utilization graph
  6. 6. type of graph also allows for the compar- ison of activity by day of week. The last chart, Table 4, presents pro- ductivity metrics for day shift versus overall productivity over time and allows for the identification of downward trends or seasonal variations in productivity. This type of analysis is especially useful for the assessment of staffing needs and will sometimes be incorporated into a staffing budget. Anesthesiologists intuitively recog- nize the value of timely and accurate data in the management of their activities. There is no question that the use of high tech digital monitors has greatly enhanced the quality of care provided in the oper- ating room. There is no reason to believe the same concept will not prove equal- ly as valuable in the management of the operating rooms themselves. Anesthesia providers just need to get over the precon- ceived notion that they are captive to the system. There is no question that the pos- session of such data and the ability to use it effectively in the education of the hos- pital administration represents a new role for many practices. The case for a more active role for anesthesia in the manage- ment of operating rooms is being made daily across the country. It will not be a wholesale transformation of the specialty but a gradual evolution from quiet ob- server to active participant. As in so many things, the best advice is to identify oppor- tunities to demonstrate small examples of process improvement and build on suc- cesses one by one. It is easy to look at these types of charts and graphs and to say, that is in- teresting but it would not be too useful in my hospital. Such an attitude, however, will inevitably be a self-fulfilling propo- sition. There is a reason why so many of the largest anesthesia practices are in- vesting in technology and data capture devices to be able to reliably measure and monitor patterns of operating utilization. They have long since learned that having the tools to manage manpower and staff- ing more effectively is the key to their cost-competitiveness and survival. This may not be the kind of technological ap- plication that captures the imagination with its sophistication or innovation but it is clearly one that ensures profitability. While there is no one best way to capture and present operating room uti- lization data there are clearly systems that are more user-friendly and flexible than others. ABC is especially proud of its F1RSTAnesthesia software and the various ways clients have been able to use its data to manage their practices more effectively and to provide unexpected value added service to their hospitals. The Communiqué Spring 2009 Page 6 Continued from page 5 Table 4: An example of utilization trends over time Operating Room Utilization Data Management
  7. 7. The Communiqué Fall 2009 Page 7 Anesthesia groups that practice in a “care team” setting use concurrency software to calculate the maximum number of cases that an anesthesiologist is medically directing at any given time. This software ultimately assigns concurrency modifiers to each claim being billed, thus influencing the expected allowable that an insurance company will pay. The biggest flaw with such concurrency programs is their inability to properly handle intra- operative handoffs, or relief. For example, Anesthesiologist A begins medically directing a case at 2:00pm. Anesthesiologist B takes over the case at 3:00pm and the case ends at 3:30pm. Unless your concurrency software has the ability to input multiple anesthesiologists with multiple start/stop times on the same case, the software is not giving you accurate data. From a billing standpoint, relief cases are billed under one anesthesiologist’s name with the total case time. This anesthesiologist’s name billed is typically the physician with the greatest amount of time in the case. However, from a compliance perspective, each physician’s start/stop times need to be analyzed for concurrency in order to properly select the correct medical direction or medical supervision modifier. In the example given above, Anesthesiologist A may have a maximum concurrency ratio of three CRNA rooms from 2:00-2:59pm. Anesthesiologist B may have a maximum concurrency ratio of five rooms from 3:00-3:30. If the concurrency analysis is run only on Anesthesiologist A from 2:00-3:30pm, the concurrency modifier assigned will be incorrect, which will result in a potential overpayment from the payer, as shown in Figure 1. In conclusion, intra-operative handoffs should be well documented on the anesthesia record and concurrency should be run on each anesthesiologist’s individual times in order to properly calculate the modifier assigned on the claim form. Since Medicare medical direction (1-4 concurrent CRNA rooms) pays 50% of the allowable to anesthesiologist, while medical supervision (5+ rooms) pays a maximum of only 4 units to the anesthesiologist, it is crucial that your concurrency reports be able to substantiate the modifier billed on each case. As part of our desire to keep both clients and readers up to date, the Communiqué has been printing compliance information since its inception. In the Compliance Corner, we will now formally keep you abreast of the various compliance issues and/or pick out a topic that would be of interest to most of our readers. Is Your Concurrency Software Compliant? Hal Nelson, CPC ABC Director of Compliance and Client Services Figure 1. Is This Case Medically Directed (QK) or Supervised (AD)? 2:00pm 3:30pm             Anesthesiologist A Anesthesiologist B 1:3 1:5
  8. 8. The Communiqué Fall 2009 Page 8 The Anesthesia Record TM powered by Shareable Ink® : A Dialogue with the Inventor Continued from page 3 things with it. This is a key capability of the Shareable Ink Anesthesia Record. We can “slice and dice” the data and push it out to various stakeholders of the anesthesia record. For example, informa- tion required for billing can be sent to the billing company without the delay and cost associated with scanning or mail- ing. Because our system conducts rule checking and can immediately notify the provider about errors, we can eliminate sending the chart back to the provider for rework that would normally add weeks to the A/R cycle. We can also send information about narcotics used during the case to the pharmacy. Sometimes, we take the data from many forms and build “dashboards,” web pages that give a view into data ag- gregated from many cases. Institutions can use these dashboards to monitor SCIP measures such as antibiotic admin- istration time and patient temperature on PACU arrival. As another example, my group has always recorded anesthesia ready time in addition to surgery start time. This way, we can measure how efficiently the OR is running. If the hospital asks us to provide an extra anesthesiologist to staff a room, we may be able demonstrate that anoth- er room is not necessary by bringing at- tention to this OR “downtime.” If there is sufficient downtime, the resource issue can be addressed by scheduling existing rooms more efficiently. Unfortunately, my group never had an easy mechanism for collecting and analyzing the data. The exercise would have been too tedious to retrospectively enter that data from all the paper charts. But now, using the Shareable Ink system, the data is available electronically and anyone with a spreadsheet can analyze it. The system can even attach time stamps to checkboxes, signatures, or any other data collected from the form. This allows groups using the Shareable Ink Anesthesia Record to do detailed data analysis with regard to CRNA supervision. Question: How does the technology by Shareable Ink compare to scanning? First, information is immediate and actionable with the Anesthesia Record. Scanning is not as timely because the pro- cess requires someone – usually not the anesthesiologist – to physically obtain the record, put it in a work queue, and then scan it. Scanned information is also less actionable. For example, if some- one scans a record with no anesthesia end time or no signature, and then, sub- mits it for payment, days or weeks would pass before the anesthesiologist is notified about the missing information. Second, all you get is a “picture” of the record with scanning. You don’t really obtain any discrete data. You can’t easily answer questions like, “what percentage of my patients are ASA 4E?” or “how many central lines did I put in last year?” from an archive of scanned records. Question: What made you come up with the Shareable Ink Anesthesia Record? I’ve always been fascinated with tech- nology. That’s probably why I chose anes- thesia as a specialty. I took a break from clinical medicine before residency to manage the healthcare market for a divi- sion within Apple Computer. I remember giving a talk in 1993 in which I predicted that someday all doctors would be car- rying PDAs. Since medical school, I’ve known that healthcare providers were mobile professionals with their own spe- cific computing needs. The digital pen is the ultimate ex- tension of mobile computing. Finally, we have a technology that fits our work- flow. Previously, in order to use an EHR, we had to modify our workflow to fit de- cades-old technology. With the Shareable Ink technology, we just do our jobs as we have for years. Only now, we seamlessly capture our information digitally in the background. Question: How did you start Shareable Ink? During residency, in the middle of the “dotcom” boom, I took a sab- batical to join a start-up company called PatientKeeper. PatientKeeper was one of the first companies to allow clinicians to use PDAs and smartphones in their
  9. 9. The Communiqué Fall 2009 Page 9 workflow. The company has grown tre- mendously over the years, and now, they have signed contracts with about 12% of US hospitals. I reached out to my friend Steve Hau, the founder of PatientKeeper, and was able to convince him to become the CEO and a co-founder of Shareable Ink. Steve has a proven track record of build- ing new companies in healthcare IT and making customers successful. He quick- ly assembled a terrific team of industry veterans. Question: Who is using the Shareable Ink Anesthesia Record? Anesthesiologists from coast to coast are using our system, and we are also working with physicians in other specialties, in both the inpatient and outpatient settings. Our anesthesiologist clients aren’t limited to any particular lo- cation or sub-specialty. We can take any existing anesthesia record and make it work with our system. Question: What are the benefits of using the Shareable Ink Anesthesia Record? There are numerous benefits that accrue to both the individual anesthe- siologists as well as to the institutions at which they practice. The main benefit to the providers is that they get almost all of the advantages of having an EHR – but without the hassles associated with changing workflow. With our system, there is virtually no learning curve or training involved; everyone already knows how to fill out an anesthesia record with a pen. Because of immediate rule checks, anesthesiolo- gists know that they are filling out their records completely and won’t be asked weeks later to recall, for a particular case, what time they transferred care in the PACU. Taken together, this positively impacts job satisfaction and the bottom line. The benefit to the institution is that they get access to data that they have always wanted but never had before — and without having to scan or key enter the records. Also, there is essentially no burden on the IT staff. No Shareable Ink software is installed on site. All the infor- mation from the pen is encrypted and transmitted to our servers where all the computing is done. Administration and providers can optionally access the data using a standard web browser and the data is always owned by the client. Question: What benefits does it bring to the anesthesia provider? The benefits are multiple. From an administrative and workflow perspec- tive, the Shareable Ink Anesthesia Record eliminates lost records, cuts down on the number of records that need to be reworked and decreases days in A/R. Providers no longer have to fill out bill- ing tickets and carry around anesthe- sia records until they reach some critical mass that reminds them to do their bill- ing and send in their paperwork. From a clinical perspective, it en- courages more complete and accurate charting since it can notify us if we’ve submitted a record with a required el- ement missing, such as an unsigned Continued on page 10
  10. 10. The Communiqué Fall 2009 Page 10 CRNA compliance statement or missing signature. From a practice management stand- point, the Shareable Ink Anesthesia Record allows you to capture all sorts of new data that was never easily available before. One of the first things my group implemented was recording our position on the call schedule on our records. With the Shareable Ink system, it’s easy to col- lect all this data so we can actually ana- lyze how much a particular position on the call schedule works over time. This will allow us to staff more efficiently. Finally, from a financial perspec- tive, we now have all the data we need in order to qualify for pay by performance or to report a new PQRI measure. If a new performance measure is initiated, we don’t have to do a lot of computer and data entry work, we just have to intro- duce a new field on a form. Question: How does Shareable Ink technology compare to current Anesthesia Information Management Systems (AIMS)? Anesthesia Information Management Systems have been commercially avail- able for over a decade yet they have been installed in less than five percent of the marketplace. I believe this lack of adop- tion is due to two primary factors: cost and difficulty of use. The Shareable Ink Anesthesia Record costs only a fraction of the amount an AIMS costs, and we can capture all of the salient data that the institutions that pay for these AIMS want. The Shareable Ink Anesthesia Record is also incredibly easy to use. Training is minimal and the workflow of the user doesn’t change. In addition, AIMS require provid- ers to use a keyboard, mouse, or other data entry device, and thus modify the way they work in order to accommodate data entry. I think this is the main reason that there has not been more widespread adoption of these systems. The approach that we’ve taken with Shareable Ink allows providers to practice the way they do now, input data in a way that is natu- ral and familiar, and still get the benefits of an electronic system. Question: How does the cost com- pare to AIMS? Current AIMS systems require new computer hardware to be installed in every operating room, sometimes even requiring the replacement of anesthesia machines! The Shareable Ink Anesthesia Record not only costs a fraction of the cost of an AIMS in implementation, it also saves the institution ongoing costs related to training and support. Our phy- sicians report that they require about half an hour of training. CRNA users, who don’t need to take advantage of the alerting or reporting functions, report that their training took just five minutes! On the support side, we’re not asking the providers to do anything new other than place the pen in a cradle. There’s not much that can go wrong so ongoing sup- port costs are miniscule. Question: What about automated vitals signs capture? The Anesthesia Record TM powered by Shareable Ink® : A Dialogue with the Inventor Continued from page 9
  11. 11. The Communiqué Fall 2009 Page 11 We don’t automatically capture vitals signs, and I believe that that is one of our strengths. Using the Shareable Ink Anesthesia Record, providers are still en- gaged with the case and record the vital signs every five minutes. This means that every five minutes the vitals have to go from our eyes, through our brains, and then be written on the anesthesia record. It’s been suggested that while using an AIMS, providers have a tendency to let the record go on “autopilot,” and they can actually be less vigilant to the vital signs. I know some controversy sur- rounds this. What we know for a fact is that cases have been litigated where the automat- ed anesthesia record failed to record the vital signs for extended periods. Also, many providers are concerned about AIMS systems capturing spurious data, such as recording an abnormally high pulse because the cautery is in use. They fear that these data might increase their liability and lead to increased documen- tation burdens to edit the readings. The Shareable Ink approach still allows for the human filtering of inaccurate vital signs so that the record reflects what ac- tually happened during the case. Question:What are the challenges of implementing the technology? The main challenge is in educating the institution. Hospitals are often re- luctant to start new IT projects because of their history of being over budget and behind schedule. Normally, once we show the parties involved how little training is involved and how minimally disruptive it is to their workflow, things go very fast. The only requirement to deploy the system is that the location have an Internet connection. As I mentioned, we don’t install any software on site. All we leave behind is a docking cradle for the pen and a driver to allow that cradle to communicate with our servers. Computing is done securely and remote- ly by Shareable Ink’s servers. Another challenge is interfacing to the wide range of hospital IT and OR in- formation systems that exist. Fortunately, the interface work isn’t required to get started. And the team at Shareable Ink has a deep knowledge and significant ex- perience at this task. Question: How does the Shareable Ink Anesthesia Record work with OR in- formation systems? We can interface into the OR information system. Often, the anesthesiologist keeps the most accurate and up to date record. This is especially true if the circulating nurse is expected to enter data into an OR system while performing clinical duties. By extracting data from the anesthesia record, powered by Shareable Ink and uploading it into the existing OR information system, Shareable Ink relieves physicians and nurses from the mundane, distracting and expensive task of data entry. The Shareable Ink Anesthesia Record is very complementary to traditional information systems because it draws on their strengths of storing, retrieving, and displaying data. Data entry is a limiting factor on all existing systems, and now, we’ve made that process a part of the existing workflow nearly effortless. Question: Why did you choose ABC to be your partner? I’ve been an ABC customer from within two busy anesthesia practices. Every few years, we re-evaluate the mar- ketplace and consider changing billing vendors and every time, we return to ABC for our business. We chose ABC to be Shareable Ink’s reseller in the anesthesia marketplace because of their market share, focus on the anesthesia market, their expertise in anesthesia billing and practice manage- ment, and their willingness to embrace new technologies. Reference: Vigoda, M.M., Lubarsky, D.A. Failure to Recognize Loss of Incoming Data in an Anesthesia Record-Keeping System May Have Increased Medical Liability. Anesth Analg 2006;102:1798-1802
  12. 12. The Communiqué Fall 2009 Page 12 Although still far from achieving mainstream adoption, anesthesia infor- mation management systems (AIMS) have made significant strides in market penetration over the last five years. Commercially viable AIMS solutions have been available for more than two decades, but it is only recently that the notion of implementing an automated anesthesia record has become widespread within the practice of anesthesiology. Perhaps the federal government’s push to increase the adoption of electron- ic health records (EHRs) as a part of the recently passed “stimulus package” will lead to near universal acceptance of AIMS, but there are other forces at work that have moved AIMS from being an interesting experiment to a vital tool for the management of anesthesia patient information. First and foremost, the leading AIMS solutions have matured in ways that reflect not only the progress of tech- nology, but also the realities of modern clinical practice. Even the most basic systems can recreate the paper anesthe- sia record; capturing data from moni- tors and anesthesia machines, as well as input from the user to document things such as medications, fluids and clinical notes. However, more advanced systems such as Picis® Anesthesia Manager have moved beyond simple record keeping, and now offer decision support tools and remote access that extend the usefulness of the electronic record. There have also been advances in configurability, usabil- ity and stability that have made AIMS easier to implement and more transpar- ent to the workflow of the average user. Probably the most significant technologi- cal advance that has directly increased adoption of AIMS has been the integra- tion and interoperability of these systems with the information infrastructure of the hospital. The most successful AIMS solu- tions are those that allow the electronic anesthesia record to operate seamlessly with the other information systems in- stalled in the hospital. The interopera- bility begins in the operating room and extends as far as the outpatient areas. In fact, the event that led to the larg- est market expansion of AIMS was the availability of the first commercially viable suite of perioperative automation solutions, Picis CareSuite, in 2003. By combining a traditional operating room management system (ORMS) with the clinical solutions for preoperative evalu- ation, anesthesia automation, and recov- ery room (PACU) documentation, AIMS adoption in the United States jumped in one single year from a handful of sys- tems to almost 100. Vendors offering stand-alone systems began to suffer and in some cases disappear, while the tradi- tional hospital information system (HIS) vendors attempted to enter the market. While interoperability of AIMS solutions was a welcome development for the IT management of the hospital, it was the gains in usability that began to turn the tide with anesthesia providers in terms of user acceptance. For example, the availability of patient data from outside the perioperative period, The State of AIMS Adoption Carlos M. Nunez, M.D. Chief Physician Executive, Picis® Wakefield, MA
  13. 13. The Communiqué Fall 2009 Page 13 such as allergies, medications, lab and other test results, has helped drive the acceptance of anesthesia automation and streamline workflow. One of the most important immediate benefits is the ability to quickly access a patient’s previous anesthesia management details without sifting through paper charts. This is especially useful for patients who have difficult airways or other notable pathology that could affect the delivery of anesthesia. The ability to copy forward portions of the patient’s previous pre- anesthesia evaluation(s) also saves a great deal of time and eliminates redundancy. As a result, the pre-anesthesia evaluation and immediate preoperative preparation of the patient became less of a paper chase and improvements in the reliability of data captured from medical devices helped make anesthesia providers more comfortable with the automation of clinical record keeping. Advanced user interface design and flexible configuration options pushed the acceptance of AIMS even further. The evidence is clear in the marketplace: those AIMS solutions that offer comprehensive interoperability beyond the four walls of the OR and integrate well into the unique workflow of anesthesia have established themselves as the leaders. The final inherent trait of AIMS that provides tremendous incentives to hospitals is the ability to use their col- lected data to facilitate both clinical and administrative functions. The growing use of decision support is an excellent ex- ample of how vast amounts of data col- lected across the perioperative period can be available to the end users of AIMS, at the point of care. AIMS-based decision support systems enable users to create their own rules, providing clinicians with timely notifications based on patient data that can help the clinician guide the course of care. Imagine the AIMS screen displaying a colored icon or sending a text message to an anesthesiologist when a patient with a history of Malignant Hyperthermia has a recorded body tem- perature that is rising. The collection of data at the point of care also makes remote access to the anesthesia record possible, so that clinicians have access to patient information from any OR or PACU bed, anywhere they happen to be. Then, after the episode of care is com- plete, all of that data is available to gen- erate billing (professional fees, supplies, pharmacy, etc.) as well as research and quality reporting. The ability to generate reports with AIMS data, as required by the Surgical Care Improvement Project (SCIP), is vital in today’s healthcare en- vironment. The information that is doc- umented in an AIMS, such as time from antibiotic dose to incision, appropriate sterile technique, use of beta-blockers, insulin use and glucose levels, and the use of intraoperative warming devices, can also be used to justify improved contract rates for insurers that are willing to com- pensate for proof of improved quality of care. The American Recovery and Reinvestment Act of 2009 (ARRA) included nearly $20 billion to stimulate the adoption of electronic health records. Beginning in 2011, the federal government will reward hospitals with incentive payments for demonstrating the “meaningful use” of information technology. After 2015, the incentive payments go away; they replaced with financial penalties for those hospitals that do not meet the government’s goals. A large part of the meaningful use criteria center around the established and growing requirements for quality reporting as mandated by the Centers for Medicare and Medicaid Services (CMS). The perioperative care areas of the hospital are where a great deal of the data that CMS requires for its quality measures reporting program are collected, such as SCIP. ARRA may provide the final push necessary to arrive at near universal adoption of AIMS in the coming years. For more information on getting to meaningful use in high acuity areas of the hospital, such as the perioperative suite, Picis invites you to visit Advocacy and download our position papers. Carlos Nunez, MD, is Picis’s Chief Physician Executive. He can be reached at Carlosnunez
  14. 14. The Communiqué Fall 2009 Page 14 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 de- fined 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 esti- mates, 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 administra- tors who typically provide the budget, and physicians, who need to use the tech- nology. A confluence of factors aimed at both potential buyers, however, is moving the AIMS industry to the tipping point of widespread adoption. Federal Initiatives First, a national emphasis on health IT through the federal economic stimu- lus package, although not directed to spe- cialty systems such as AIMS, will likely leave such specialty groups as lone users of paper records in an electronic envi- ronment – a situation that will hasten conversion. A secondary push toward health IT has been proposed through the national health care reform proposal re- cently 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 sur- rounding healthcare reform, reduc- ing 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 pro- viders who bill for their services and the RAC (Recovery Audit Contractor) pro- gram is the latest permutation of that The Tipping Point for Anesthesia Information Management Systems Teecie Cozad Vice President, Product Management, DocuSys, Inc. Atlanta, GA
  15. 15. The Communiqué Fall 2009 Page 15 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 medi- cal compliance and documentation of start and end times, invasive lines, post- operative pain services, medical neces- sity 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 mea- sures are adopted by payers, the more technology will play a role in prompting the clinician to document their evalu- ations and actions and to report their performance effectively. While relatively small bonuses are held out to stimulate participation in these measurement pro- grams now, the general consensus is that physician payments will go the route of hospital payments where bonuses for re- porting 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 appropri- ate subset of patients to avoid message fatigue. Wrong site surgery is another in- stance where one can imagine the an- esthesia 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 respon- sibility 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 verifica- tion and reporting of adverse medication reactions. Utilizing an AIMS that incor- porates a drug information database can Continued on page 16 1 A recent Medicare MLN Matters article (MM6405) indicates that Medicare no longer covers any hospital or other services provided in connection with a wrong site/wrong patient/wrong procedure episode, stating spe- cifically that “All providers in the operating room when the error occurs, who could bill individually for their services, are not eligible for payment..”
  16. 16. The Communiqué Fall 2009 Page 16 standardize allergy and home medica- tion documentation, eliminate dupli- cate 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 al- lergy alerting and potential drug-to-drug interactions. Capturing postoperative complica- tions is a required and necessary part of the provision of anesthesia. A feature- rich AIMS of today should allow the pro- vider 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 doc- umentation from the generally available Anesthesia Record. Additionally, there are active projects aimed at building multi-institutional clinical anesthesia da- tabases 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 infor- mation systems as well as AIMS data. An important benefit of technolo- gy highlighted by the advent of Personal Health Records (PHRs) is a concept that the Cleveland Clinic and others imple- mented a decade ago – that of having the patient participate in their preopera- tive 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 medi- cal team for optimization well in advance of the day of surgery. Using technology in this way permits the primary care pro- vider, surgeon, anesthesiologist, preop- erative nurse and the patient to work in concert to improve care and eliminate duplicate testing – additional goals of na- tional 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 con- vinced of the value of an AIMS for a pur- chase 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 manufactur- ers 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 han- dling than others to thoroughly docu- ment 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 docu- menting physiologic data. Some sys- tems, like DocuSys, have minimized the work involved in supply and drug utili- zation 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 anes- thesia 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 The Tipping Point for Anesthesia Information Management Systems Continued from page 15
  17. 17. The Communiqué Fall 2009 Page 17 court than an incomplete hand-written record. Most providers utilizing AIMS now enter a quick note to explain aber- rant physiologic data recordings. The federal Drug Enforcement Agency (DEA) has made additional func- tionality of some AIMS, like DocuSys, a real benefit. With requirements for anes- thesia 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 oper- ating room because of the difficulties en- countered 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 re- cords in a manual world can be slow and inefficient. Immediate access to AIMS records means that the anesthesiolo- gist can quickly review a patient’s previ- ous airway management techniques in preop to assist in planning. A strong AIMS should automatically post com- plications 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 pro- vider tracking systems. Most AIMS utilize the work station monitor and/or plasma screens to provide boards that document a patient’s progress through the perioper- ative 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 avail- able in an AIMS can permit anesthesia managers to gather data for underuti- lized FTEs that can successfully result in needed stipends or produce the proof sources for additional manpower when there is high utilization. Those with departmental responsi- bilities 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 trans- mission 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 bill- ing destination, reporting on closed, opened but not completed, and cancelled cases. Those who have successfully im- plemented AIMS with billing support have seen their “Days to Bill Drop” de- crease 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 ac- complish their wish. Hospitals lose mil- lions of dollars every year because many co-existing diseases are not adequately documented. No other physician group is better positioned to provide the docu- mentation that can result in accurate identification of co-morbidities for surgi- cal 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 preopera- tive nursing documentation to validate it, allows the anesthesiologist to spend a couple of minutes on identifying co- morbidities on a subset of surgical pa- tients. This strategic use of an anesthesia resource can significantly improve the fi- nancial status of the hospital. More ac- curately capturing charges on all items used for a particular patient and provid- ing information that allows the hospital to more accurately track inventories of drugs and supplies provides even more ammunition in convincing hospital ex- ecutives that an Anesthesia Information Management System is an investment that cannot wait. Teecie Cozad is Vice President, Product Management at DocuSys, Inc. in Atlanta, GA. Questions may be sent to tcozad@; readers may also find further information at
  18. 18. The Communiqué Spring 2008 Page 18The Communiqué Fall 2009 Page 18 You cannot open a newspaper or turn on the television today without hearing about healthcare reform and healthcare quality. The driving force behind healthcare reform is that it is currently 18.4% of our gross domestic product. Despite the amount of money being spent on healthcare, hospitals and practices alike are concerned with what may happen to already diminishing mar- gins and therefore are looking to decrease costs. Quantum Clinical Navigation System™ has been quietly working in the background for more than twelve years providing proof of quality and help- ing hospitals, physicians and practices decrease costs and implement pay for performance models. By capturing 50 perioperative in- dicators Quantum CNS can measure numerous types of outcomes: 1. Efficiency measures such as case delays and cancelations; 2. Practitioner performance, includ- ing measuring complications or incidents and answering the fol- lowing two questions: a. Which doctor is not per- forming according to best practices or industry guide- lines for evidence based medicine? b. How can we mentor the doctor to become a better practitioner? 3. Critical quality indicators that assist in meeting JCAHO stan- dards, SCIP initiatives and PFP initiatives. Quantum CNS also produces reports that allow clients to measure the CQI data by loca- tion, physician and comparative benchmarks. Numerous best prac- tices have been instituted based on CQI results; 4. Patient satisfaction through patient satisfaction surveys administered after surgery or once the patient has returned home, and 5. CQI data captured throughout the continuum of care: patient check in, holding room, operating room, post-op, hospital floor, home, and reported back to the physician, surgeon and hospital. Southeast Anesthesiology Consultants, the founding company of Quantum CNS, has been using the system since its creation. “We wanted to be able to mea- sure, analyze and continuously improve our processes and performance,” said Dr. Richard Gilbert, President and CEO of Southeast Anesthesiology Consultants and Quantum CNS. Quantum is designed to flow natu- rally with the patient care models already in use throughout physician groups and hospitals. Unlike expensive healthcare IT systems which force clinicians to bear the burden of cumbersome interfaces and extra steps, Quantum CNS provides a very high “return on clinician time” in The Cost-Cutting Approach To Healthcare Reform John M. Kunysz FACHE, Chief Operating Officer, Quantum Clinical Navigation System™ Charlotte, NC
  19. 19. The Communiqué Fall 2009 Page 19 addition to the standard “return on in- vestment” model. One example of the way Quantum CNS’s real time report- ing helped Southeast Anesthesiology Consultants occurred in their Obstetrics Anesthesiology division. One of SAC’s physicians always received patient sat- isfaction scores of 98% or better. A few months ago, for no particular reason, this physician’s score began to drop dramatically. In less than two weeks he went from patient satisfaction scores of 99% to scores below 70%. Because of the real time reporting that this physician’s hospital chief received, SAC was able to quickly intervene, discuss the results with the physician and see immediate improvement with the scores rebound- ing to 99% in a matter of days. “It was remarkable,” commented John Kunysz, COO of Quantum CNS, “This particular physician’s scores dropped dramati- cally and then rebounded in less than 24 hours due to the data Quantum pro- vides on a real time basis.” Actions like this have kept SAC’s overall patient satis- faction 98% or better for over five years. This kind of real time reporting and im- mediate focused intervention is not pos- sible with most traditional QA programs using retrospective chart review. Another way that Quantum CNS’s reporting data is invaluable for physi- cians and hospitals is that it can aid in payer negotiations. Instead of having to rely on payer data, SAC can proudly showcase their own data, prove that they are able to beat all national benchmarks and ultimately use it as a tool to negotiate better reimbursement rates. Finally, Quantum Clinical Navigation System aids in cost re- duction. If you were to achieve the level of benchmarks that Southeast Anesthesiology Consultants can achieve with antibiotic administration, lower- ing of myocardial infarction and stroke incidences nationwide the United States would save more than $5 bil- lion in healthcare expenses each year. (See “Proper Antibiotic Administration Savings”, inset) These cost savings would allow hospitals and practices to begin implementing expensive technol- ogy, such as EMR systems, and could lessen the burden of healthcare reform on an already weak economy. Proper Antibiotic Administration Savings The national incidence of surgical site infection is 3-5% of all patients. Incidents of SSI cost approximately $3,000 for an additional 7-9 hospital days per patient. Appropriate administration of antibiotics decreases SSI 40-80%. The current benchmark for appropriate antibiotic administration is 50-75% of the time. If SAC administers antibiotics 90% of the time appropriately they will save $6.48 million dollars a year on 100,000 patients. Being able to increase the percentage of time that proper antibiotic administration occurs would result in a multi-million dollar savings nationwide. *Cost & Benchmark source: Barnard, Bonnie MPH, CIC “Fighting Surgical Site Infections” Myocardial Infarction # Patients % Patients SAC 19 0.02% National Benchmark* 205 0.19% Number of patients undergoing anesthesia annually: SAC- 95,205 patients/year US approx. 40 million patients/year. Average cost to traditional health insurer for first 90 days after heart attack per patient $ 38,501** Total cost SAC patients $ 731,519 Total cost National Benchmark $ 7,892,705 Estimated savings to health plans/patients resulting from SAC reduced events = $7,163,236 Estimated national savings if benchmark reduced to SAC benchmark levels = $2.618 Billion *Benchmark Source: Chung, Dorothy and Stevens, Robert, “Evidence-based Practice of Anesthesiology,” page 379. ** Cost Source: NBER Working Paper No. 6514, 98, National Bureau of Economic Research. Stroke # Patients % Patients SAC 19 0.020% National Benchmark* 476 0.5% Number of patients undergoing anesthesia annually: SAC-95,205 patients per year, US approximately 40 million patients per year. Cost at discharge for inpatient care per patient $ 9,882** Total cost SAC patients $ 187,758 Total cost National Benchmark $ 4,703,832 Estimated savings to health plans/patients resulting from SAC reduced events = $4,516,074 Estimated national savings if benchmark reduced to SAC benchmark levels = $1.897 Billion *National benchmark is <1%, so .5% is used for calculation. *Benchmark Source: Fleisher, Lee; ”Evidence-Based Practice of Anesthesiology, page 163. **Cost Source: Neurology, Vol 46, Issue 3, 854-860, 1996, American Academy of Neurology, “Inpatient costs of specific cerebrovascular events at five academic medical centers” John M. Kunysz, FACHE, is a licensed CPA formerly with Pr i ce w a te r h o u s e Coopers and KPMG.  He received his MBA from the University of California, Los Angeles, and Bachelor of Science degree from San Diego State University. For ad- ditional information regarding Quantum Clinical Navigation System visit www. or call 1.800.354.3568.
  20. 20. The Communiqué Fall 2009 Page 20 13 Steps to a Disastrous Anesthesia Information System Implementation Phil Mesisca, MBA, CMPE University of Pennsylvania Health System, Philadelphia, PA Implementing an Anesthesia Information System (AIS) is a major un- dertaking for an anesthesia practice. The question is less about “should we” and more about “when or how should we” as it is inevitable that most practices will even- tually make the move. This article will review the steps to be avoided for a suc- cessful AIS implementation. 1. Purchase Vaporware. Ignore any discussion with a vendor that includes “… not now, but we will be able to handle that in our next ver- sion …”. 2. Assume The Ais Will Fix All Your Operational Problems. In the words of Bill Gates “The first rule of any technology used in a busi- ness is that automation applied to an efficient operation will magnify the ef- ficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.” If you have someone constantly tracking down missing anesthesia records now, you’ll probably have someone tracking down incomplete or open electronic anesthesia records later. 3. Under-Estimate The Time And Resources Needed For Implementation. Most large capital investment projects come in late and over-budget. There will be significantly more issues than you will anticipate and make sure you prepare for the time devoted to the one out of every 5 clinicians who will offer significant resistance.i 4. Only Consider The Costs And Resources Needed To Implement. You can’t prepare for every future problem so prepare for your response to a problem. Think about on-going issues and future needs such as tech- nical support, upgrades, training, record security, interfaces, on-going fees, data mining, expansion licenses, backup processes, etc. There is an enormous amount of work in prepar- ing for the implementation, but many practices don’t properly plan for the continued resources and time needed for the months/years after the go-live date. 5. Let The Administrative Team Take Complete Responsibility For Implementation. Key physicians and CRNAs must be involved for a successful implemen- tation. These individuals must also be given the needed time to properly plan and implement – and remember “implement” is beyond the day the system goes live. 6. If The Hospital Is Funding The AIS, Make Sure You Allow It To Dictate What System You Will Implement Even If You Know That It Will Not Meet Your Needs. You certainly need to be reasonable, but implementing a system that isn’t going to do the job properly will be a lose/lose for both your group and the hospital. 7. Modify The Ais To Accommodate How You Do Things Today In Your Practice. The more willing a practice is to be flexible and modify work processes to take advantage of the technology, the higher the probability that the poten- tial benefits will be realized. 8. Ignore The Research That Documents The Enormous Difficulty For People To Change And Just Assume That Everyone Will Embrace This New Technology. Consider a recent study that showed that despite the real possibility of death if patients did not change their lifestyle, fewer than 15% of heart
  21. 21. The Communiqué Fall 2009 Page 21 attack survivors were following their doctor’s advice to adhere to a healthy diet just one year after their heart attack.ii Even if things go perfectly, few people embrace change. 9. Don’t Fill The Open Clerical Position In Your Practice Since You Are About To Implement Your New Ais And You’ll Surely Have Much Less Need For These Positions Once You Go Live. Before, during and for months after implementation you will have more need than ever for administrative support. This is also a critical time to have stability in key positions. President Abraham Lincoln believed that his nomination as the Republican candidate for his second term had not come because he was the best man, but rather because the party had con- cluded that it would be best to “not swap horses while crossing the river” since they were in the middle of the war. Good advice to remember. 10. Set Unrealistic Expectations. No system will meet all your needs and wants. Forget about your wants. Prioritize your needs. 11. Be An Eternal Optimist And Avoid Conflict. It is imperative to confront the issues, debate them, fix them, and move on. Consider the Stockdale Paradox as noted by famed author Jim Collins in his landmark book Good to Great. It’s named after Admiral James Stockdale, who survived 7 years as a POW during the Vietnam War. You can listen to a brief audio on this on Collins’s web site (http://www.jimcol- html#audio=59), but the key quote from the book is “You must never con- fuse faith that you will prevail in the end – which you can never afford to lose – with the discipline to confront the most brutal facts of your current reality, whatever they might be.”iii 12. Worry That This Will Be Bad For Billing Compliance, Malpractice Claims, Or Patient Care. Billing compliance documentation will be much better as long as your ac- tions are compliant. Non-compliant actions will be duly noted in the elec- tronic system (e.g. If you note at 11:00 that you were present for induction but induction actually occurs at 11:42 you will have a problem). So if you do the right thing the documentation proving that will be better than ever. A survey published in Anesthesia & Analgesia showed that departments using an AIS for anesthesia record keeping believed that these systems were useful for managing malpractice risk and did not increase malpractice exposure.iv A study at the University of Michigan showed that the use of electron- ic reminders improved procedure documentation compliance and pro- fessional fee reimbursement.v Another study at Massachusetts General Hospital showed that real-time checking of electronic records for doc- umentation errors and automatically text messaging clinicians greatly im- proved the quality of 13. Underestimate The Value Of An AIS. An MGMA survey across all medical practices reflected that after the first 6 to 24 months, the benefits of electron- ic health record adoption generally increasingly exceed the cost, and most practices eventually wonder how they ever conducted business without an electronic record.� vii Although anes- thesia is certainly very different from other specialties, similar results can be expected. So the good news is that eventually you will have better documentation for billing compliance. Eventually charge cap- ture will be more accurate. Eventually the billing cycle will be faster. Eventually mal- practice risk will be reduced. Eventually patient care will be better. Eventually you’ll be telling stories to the residents and SRNAs about life before the AIS imple- mentation and how paper was used. They will stare at you in disbelief. i MGMA Information Exchange – Electronic Health Records, November 2006. ii University of Massachusetts Medical School (2008, February 1). Patients Diagnosed with Coronary Heart Disease Continue Poor Diets, Study Shows. ScienceDaily. Retrieved August 28, 2009, from http:// iii Collins, Jim. Good to Great: Why Some Companies Make the Leap…and Others Don’t. Harper Business; Edition 1, October 16, 2001. iv Feldman JM. Do Anesthesia Information Systems Increase Malpractice Exposure? Results of Survey. Anesthesia & Analgesia. 2004; 99: 840-843. v Kheterpal S, Gupta R, Blum JM, Tremper KK, O’Reilly M, Kazanjian PE. Electronic reminders im- prove procedure documentation compliance and professional fee reimbursement. Anesthesia & Analgesia. 2007 March; 104(3):592-7. vi Sandberg WS, Sandberg EH, Seim AR, Anupama S, Ehrenfeld JM, Spring SF,Walsh JL. Real-time checking of electronic anesthesia records for documentation errors and automatically text messaging clinicians improves quality of documentation. Anesthesia & Analgesia. 2008 January; 106(1): 192-201. vii MGMA Electronic Health Records: Perspective from the Adopters, October 2007. Phil Mesisca, MBA, CMPE is the Chief Operating Officer for the Department of Anesthesiology & Critical Care and the Department of Otorhinolaryngology – Head and Neck Surgery at the University of Pennsylvania Health System in Philadelphia. He can be reached at mesis-
  22. 22. The Communiqué Fall 2009 Page 22 Virtually all large anesthesiology practices have a corporate website. Some are quite detailed and complex. Fewer medium and small practices maintain a web presence. Should every practice consider creating a practice website or upgrading its current site? After examining a number of anesthesia practice websites, one can see that most have common elements and purposes. Before considering website design, the practice should seriously consider the purpose of the website and its intended effects. The reasons given by anesthesia practices for expending the time and money needed to produce an effective website are to implement one or more of the following: 1. Establish a “web presence” 2. Recruit anesthesia personnel via the website 3. Provide patient information 4. Assist in the patient billing process 5. Schedule anesthesiologists via surgeon preference 6. Internal uses such as maintaining call schedules, document retrieval and communications. 7. Marketing to patients, surgeons and facilities seeking anesthesia coverage. Web Presence Currently, almost every business has a website, so anesthesiology practices may believe that they too should have one. However, many surgical anesthesiology practices with exclusive hospital contracts do not experience competitive pressure and have not yet seen the need for a web presence. Pain management practices are more market- driven and usually maintain a web site that can help promote their services to patients and referring physicians. Although a web presence alone may not be the motivating factor to establish a website, practices should consider the fact that most businesses are found these days via internet searches. A simple but well designed website may be an alternative to a costly listing in the business pages of the local telephone book. Recruiting Some anesthesia practices state that their website is mainly for recruiting purposes. This is especially true of practices that employ CRNAs and experience difficulty with hiring and turnover. A properly designed and maintained web site can appear at the top of search results that are run by physicians or CRNAs seeking employment in your area. Some practices post jobs and allow resumes to be submitted through their website. If your local competitors are doing this and you are not, you are at a disadvantage. With proper search engine placement and a long term strategy for recruitment, the anesthesia website can reduce or eliminate the need for outside recruiters as well as for recruiting and advertising fees. Patient Medical Information Many practices place extensive patient education information on their web site. This information may be generic such as the description of the types of anesthesia and anesthesia complications. Specific information Anesthesiology Practice Web Sites Joe Laden Anesthesia Associates of Louisville, PSC Louisville, KY
  23. 23. The Communiqué Fall 2009 Page 23 such as the anesthesia group’s preoperative testing requirements can be available on the website. The ASA has patient information on its website that can be linked to. Patient Billing In addition to billing and collection policies and procedures, some practices have links to the practice’s billing company. It may also be possible to provide a mechanism for patients to view and pay their bills on the practice web site with credit cards and PayPal. Anesthesia and Surgery Scheduling In some areas of the country, anesthesiologists compete within hospitals and are scheduled by surgeon preference. A web presence and scheduling system are vital to these practices. Marketing Beyond a simple “web presence”, some anesthesiology groups market their skills and experience to the community and to prospective facilities in need of anesthesiology services. To do this the website could describe the group’s accomplishments and special services it delivers to the facilities at which it operates. If the group is involved in community activities and charities, these can be promoted on the web site. Practices with office-based pain management divisions usually describe these services on the website and provide contact, location and hours of operation information. Internal Use Some practices maintain a website only for internal use and some include a private section with password access on their public website. Internal uses include: call and vacation schedules, posting of clinical and business documents and internal communications. Practices that use a commercial web-based scheduling system can post a link to their system here. Hosting and Cost A website can be hosted on your corporate network or via a web hosting service. Hosting should not cost more than a few hundred dollars per year. The cost of designing and implementing a web site can range from zero for a simple web page hand-coded by someone in the practice to tens of thousands of dollars for the elaborate web site of a large anesthesiology practice. Website Placement If you want prospective employees and local patients to find your website by searching using Google, Bing, Yahoo and other search engines, you need to take some steps to assure that your site will be retrieved high in the search engine results lists. This is called Search Engine Optimization and the techniques to do this will be known by your website designer. Implementing Your Website An anesthesiology practice will most likely use a professional website design company to product a website or upgrade its current website. However, before the website design work is done, the practice manager and one or more physicians should examine the websites of many local and national anesthesiology practices to obtain ideas about the website elements the practice would like to emulate. Having a good idea as to the layout and features of one’s website before the implementation process starts can save the practice time and money and make it much more likely to produce an effective result. Continuing Relevance After the anesthesiology website is implemented, it should be updated frequently with current information Continued on page 24
  24. 24. The Communiqué Fall 2009 Page 24 about the practice. If you scan the web looking for anesthesia group web sites, you will find ones that look like they have not been updated in years. Someone in your practice should be designated to keep the website up-to-date. One way to make your website look current is to include frequently updated news items or a patient information blog on the front page. Anesthesiology Practice Web Sites Continued from page 23 Website Main Sections Information about the Practice History Mission Statement Group makeup Message from group leader(s) Services Provided: (e.g.: Surgical Anesthesia, Ambulatory Anesthesia, Chronic Pain, Acute Pain, OB Anesthesia, Neuroanesthesia, Cardiac Anesthesia, Critical Care Anesthesia) Special Services Quality Assurance Program Practice Divisions (OR, OB, Pain, Critical Care, Office Based) Facilities Covered Description and pictures of facilities Links to facilities Location/Directions/Maps Self-promotion & differentiation from competing groups Information about group in video format Providers (MD,CRNA,AA) Names of providers Provider biographies/qualifications Provider photographs Links to articles and accomplishments of group members Patient Information Medical Information Description of types of anesthesia OB anesthesia considerations Fasting Guidelines Preoperative testing Pre-anesthesia questionnaire Recruiting CRNA opportunities MD opportunities Administrative positions Ability to email or upload resume City, state and community information Links to area attractions, real estate and schools Administration/Billing Billing Information Insurance accepted Billing policies and procedures Link to billing company Online Payments: Credit Card/PayPal Support staff names and contact Information Private Access Sections MD/CRNA Call Schedules Vacation Schedules Link to scheduling software Internal Communication / Private Email Link to group’s intranet Access to Company Documents Policies and Procedures Medical Information Links to anesthesiology clinical sites Access to patient billing information Access to Quality Management/Assurance System ASA’s Lifelineto TheAmericanSocietyofAnesthesiologists (ASA) recently launched a website, http:// to help educate and inform patients and the public at large. Among the important tools on this site are the Anesthesia&Me© checklist, a form to be filled out with an individual’s medical history, current medications, allergies and additional items necessary for proper anesthesia care. also gives patients details about what to expect before and after surgery from an anesthesia perspective. In the September, 2009 issue of its Newsletter, ASA asked all members to post a link to the new website from their own websites and to help spread the word by other means. Joe Laden has served as the Business Manager for Anest- hesia Associates of Louisville, PSC since 1981. He has written many articles about anesthesia business topics and has made presentations at MGMA, ASA and other business conferences. To contact Joe with any questions or comments about infor- mation in article: joeladen@aalouisville. com. More lists of academic and private practice websites can be found at http:// Private Practice Pediatric Academic default.aspx Pain Some examples of Good Anesthesia Practice Websites:
  25. 25. The Communiqué Fall 2009 Page 25 The Health Information Technology for Economic and Clinical Health Act (“HITECH Act”), included as part of the American Recovery and Reinvestment Act of 2009 (“ARRA”), significantly alters and supplements provisions of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) protecting the privacy and security of individuals’ protected health information (“PHI”). Subtitle D of HITECH— pertaining to patients’ privacy rights, breach notification, and consequences of breaching private information— significantly expands the HIPAA privacy and security provisions. This article will summarize some key aspects of the privacy and security portions of the HITECH Act. Liabilities of Covered Entities and Business Associates In one of the most significant expansions of HIPAA effectuated by the HITECH Act, the HITECH Act expanded certain requirements, which previously only governed covered entities,1 to also govern business associates of covered entities.2 Specifically, Section 13401 of the HITECH Act directly applied the administrative, physical and technical safeguard requirements of the HIPAA Security Rule to business associates, and mandated that business associates maintain policies, procedures and documentation of security practices. In addition, pursuant to Section 13404 of the HITECH Act, the privacy requirements addressed by the HITECH Act (and summarized in this article) are made applicable not only to covered entities, but also to their business associates. Whereas HIPAA specifically governed covered entities, and thus made only covered entities liable for HIPAA violations, both covered entities and business associates are liable for HIPAA violations based on the HIPAA amendments in the HITECH Act. Prior to HITECH, it was the covered entity’s responsibility to ensure the business associate complied with HIPAA standards. If a business associate committed a HIPAA violation, the consequence was termination of the contract if the business associate remained non-compliant. Now, if a business associate is non-compliant, then that business entity is subject to consequences directly from the HHS, including criminal and civil liabilities. Required Notification for Information Breaches Effective September 23, 2009, both covered entities and their business associates will be liable for breaches of a patient’s unsecured protected health information.3 The HITECH Act requires a covered entity or its business associate to notify an individual of a breach of that individual’s unsecured protected health information within 60 days of discovering the breach. When a breach involves individual consumers, depending on the number of individuals who are involved, an individual notification or media notification will be utilized. Notification must also be made to the Department of HHS immediately if the breach involves 500 or more individuals. If the breach involves less than 500 individuals, the provider can maintain such information on a log, which must be provided annually to HHS. Guidance from HHS Surrounding Breach Notification On April 29, 2009, HHS published additional guidance regarding the HITECH Act’s requirements regarding the breach notification requirements for unsecured protected health information.4 Note that the breach notification requirements apply only to unsecured protected health information, which is defined as protected health information that is not unusable, unreadable or indecipherable to unauthorized individuals. The additional guidance was mandated by Section 1302 (h) (2) 1 A covered entity is defined as “(1) [a] health plan. (2)A health care clearinghouse. (3) A health care provider who transmits any health information in electronic form in connection with a transaction covered by this subchapter.” 2 A business associate is “a person or organization, other than a member of a covered entity’s workforce, that performs certain functions or activities on behalf of, or provides certain services to, a covered entity that involve the use or disclosure of individually identifiable health information. Business associate functions or activities on behalf of a covered entity include claims processing, data analysis, utilization review and billing.” 3 Unsecured protected health information is defined as “protected health information that is not secured through the use of a technology or methodology specified by the Secretary….” HITECH § 13402(h)(1)(A). Continued on page 26 HITECH in a High Tech Era Abby Pendleton, Esq. Jessica L. Gustafson, Esq.i The Health Law Partners, P.C. Southfield, MI
  26. 26. The Communiqué Fall 2009 Page 26 of the HITECH Act, which required HHS to issue guidance “specifying the technologies and methodologies that render protected health information unusable, unreadable, or indecipherable to unauthorized individuals ….” Although compliance with this guidance is not mandatory, HHS emphasized that following the guidance will serve as a safe harbor, resulting in “covered entities and business associates not being required to provide the notification otherwise required by section 13402 in the event of a breach.” On August 24, 2009, HHS published an Interim Final Rule,5 which clarifies guidance specifying technologies and methodologies that render PHI unusable, unreadable or indecipherable to unauthorized individuals, and further outlines new regulations governing covered entities’ and business associates’ responsibilities under the HITECH Act to provide notification to affected individuals and to HHS following the discovery of a breach of unsecured PHI. The new regulations will be codified at 45 C.F.R. § 164.400 et seq. The Stakes Are Raised – Increased Enforcement As noted above, the HITECH Act contains provisions so that penalties that apply to covered entities for violations of HIPAA also apply to business associates. Further, the HITECH Act revises and expands current penalty provisions for violations of health privacy and security regulations. The HITECH Act contains new provisions related to noncompliance due to “willful neglect” and requires the government to formally investigate any complaint of a violation if a preliminary investigation of the facts indicates a possible violation due to willful neglect. The HITECH Act also replaces the current penalty of $100 per violation with a new tiered-penalty system. Of particular importance, the HITECH Act also includes a provision authorizing enforcement by State Attorney General Offices if the attorney general of a State has reason to believe that an interest of one or more residents of that State has been or is threatened or adversely affected. In such cases, the Attorney General can bring a civil action on behalf of the state residents to enjoin any continuing violation or to obtain damages on behalf of the residents. The court may also award costs and reasonable attorney fees to the State. 6 Required Accounting of Disclosures Involving Electronic Health Records As many providers are aware, under HIPAA, covered entities are not required to provide individuals with an accounting of disclosures of their protected health information if the disclosure is related to treatment, payment, or the health care operations of the covered entity. Per the HITECH Act, providers who use or maintain electronic health records will be required to account for disclosures related to treatment, payment, or the health care operations of the covered entity. In such cases, the accounting period is limited to three (3) years prior to the date on which the accounting is requested. The effective date for this new requirement is dependent upon whether the provider acquired an electronic health records as of January 1, 2009 or after January 1, 2009. For users of electronic records 4 74 Fed. Reg. 19006 (April 17, 2009), available at 5 74 Fed. Reg. 42740 (August 24, 2009), available at =282472267445+0+2+0&WAISaction=retrieve 6 Section 13410 of the HITECH Act. HITECH in a High Tech Era Continued from page 25
  27. 27. The Communiqué Fall 2009 Page 27 as of January 1, 2009, the HITECH Act applies to disclosures made on and after January 1, 2014. For users acquiring electronic health records after January 1, 2009, the HITECH Act applies to disclosures made on and after the later of January 1, 2011 or the date the entities acquires the electronic health record. 7 The Minimum Necessary Rule With regard to non-treatment situations, HIPAA requires providers to only use the minimum amount of PHI necessary to accomplish permitted tasks. Section 13405 of the HITECH Act clarifies that a covered entity will be seen as having complied with this “minimum necessary” standard if it limits the disclosed PHI to the “limited data set.” The limited data set excludes identifying information such as names, addresses, telephone numbers, social security numbers, etc. However, if the limited data set is not sufficient, the minimum necessary standard applies. By August 2010, HHS will issue guidance surrounding the definition of minimum necessary. Until this guidance is issued, the Act requires “in the case of the disclosure of protected health information, the covered entity or business associate disclosing such information shall determine what constitutes the minimum necessary to accomplish the intended purpose of such disclosure.” Prohibitions on Sale of Electronic Health Records or PHI Unless one of six (6) specified exceptions apply, the HITECH Act prohibits a covered entity or business associate from directly or indirectly receiving remuneration in exchange for any protected health information, unless the entity obtained a valid HIPAA authorization that specifies whether the protected health information can be further exchanged for remuneration. The exceptions to the general prohibition include the following: • The purpose of the exchange is for public health activities; • The purpose is for research and the price charged reflects the costs of preparation and transmittal of the data for such purpose; • The purpose is for treatment, subject to additional protections promulgated by regulation; • The purpose is in connection with the business operations of the entity; • The purpose of the exchange is for remuneration that is provided by a covered entity to a business associate for activities involving the exchange of protected health information that the business associate undertakes on behalf of and at the specific request of the covered entity pursuant to a business associate agreement; • The purpose of the exchange is to provide an individual with a copy of his or her own protected health information. HHS is authorized to develop additional exceptions. Notably, the effective date for this provision is six (6) months after the date of the promulgation of final regulations (HHS is responsible for promulgating regulations no later than 18 months after the enactment date of the Act).8 Access to Information in Electronic Format The HITECH Act states that where a covered entity uses or maintains an electronic health record with respect to protected health information, the individual shall have a right to obtain from the covered entity a copy of such information in an electronic format.9 Conclusion The HITECH Act significantly alters and supplements provisions of HIPAA protecting the privacy and security of individual’s PHI. Providers and their business associates are well advised to familiarize themselves with such requirements in order to remain in compliance with the expanded health information privacy and security requirements. i The authors would like to thank Neda Mirafzali, a 3L law student at Michigan State University Law School and a law clerk currently working with The Health Law Partners, P.C., for her contributions to and assistance with this article. 7 Section 13405 (c) of the HITECH Act. 8 Section 13405 (d) of the HITECH Act. 9 Section 13405 (e) of the HITECH Act. Abby Pendleton and Jessica L. Gustafson are partners with the health care law firm of The Health Law Partners, P.C.  The firm represents hospitals, physicians, and other health care providers and suppliers with respect to their health care legal needs.  Pendleton and Gustafson co-lead the firm’s Recovery Audit Contractor (“RAC”) and Medicare practice group, and specialize in a number of areas, including: RAC, Medicare, Medicaid and other payor audit appeals, healthcare regulatory matters, compliance matters, reimbursement and contracting matters, transactional and corporate matters, and licensing, staff privilege and payor de-participation matters.  Pendleton and Gustafson also regularly assist attorneys with their health care legal needs. They can be reached at (248) 996-8510 or apendleton@thehlp. com and  Abby Pendleton Jessica L. Gustafson
  28. 28. Professional Events ANESTHESIA BUSINESS CONSULTANTS 255 W. Michigan Ave. P.O. Box 1123 Jackson, MI 49204 Phone: (800) 242-1131 Fax: (517) 787-0529 Web site: Date Event Location Contact Info Oct. 17-21, 2009 ASA Annual Meeting Morial Convention Center, New Orleans, LA Oct. 11-14, 2009 MGMA Annual Conference Colorado Convention Center, Denver, CO Oct. 26-30, 2009 CSA Fall Hawaiian Seminar Grand Hyatt Kauai Resort & Spa, Poipu Beach, Kauai Nov. 6-8, 2009 Association of Anesthesiology Program Directors/Society of Academic Anesthesiology Chairs Annual Meeting Boston Park Plaza, Boston, MA Dec. 11-15, 2009 New York State Society of Anesthesiologists Postgraduate Assembly in Anesthesiology Marriott Marquis, New York, NY Jan. 17-22, 2010 Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Paradise Island, Bahamas Jan. 18-22, 2010 CSA Winter Hawaiian Seminar Hyatt Regency Maui Resort & Spa, Ka’anapali Beach, Maui Jan. 29-31, 2010 ASA Conference on Practice Management Marriott Marquis, Atlanta, GA