A publication dedicated to bringing articles and advice, specific to the anesthesia and pain management community, that are practical and tangible.
This edition covers the following topics:
• Using Big Data for Big Research: MPOG, NACOR and other Anesthesia Registries
• Another Year of Changes Lies Ahead for Anesthesiologists
• Disruptive Change, Anesthesiologists, and ASCs
• Performing High Acuity Cases in ASCs: The Anesthesiologist’s Role
• Endoscopy: Revisited
• Reporting Postoperative Pain Management in 2014
• 2014 CPT Coding and Key Reimbursement Changes
The document discusses quality management in anesthesia practices. It introduces the Anesthesia Incident Reporting System (AIRS), which allows providers to anonymously report unintended events or "near misses" that did not harm patients but had potential to. Near misses provide teaching opportunities at morbidity and mortality conferences. Mature practices encourage self-reporting of near misses through online forms or other methods. Reported cases are reviewed to identify those with educational value for discussing key decision points with the goal of improving patient safety.
The document discusses the challenges facing ophthalmology practices and electronic health record (EHR) vendors in transitioning to digital medical records. It notes that while around half of ophthalmologists have implemented or are implementing EHRs, customer satisfaction with EHR systems is low. The key driver for adoption is government regulations and incentives, with Meaningful Use Stage 2 requirements proving difficult for practices and vendors to meet. The article predicts that stringent requirements will force consolidation in the EHR industry, with many small vendors unable to survive due to the resources needed to keep up with evolving standards.
Precision medicine and AI: problems aheadNeil Raden
This document discusses the challenges of using AI and machine learning in healthcare due to issues with data silos and lack of data sharing. Healthcare data is fragmented across different organizations, making it difficult to access enough high-quality data needed to train accurate AI models. This fragmentation was caused by organizations independently developing their own IT systems, and impacts the ability to develop personalized medicine models that need access to diverse patient data sources. Overcoming these challenges will require addressing issues of data governance like ownership, responsibility and privacy.
The document discusses trends in the LASIK procedure market over the past 20 years and predictions for the future. It summarizes that while LASIK demand dropped during the economic recession, the cyclical nature of the economy and improving consumer confidence suggests demand will rise again. It also cites increasing use of lasers in cataract surgery, the large pool of potential patients in Generation Y, higher resolution consumer electronics stimulating demand, and the growing role of the internet and social media as factors that will positively influence future LASIK demand.
The document discusses the challenges and limitations of the Physician Payments Sunshine Act, which requires drug and medical device companies to report payments and gifts provided to physicians. While intended to increase transparency, it faces issues in fully capturing all financial relationships and providing proper context. The data has had limited impact on physicians and patients, but is being utilized by other groups like researchers and lawyers. Overall, the Act faces obstacles in communicating complex financial data in a clear and meaningful way to different audiences.
1) The study analyzed data from over 11,000 LASIK procedures to understand how long it takes patients to schedule surgery after their initial consultation.
2) They found that slightly over 1/3 of patients scheduled surgery within 2 weeks, while another 25% scheduled within 1 month. However, about 30% delayed scheduling for 1-4 months.
3) When comparing subgroups, contact lens failures were least likely to schedule quickly, while nearsighted patients under 25 tended to schedule the fastest on average. Patients who had surgery more recently also tended to take longer to schedule.
Wavefront-guided cataract surgery using the ORange intraoperative wavefront system provides refractive information during surgery to help improve outcomes. Nine surgeons were surveyed who have collectively used ORange for over 6,000 cases. Their use of ORange has led to higher fees for premium IOL surgery, lower enhancement rates around 5% compared to 17% previously, and increased confidence in outcomes leading to higher patient conversion rates to premium IOLs. While ORange adds some time in surgery, surgeons find the benefits of fewer unhappy patients needing enhancements outweigh the costs of extra operating time.
The document discusses quality management in anesthesia practices. It introduces the Anesthesia Incident Reporting System (AIRS), which allows providers to anonymously report unintended events or "near misses" that did not harm patients but had potential to. Near misses provide teaching opportunities at morbidity and mortality conferences. Mature practices encourage self-reporting of near misses through online forms or other methods. Reported cases are reviewed to identify those with educational value for discussing key decision points with the goal of improving patient safety.
The document discusses the challenges facing ophthalmology practices and electronic health record (EHR) vendors in transitioning to digital medical records. It notes that while around half of ophthalmologists have implemented or are implementing EHRs, customer satisfaction with EHR systems is low. The key driver for adoption is government regulations and incentives, with Meaningful Use Stage 2 requirements proving difficult for practices and vendors to meet. The article predicts that stringent requirements will force consolidation in the EHR industry, with many small vendors unable to survive due to the resources needed to keep up with evolving standards.
Precision medicine and AI: problems aheadNeil Raden
This document discusses the challenges of using AI and machine learning in healthcare due to issues with data silos and lack of data sharing. Healthcare data is fragmented across different organizations, making it difficult to access enough high-quality data needed to train accurate AI models. This fragmentation was caused by organizations independently developing their own IT systems, and impacts the ability to develop personalized medicine models that need access to diverse patient data sources. Overcoming these challenges will require addressing issues of data governance like ownership, responsibility and privacy.
The document discusses trends in the LASIK procedure market over the past 20 years and predictions for the future. It summarizes that while LASIK demand dropped during the economic recession, the cyclical nature of the economy and improving consumer confidence suggests demand will rise again. It also cites increasing use of lasers in cataract surgery, the large pool of potential patients in Generation Y, higher resolution consumer electronics stimulating demand, and the growing role of the internet and social media as factors that will positively influence future LASIK demand.
The document discusses the challenges and limitations of the Physician Payments Sunshine Act, which requires drug and medical device companies to report payments and gifts provided to physicians. While intended to increase transparency, it faces issues in fully capturing all financial relationships and providing proper context. The data has had limited impact on physicians and patients, but is being utilized by other groups like researchers and lawyers. Overall, the Act faces obstacles in communicating complex financial data in a clear and meaningful way to different audiences.
1) The study analyzed data from over 11,000 LASIK procedures to understand how long it takes patients to schedule surgery after their initial consultation.
2) They found that slightly over 1/3 of patients scheduled surgery within 2 weeks, while another 25% scheduled within 1 month. However, about 30% delayed scheduling for 1-4 months.
3) When comparing subgroups, contact lens failures were least likely to schedule quickly, while nearsighted patients under 25 tended to schedule the fastest on average. Patients who had surgery more recently also tended to take longer to schedule.
Wavefront-guided cataract surgery using the ORange intraoperative wavefront system provides refractive information during surgery to help improve outcomes. Nine surgeons were surveyed who have collectively used ORange for over 6,000 cases. Their use of ORange has led to higher fees for premium IOL surgery, lower enhancement rates around 5% compared to 17% previously, and increased confidence in outcomes leading to higher patient conversion rates to premium IOLs. While ORange adds some time in surgery, surgeons find the benefits of fewer unhappy patients needing enhancements outweigh the costs of extra operating time.
This document discusses the rise of "docpreneurs", or young physician entrepreneurs who are using their medical training and technology skills to launch startups aimed at improving healthcare. It profiles several physician entrepreneurs in the Boston area who have started companies like Twiage, an app that sends patient data from ambulances to hospitals, and Symcat, a symptom checker app. These docpreneurs are being supported by Boston's strong academic institutions and growing entrepreneurial ecosystem. While these physicians still practice clinically, they are also pursuing entrepreneurship to have a bigger impact on healthcare and drive innovation. Hackathons and accelerators are helping generate and develop their ideas into new companies.
Artificial intelligence in healthcare quality and its impact by Dr.Mahboob al...Healthcare consultant
This document discusses several ways that artificial intelligence could impact healthcare by 2020. It begins by outlining 12 artificial intelligence innovations that a panel from Partners HealthCare identified as having potential to significantly change clinical care within the next year. These include using AI to improve access to mental healthcare, streamline clinical workflows with voice assistants, identify patients at risk of domestic violence, and help treat conditions like strokes and eye diseases. The document then examines each innovation in more detail, focusing on how AI may reduce administrative burdens on providers, unlock health data sharing, monitor brain health, detect malaria, and augment medical diagnostics. Overall, the panel is optimistic that with further advances, AI will be integrated into many areas of medicine to enhance care delivery over
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!
Visit www.anesthesiallc.com for more information!
The document describes how a new intelligence solution called the Readmission Prevention Solution was developed and implemented at Advocate Health Care using DMAIC (Define, Measure, Analyze, Improve, Control) principles. It details how the previous manual process for assessing readmission risk was time-consuming and inefficient. A new algorithm called the All-Cause Readmission Risk Algorithm was developed to automatically predict individual patient readmission risk based on data from their electronic health records. The new solution improved the workflow for care managers and provided additional features to help proactively mitigate readmission risk.
Pascal Metrics - Current Use Of Technology In Automating Patient Harm Identif...William Andrews
Patient safety leaders agree that understanding the full extent and patterns of patient harm is important, but hospitals currently lack tools to comprehensively measure harm. A survey found that while harm is commonly discussed, these discussions are likely informed by limited voluntary reporting that detects only a small fraction of actual harm. Nearly all respondents agreed that technology providing real-time data on harm patterns would be valuable. The document proposes that automated systems using electronic medical record data in patient safety organizations could reliably detect harms, allowing hospitals to learn from this information to improve care delivery and reduce costs.
hunter Whitney The Journal of Precision MedicineHunter Whitney
This document discusses the need for improved data visualization tools for precision medicine. It notes that while collecting large amounts of health data, not enough focus has been placed on designing tools to clearly display and make this data digestible and actionable for medical professionals and patients. The article interviews one expert who believes that more funding needs to go towards designing these visualization systems so that the full potential of precision medicine can be realized.
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!
Visit www.anesthesiallc.com for more information!
The document provides tips for leading quality and safety improvements, noting that leaders need to prioritize high-cost problems, lead improvement processes using systematic methods, and monitor outcomes to evaluate savings and spread successful changes. It emphasizes using data to motivate improvements and setting measurable targets to track progress and savings from reductions in waste and avoidable harm.
9) balik what makes positive pt experience pt safety monitor journal oct11ekha chosiah
This document discusses factors that contribute to positive patient experiences in the hospital setting. It summarizes a report by the Institute for Healthcare Improvement that identified five primary drivers of excellent patient care and experience: leadership, staff commitment, respectful partnerships with patients, reliable care processes, and evidence-based practices. The report found that improving patient experience requires an integrated, system-wide approach rather than isolated initiatives. It also emphasizes the importance of understanding the patient perspective by observing their journey through the healthcare system.
How to Use Data to Improve Patient Safety: A Two-Part DiscussionHealth Catalyst
As healthcare organizations continue to experience expenses growing faster than revenues, value based care, and consumer transparency of costs and quality, patient safety will be an important determinant of success. This session will describe the sociotechnical attributes of a safe system, the challenges, the barriers and opportunities, and how to use data and your culture of safety as a powerful tool to drive down adverse events.
Attendees will learn:
Why patient safety and quality are important.
How data can help improve patient safety.
The history of patient safety and where we are today.
What components make up a safety analytics culture.
How the internal safety culture directly impacts patient safety metrics.
To describe basic guidelines for improving a safety culture with analytics.
Pediatric Adverse Drug Events PresentationJordan Gamart
This document summarizes a webinar on pediatric adverse drug events hosted by the Patient Safety Movement Foundation. The webinar featured presentations from Dr. Anne Lyren on Children's Hospitals' Solutions for Patient Safety and Dr. James Broselow on eBroselow. Dr. Lyren discussed strategies to reduce pediatric adverse drug events through programs, checklists, and technology. Dr. Broselow discussed how assistive technologies can help standardize and simplify drug administration in pediatrics to reduce errors through features like dose verification and guidelines. The webinar provided an overview of initiatives and tools to help hospitals improve pediatric safety.
This document discusses the future of radiology and strategies for radiologists to remain relevant. It notes that while the future of radiology is bright, the future of radiologists is less certain. It recommends that radiologists focus on becoming experts in diagnosis, take quality seriously by implementing robust quality assurance programs, and measure radiology's economic impact by tracking metrics like decreased length of stay and lower costs. This will help radiologists transform their business models to succeed in a changing healthcare environment.
Demystifying Text Analytics and NLP in HealthcareHealth Catalyst
Leading the discussion, we have two exceptional thinkers in this space, Mike Dow, a former CIO and current Health Catalyst product manager and software developer, and Dr. Carolyn Simpkins, Health Catalyst’s Chief Medical Informatics Officer.
They will share thoughts on the challenges of text in clinical analytics as well as demonstrate:
Why text is an important part of clinical analytics
Why a text search is not enough
How clinical text search can be refined with NLP techniques
Healthcare providers took an average of 8.1 minutes to complete scheduling calls, which was longer than the cross-industry average of 3.7 minutes. Calls were frequently transferred, occurring 63% of the time for providers compared to best practices of 5.7%. Despite long wait times and transfers, only 59% of calls resulted in a scheduled appointment on the first attempt, falling below cross-industry averages.
All You Ever Needed to Know About the Healthcare Design IndustrySara Marberry
So you want to work in healthcare design. What do you need to know about the industry? Here's a quick overview of some of the important stats, trends, resources, etc.
Quality improvement is important in ensuring continuous development in service delivery, design or staff education hence a continuous improvement in patient outcome. Patient satisfaction begins in the ED, service delivery in the ED should be exemplary to ensure a better reputation for the hospital in the community and among patients. Quality improvement in the ED will improve patients’ outcomes, the process of care and reduce mortality due to ED delay.
Care Management - Critical Component Of Effective Population HealthHealth Catalyst
In this first webinar, of a two-part series, Dr. Kathleen Clary will share how analytics can be used to answer these questions to ensure delivery of a well-organized and effective care management program.
Dr. Clary will discuss how analytics can enable:
Data integration from multiple EMRs and data sources
Patient stratification and intake
Care coordination
Patient engagement
Performance measurement
We look forward to you joining us!
This document discusses a quality improvement project aimed at reducing emergency room wait times. A team of 3 nurses will lead the project. They plan to research current best practices for minimizing wait times and improving the patient experience in the ER. Options may include adjustments to staffing, facility layout, or patient flow. The team will evaluate several proposals before testing a new approach. Their goals are to enhance patient satisfaction, safety, and hospital reimbursement by addressing long wait times in the ER.
The Communiqué is a publication dedicated to bringing articles and advice, specific to the anesthesia and pain management community, that are practical and tangible. ABC is happy to provide The Communiqué electronically as well as hard-copy versions. The Communiqué features articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators.
Tony Mira, President & CEO, explains, “The Fall 2014 issue features several experts in anesthesia practice management providing helpful advice, starting with Danielle Reicher, MD, an Anesthesiologist from San Diego, CA. Dr. Reicher describes a specific and very important application of EHR technology in Making Meaningful Use More Meaningful: communicating with patients." Dr. Reicher states, “While we may not be a daily fixture in the medical lives of our patients, our role is critical and the information we gather can be extremely vital to the electronic medical record. Let’s make Meaningful Use even more meaningful!”
Another author we are proud to feature is Steven Dale Boggs, MD, MBA, Director of the OR and Chief of the Anesthesia Service at the James J. Peters VA Medical Center in Bronx, NY as well as Associate Professor of Anesthesiology at The Icahn School of Medicine at Mount Sinai in Manhattan, NY. One of Dr. Boggs’s areas of particular interest is GI sedation. For the past several years, Dr. Boggs has been working closely with endoscopists at Mount Sinai in New York and elsewhere, evaluating turnover time and safety metrics. He will be presenting at The ANESTHESIOLOGY™ 2014 annual meeting in New Orleans with a Point-Counterpoint session on Monday, October 13th and on a panel Tuesday, October 14th, and he gives us a detailed preview of his arguments in Computer-Assisted Personalized Sedation (CAPS): Will It Change the Way Moderate Sedation is Administered? ABC was pleased to have the opportunity to provide Dr. Boggs with claims data showing that the cost of anesthesia and anesthesia providers may be quite competitive with cost of CAPS.
For these and past Communiqué articles, please log on to ABC’s web site at www.anesthesiallc.com 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 info@anesthesiallc.com. We look forward to providing you with compliance, coding and practice management news through The Communiqué.
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!
Visit www.anesthesiallc.com for more information!
This document discusses the rise of "docpreneurs", or young physician entrepreneurs who are using their medical training and technology skills to launch startups aimed at improving healthcare. It profiles several physician entrepreneurs in the Boston area who have started companies like Twiage, an app that sends patient data from ambulances to hospitals, and Symcat, a symptom checker app. These docpreneurs are being supported by Boston's strong academic institutions and growing entrepreneurial ecosystem. While these physicians still practice clinically, they are also pursuing entrepreneurship to have a bigger impact on healthcare and drive innovation. Hackathons and accelerators are helping generate and develop their ideas into new companies.
Artificial intelligence in healthcare quality and its impact by Dr.Mahboob al...Healthcare consultant
This document discusses several ways that artificial intelligence could impact healthcare by 2020. It begins by outlining 12 artificial intelligence innovations that a panel from Partners HealthCare identified as having potential to significantly change clinical care within the next year. These include using AI to improve access to mental healthcare, streamline clinical workflows with voice assistants, identify patients at risk of domestic violence, and help treat conditions like strokes and eye diseases. The document then examines each innovation in more detail, focusing on how AI may reduce administrative burdens on providers, unlock health data sharing, monitor brain health, detect malaria, and augment medical diagnostics. Overall, the panel is optimistic that with further advances, AI will be integrated into many areas of medicine to enhance care delivery over
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!
Visit www.anesthesiallc.com for more information!
The document describes how a new intelligence solution called the Readmission Prevention Solution was developed and implemented at Advocate Health Care using DMAIC (Define, Measure, Analyze, Improve, Control) principles. It details how the previous manual process for assessing readmission risk was time-consuming and inefficient. A new algorithm called the All-Cause Readmission Risk Algorithm was developed to automatically predict individual patient readmission risk based on data from their electronic health records. The new solution improved the workflow for care managers and provided additional features to help proactively mitigate readmission risk.
Pascal Metrics - Current Use Of Technology In Automating Patient Harm Identif...William Andrews
Patient safety leaders agree that understanding the full extent and patterns of patient harm is important, but hospitals currently lack tools to comprehensively measure harm. A survey found that while harm is commonly discussed, these discussions are likely informed by limited voluntary reporting that detects only a small fraction of actual harm. Nearly all respondents agreed that technology providing real-time data on harm patterns would be valuable. The document proposes that automated systems using electronic medical record data in patient safety organizations could reliably detect harms, allowing hospitals to learn from this information to improve care delivery and reduce costs.
hunter Whitney The Journal of Precision MedicineHunter Whitney
This document discusses the need for improved data visualization tools for precision medicine. It notes that while collecting large amounts of health data, not enough focus has been placed on designing tools to clearly display and make this data digestible and actionable for medical professionals and patients. The article interviews one expert who believes that more funding needs to go towards designing these visualization systems so that the full potential of precision medicine can be realized.
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!
Visit www.anesthesiallc.com for more information!
The document provides tips for leading quality and safety improvements, noting that leaders need to prioritize high-cost problems, lead improvement processes using systematic methods, and monitor outcomes to evaluate savings and spread successful changes. It emphasizes using data to motivate improvements and setting measurable targets to track progress and savings from reductions in waste and avoidable harm.
9) balik what makes positive pt experience pt safety monitor journal oct11ekha chosiah
This document discusses factors that contribute to positive patient experiences in the hospital setting. It summarizes a report by the Institute for Healthcare Improvement that identified five primary drivers of excellent patient care and experience: leadership, staff commitment, respectful partnerships with patients, reliable care processes, and evidence-based practices. The report found that improving patient experience requires an integrated, system-wide approach rather than isolated initiatives. It also emphasizes the importance of understanding the patient perspective by observing their journey through the healthcare system.
How to Use Data to Improve Patient Safety: A Two-Part DiscussionHealth Catalyst
As healthcare organizations continue to experience expenses growing faster than revenues, value based care, and consumer transparency of costs and quality, patient safety will be an important determinant of success. This session will describe the sociotechnical attributes of a safe system, the challenges, the barriers and opportunities, and how to use data and your culture of safety as a powerful tool to drive down adverse events.
Attendees will learn:
Why patient safety and quality are important.
How data can help improve patient safety.
The history of patient safety and where we are today.
What components make up a safety analytics culture.
How the internal safety culture directly impacts patient safety metrics.
To describe basic guidelines for improving a safety culture with analytics.
Pediatric Adverse Drug Events PresentationJordan Gamart
This document summarizes a webinar on pediatric adverse drug events hosted by the Patient Safety Movement Foundation. The webinar featured presentations from Dr. Anne Lyren on Children's Hospitals' Solutions for Patient Safety and Dr. James Broselow on eBroselow. Dr. Lyren discussed strategies to reduce pediatric adverse drug events through programs, checklists, and technology. Dr. Broselow discussed how assistive technologies can help standardize and simplify drug administration in pediatrics to reduce errors through features like dose verification and guidelines. The webinar provided an overview of initiatives and tools to help hospitals improve pediatric safety.
This document discusses the future of radiology and strategies for radiologists to remain relevant. It notes that while the future of radiology is bright, the future of radiologists is less certain. It recommends that radiologists focus on becoming experts in diagnosis, take quality seriously by implementing robust quality assurance programs, and measure radiology's economic impact by tracking metrics like decreased length of stay and lower costs. This will help radiologists transform their business models to succeed in a changing healthcare environment.
Demystifying Text Analytics and NLP in HealthcareHealth Catalyst
Leading the discussion, we have two exceptional thinkers in this space, Mike Dow, a former CIO and current Health Catalyst product manager and software developer, and Dr. Carolyn Simpkins, Health Catalyst’s Chief Medical Informatics Officer.
They will share thoughts on the challenges of text in clinical analytics as well as demonstrate:
Why text is an important part of clinical analytics
Why a text search is not enough
How clinical text search can be refined with NLP techniques
Healthcare providers took an average of 8.1 minutes to complete scheduling calls, which was longer than the cross-industry average of 3.7 minutes. Calls were frequently transferred, occurring 63% of the time for providers compared to best practices of 5.7%. Despite long wait times and transfers, only 59% of calls resulted in a scheduled appointment on the first attempt, falling below cross-industry averages.
All You Ever Needed to Know About the Healthcare Design IndustrySara Marberry
So you want to work in healthcare design. What do you need to know about the industry? Here's a quick overview of some of the important stats, trends, resources, etc.
Quality improvement is important in ensuring continuous development in service delivery, design or staff education hence a continuous improvement in patient outcome. Patient satisfaction begins in the ED, service delivery in the ED should be exemplary to ensure a better reputation for the hospital in the community and among patients. Quality improvement in the ED will improve patients’ outcomes, the process of care and reduce mortality due to ED delay.
Care Management - Critical Component Of Effective Population HealthHealth Catalyst
In this first webinar, of a two-part series, Dr. Kathleen Clary will share how analytics can be used to answer these questions to ensure delivery of a well-organized and effective care management program.
Dr. Clary will discuss how analytics can enable:
Data integration from multiple EMRs and data sources
Patient stratification and intake
Care coordination
Patient engagement
Performance measurement
We look forward to you joining us!
This document discusses a quality improvement project aimed at reducing emergency room wait times. A team of 3 nurses will lead the project. They plan to research current best practices for minimizing wait times and improving the patient experience in the ER. Options may include adjustments to staffing, facility layout, or patient flow. The team will evaluate several proposals before testing a new approach. Their goals are to enhance patient satisfaction, safety, and hospital reimbursement by addressing long wait times in the ER.
The Communiqué is a publication dedicated to bringing articles and advice, specific to the anesthesia and pain management community, that are practical and tangible. ABC is happy to provide The Communiqué electronically as well as hard-copy versions. The Communiqué features articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators.
Tony Mira, President & CEO, explains, “The Fall 2014 issue features several experts in anesthesia practice management providing helpful advice, starting with Danielle Reicher, MD, an Anesthesiologist from San Diego, CA. Dr. Reicher describes a specific and very important application of EHR technology in Making Meaningful Use More Meaningful: communicating with patients." Dr. Reicher states, “While we may not be a daily fixture in the medical lives of our patients, our role is critical and the information we gather can be extremely vital to the electronic medical record. Let’s make Meaningful Use even more meaningful!”
Another author we are proud to feature is Steven Dale Boggs, MD, MBA, Director of the OR and Chief of the Anesthesia Service at the James J. Peters VA Medical Center in Bronx, NY as well as Associate Professor of Anesthesiology at The Icahn School of Medicine at Mount Sinai in Manhattan, NY. One of Dr. Boggs’s areas of particular interest is GI sedation. For the past several years, Dr. Boggs has been working closely with endoscopists at Mount Sinai in New York and elsewhere, evaluating turnover time and safety metrics. He will be presenting at The ANESTHESIOLOGY™ 2014 annual meeting in New Orleans with a Point-Counterpoint session on Monday, October 13th and on a panel Tuesday, October 14th, and he gives us a detailed preview of his arguments in Computer-Assisted Personalized Sedation (CAPS): Will It Change the Way Moderate Sedation is Administered? ABC was pleased to have the opportunity to provide Dr. Boggs with claims data showing that the cost of anesthesia and anesthesia providers may be quite competitive with cost of CAPS.
For these and past Communiqué articles, please log on to ABC’s web site at www.anesthesiallc.com 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 info@anesthesiallc.com. We look forward to providing you with compliance, coding and practice management news through The Communiqué.
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!
Visit www.anesthesiallc.com for more information!
This issue features the following pieces:
The Dark Side of Quality
Quality and Other Components of the Value Proposition
What Do Hospitals Want From Anesthesia Groups?
The Physician-Owned Management Services Organization
Should You Apologize for a Poor Outcome?
Thinking of Investing In, or Renting Space In, an ASC?
ICD-10 is the Latest Y2K: The Potential Impact on Provider Revenue
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!
Visit www.anesthesiallc.com for more information!
AnesthesiaOS is a cloud-based electronic health record (EHR) system developed by anesthesiologists to be intuitive and mobile. It captures data from different sources to provide a holistic view of a patient's health. AnesthesiaOS aims to simplify workflows for healthcare providers and improve clinical outcomes while lowering costs. The system leverages technologies from Dell and Microsoft and provides analytics and customizable reports to help clients improve efficiency.
2Running Head Nursing Informatics on Patient Outcomes 2Nurs.docxlorainedeserre
2
Running Head: Nursing Informatics on Patient Outcomes
2
Nursing Informatics on Patient Outcomes
The Impact of Nursing Informatics on Patient Outcomes and Patient Care Efficiencies
Nicole L Rosser
Walden University
NURS 6051
June 16, 2019
The Impact of Nursing Informatics on Patient Outcomes and Patient Care Efficiencies
According to Agha (2014) “Information technology has been linked to productivity growth in a wide variety of sectors, and health information technology (HIT) is a leading example of an innovation with the potential to transform industry-wide productivity.” Due to evidence-based practice research with informatics in the healthcare setting has proven to be a well-known, much needed entity. Studies have shown the efficiency of technology in healthcare improved documentation for healthcare providers and nurses. Healthcare technology also provides a means for organizations to communicate with each other without even picking up a phone. Another, aspect of technology in healthcare allows the healthcare team to monitor trends and changes in a patient’s status. For example, a critical patient on a cardiac monitor would alarm to quickly notify the nurse that a critical change has occurred for timely interventions to take place. With stroke being the fifth leading cause of death in the U.S. adopting Stroke Telemedicine into practice would be innovative for any organization. Much research has shown that healthcare facilities remain untrained and unprepared for stroke care and management.
Proposed Project
The project proposed to better equip my organization with treating stroke patients is Telestroke. According to the Mayo Clinic (2019) “In telestroke, also called stroke telemedicine, doctors who have advanced training in treating strokes can use technology to treat people who have had strokes in another location.” The use of this system is said to reduce wait time for an onsite neurologist and to increase one’s chances of receiving prompt treatment for a desirable outcome. This service will also save money by preventing Medicare and Medicaid from having to pay rehabilitation cost due to disabilities and long-term care. Telestroke will also provide efficient time for Tissue Plasminogen Activator (tPA). The drug tPA is an FDA-approved medication also known as a clot buster use in treating strokes to dissolve that which may be causing an ischemic stroke. However, it is contraindicated with a hemorrhagic stroke which may cause an excessive amount of bleeding if given due to the broken vessels that may have caused the stroke. This service has brought together neurologist and emergency physicians that feel using Telestroke will reduce geographical disparities and prevent increased cost from misuse of other medical facilities.
Stakeholder Impacted by This Project
One of the main stakeholdersthat would be affected in this project would be Dr. Buehler who is the regional director of all the Urgent Cares and Clinical Decision- ...
KinexCONNECT improves patient experience and therapy compliance during recovery from total knee replacement Focus groups conducted by Kinex Medical Company and HealthFactors. Authored by: Mike Buckholdt, BA, MPT, and Ram Rajagopalan, MS, MBA
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!
Visit www.anesthesiallc.com for more information!
Special Report: Getting the Optimal Return on X-ray EquipmentCarestream
Radiology administrators need to meticulously analyze their spending to get the best possible return on their investment in medical imaging equipment. In this special report, we explore several approaches to get the maximum return on this important capital investment.
The Impact of Technology on Clinical and IT SystemsIntroduction.docxoreo10
The Impact of Technology on Clinical and IT Systems
Introduction
One of the factors driving change in the health care delivery system is the rapidly evolving technology that emerges from research and development. Emerging technologies create rapid and profound change in the delivery system and may have drastic financial impacts. However, adapting new technologies without a clear understanding of what they can do for and to the system is never a good idea. They must be evaluated for their abilities to enhance the quality of care, along with their capacity to drive new revenue in a procedure-based delivery system. Finally, the cost of new technology is highly correlated with how new it is, and whether it is a stand-alone product with no competition. All of these factors combine to make it essential to do careful business and clinical analyses prior to committing to even the most appealing new technology.
In this module, we will examine two types of new technology: clinical applications and the electronic medical record (EMR).
Clinical Technology
In the realm of clinical technology, there are numerous subgroups. In selected subgroups, we will explore examples of new technology that is in the research and development pipeline.
Cardiovascular
The underlying theme of technology in cardiovascular care is the shift from significantly invasive approaches, such as open cardiac bypass surgery requiring a split sterna surgical approach and the use of a heart lung machine to maintain the patient during surgery, toward minimally invasive or noninvasive techniques. Ultra-wide band radar devices allow the measurement of cardiac output, heart rate, heart rhythm, and patterns of blood flow without any invasion of the body. The device is roughly the size of a deck of cards and can be worn in a shirt pocket without leads or monitor pads. The use of this type of radar-based approach allows noninvasive monitoring without pain or limitation of movement by patients.
Another cardiovascular application is the use of bio-absorbable, drug-eluting stents to open coronary arteries. The old technology required a surgical intervention that involved removing an artery from another part of the body and suturing it to the blocked coronary artery to provide a bridge for blood to flow past the blockage. This generally required hours in the operating room, with a patient on a heart bypass machine, and several days to a week in the intensive care unit after surgery. This has been largely replaced by placing stents or coils in the coronary arteries to hold them open. This is done in the cardiac catheterization lab under sedation or light anesthesia and is accomplished by threading a catheter through the arm or leg vein up to the heart and into the artery. However, historically these types of stents could block up again. The newest technology involves placing a bio-absorbable stent that eventually melts into the arterial wall, along with the drug-eluting aspect, which prevents clot ...
LECTUREThe Impact of Technology on Clinical and IT SystemsIn.docxsmile790243
LECTURE
The Impact of Technology on Clinical and IT Systems
Introduction
One of the factors driving change in the health care delivery system is the rapidly evolving technology that emerges from research and development. Emerging technologies create rapid and profound change in the delivery system and may have drastic financial impacts. However, adapting new technologies without a clear understanding of what they can do for and to the system is never a good idea. They must be evaluated for their abilities to enhance the quality of care, along with their capacity to drive new revenue in a procedure-based delivery system. Finally, the cost of new technology is highly correlated with how new it is, and whether it is a stand-alone product with no competition. All of these factors combine to make it essential to do careful business and clinical analyses prior to committing to even the most appealing new technology.
In this module, we will examine two types of new technology: clinical applications and the electronic medical record (EMR).
Clinical Technology
In the realm of clinical technology, there are numerous subgroups. In selected subgroups, we will explore examples of new technology that is in the research and development pipeline.
Cardiovascular
The underlying theme of technology in cardiovascular care is the shift from significantly invasive approaches, such as open cardiac bypass surgery requiring a split sterna surgical approach and the use of a heart lung machine to maintain the patient during surgery, toward minimally invasive or noninvasive techniques. Ultra-wide band radar devices allow the measurement of cardiac output, heart rate, heart rhythm, and patterns of blood flow without any invasion of the body. The device is roughly the size of a deck of cards and can be worn in a shirt pocket without leads or monitor pads. The use of this type of radar-based approach allows noninvasive monitoring without pain or limitation of movement by patients.
Another cardiovascular application is the use of bio-absorbable, drug-eluting stents to open coronary arteries. The old technology required a surgical intervention that involved removing an artery from another part of the body and suturing it to the blocked coronary artery to provide a bridge for blood to flow past the blockage. This generally required hours in the operating room, with a patient on a heart bypass machine, and several days to a week in the intensive care unit after surgery. This has been largely replaced by placing stents or coils in the coronary arteries to hold them open. This is done in the cardiac catheterization lab under sedation or light anesthesia and is accomplished by threading a catheter through the arm or leg vein up to the heart and into the artery. However, historically these types of stents could block up again. The newest technology involves placing a bio-absorbable stent that eventually melts into the arterial wall, along with the drug-eluting aspect, which preven ...
1. The document discusses the advantages and disadvantages of implementing an electronic health record (EHR) system to replace a paper-based system.
2. A key disadvantage is the high cost of implementation, with the cost of Alberta's new clinical information system estimated at $1.6 billion over 10 years.
3. Another disadvantage is a lack of interoperability between existing EHR systems, which prevents patient information from being shared and understood across health settings.
Please follow instructions carefully. Thank you so kindly. Ass.docxmattjtoni51554
The document discusses key changes in quality management and patient safety in the healthcare industry. It outlines several major developments that have advanced this area, including a 1999 IOM report that found medical errors resulted in up to 98,000 deaths per year. This prompted increased focus on quality, errors, and transparency from hospitals and regulators. It also discusses ongoing challenges like the need for standardized quality measures and electronic medical records to further improve outcomes.
Anesthesia Business Consultants' Communique newsletter is dedicated to bringing articles and advice, specific to the anesthesia and pain management community, that are practical and tangible.
Health systems recognize the potential of digital health but e-health programs have had modest returns. Ambitious initiatives focus on providing clinicians information but struggle with legacy systems that impede data integration. The solution is a digital services platform that holds healthcare data and optimizes access through APIs and services for identity, access and consent management. This platform could serve as an innovation ecosystem for third-party digital health services and advanced by health systems. It could revolutionize health services and help bend the cost curve through contextualized information, ushering in an era of "Healthcare 3.0."
Harness Your Clinical and Financial Data with an Enterprise Health Informat...Perficient, Inc.
The importance of Enterprise Health Information Exchange (EHIE) as a key way to empower your physicians and patients and demonstrate meaningful use of electronic health records:
- Present the business case for EHIE as an important architecture that matters to progressive health systems
- Take a look at some of the market-leading EHIE architectures and products
- Provide real exam...ples of organizations that are using EHIE to improve their operations
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!
Visit www.anesthesiallc.com for more information!
INTEGRATING MACHINE LEARNING IN CLINICAL DECISION SUPPORT SYSTEMShiij
This review article examines the role of machine learning (ML) in enhancing Clinical Decision Support
Systems (CDSSs) within the modern healthcare landscape. Focusing on the integration of various ML
algorithms, such as regression, random forest, and neural networks, the review aims to showcase their
potential in advancing patient care. A rapid review methodology was utilized, involving a survey of recent
articles from PubMed and Google Scholar on ML applications in healthcare. Key findings include the
demonstration of ML's predictive power in patient outcomes, its ability to augment clinician knowledge,
and the effectiveness of ensemble algorithmic approaches. The review highlights specific applications of
diverse ML models, including moment kernel machines in predicting surgical outcomes, k-means clustering
in simplifying disease phenotypes, and extreme gradient boosting in estimating injury risk. Emphasizing
the potential of ML to tackle current healthcare challenges, the article highlights the critical role of ML in
evolving CDSSs for improved clinical decision-making and patient care. This comprehensive review also
addresses the challenges and limitations of integrating ML into healthcare systems, advocating for a
collaborative approach to refine these systems for safety, efficacy, and equity.
INTEGRATING MACHINE LEARNING IN CLINICAL DECISION SUPPORT SYSTEMShiij
This review article examines the role of machine learning (ML) in enhancing Clinical Decision Support
Systems (CDSSs) within the modern healthcare landscape. Focusing on the integration of various ML
algorithms, such as regression, random forest, and neural networks, the review aims to showcase their
potential in advancing patient care. A rapid review methodology was utilized, involving a survey of recent
articles from PubMed and Google Scholar on ML applications in healthcare. Key findings include the
demonstration of ML's predictive power in patient outcomes, its ability to augment clinician knowledge,
and the effectiveness of ensemble algorithmic approaches. The review highlights specific applications of
diverse ML models, including moment kernel machines in predicting surgical outcomes, k-means clustering
in simplifying disease phenotypes, and extreme gradient boosting in estimating injury risk. Emphasizing
the potential of ML to tackle current healthcare challenges, the article highlights the critical role of ML in
evolving CDSSs for improved clinical decision-making and patient care. This comprehensive review also
addresses the challenges and limitations of integrating ML into healthcare systems, advocating for a
collaborative approach to refine these systems for safety, efficacy, and equity.
Personiform is a social health record platform that allows patients to securely share health information with providers and caregivers. It aims to improve patient-provider communication and engagement by allowing patients to log symptoms and health concerns, and request evaluations from providers. Providers can then generate medical codes from the patient information to integrate with electronic medical records for billing and records. The platform seeks to address limitations of existing health IT and better engage patients in their care through an intuitive social media-like interface.
Similar to Winter 2014 Communique From Anesthesia Business Consultants (20)
The Communique is a publication dedicated to bringing articles and advice, specific to the anesthesia and pain management community, that are practical and relevant.
Anesthesia Business Consultants (ABC), a leading provider in billing and practice management for the anesthesia and pain management specialty, is pleased to announce that the Winter 2015 issue of its quarterly newsletter, The Communiqué, is now available.
ABC offers The Communiqué electronically as well as in hard copy, both on a complimentary basis. The Communiqué features articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators.
Tony Mira, President & CEO, explains, “If you are a regular reader of the Communiqué, then the Winter 2015 issue will be of interest to you. We always strive to provide content that reflects reciprocal and often iterative learning. And we are taking it up a notch this issue with a very interesting give-and-take between experts such as Michael Hicks, MD, MBA, and Joe Laden in their article Point-Counterpoint: Do National Anesthesia Management Companies Increase Revenues for Acquired Groups? This discussion began in an electronic list serv on the website of the Medical Group Management Association-Anesthesia Administration Assembly, of which both Dr. Hicks and Mr. Laden are members. The dialogue between Dr. Hicks and Mr. Laden has ended up introducing an important topic that has not been touched on previously in the Communiqué—the inherent limitations of compensation surveys in a consolidating marketplace.
The QCDR is a topic on everyone’s thoughts these days. We attempt to further clarify the topic with a timely article by Richard Dutton, MD, MBA and Matthew Popovich, PhD. Their article on the ASA-Anesthesia Quality Institute’s Quality Clinical Data Registry, QCDR Made Simple—Ha! asks and answers the questions so many of you are raising about the QCDR, and the QCDR’s designers/managers, for example, “What are my options?” and “What measures can I report on?” It is a format that should make it easier for readers to assess whether and how to participate in reporting to the QCDR, even as the registry and its requirements continue to develop.
Anesthesia Business Consultants' Communique newsletter is dedicated to bringing articles and advice, specific to the anesthesia and pain management community, that are practical and tangible.
This edition covers the following topics:
Working For Tips
M&As Still Going Strong: Position Your Anesthesia Practice
Pre-Op Your Anesthesia Practice
What’s Your Anesthesia Group Worth? And Why it Might Not Make Any Difference.
Management Service Organizations and Anesthesia Practices Today and in the Future
Changes Involving Payment for Post-Operative Pain Procedures
The Role of Anesthesiologists in the Intensive Care Unit
Improving the Documentation of Anesthesia Procedures
Reporting Critical Care Services
Field Avoidance and Special Positioning
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!
Visit www.anesthesiallc.com for more information!
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!
Visit www.anesthesiallc.com for more information!
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!
Visit www.anesthesiallc.com for more information!
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!
Visit www.anesthesiallc.com for more information!
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!
Visit www.anesthesiallc.com for more information!
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!
Visit www.anesthesiallc.com for more information!
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!
Visit www.anesthesiallc.com for more information!
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!
Visit www.anesthesiallc.com for more information!
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!
Visit www.anesthesiallc.com for more information!
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!
Visit www.anesthesiallc.com for more information!
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!
Visit www.anesthesiallc.com for more information!
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!
Visit www.anesthesiallc.com for more information!
HCL Notes and Domino License Cost Reduction in the World of DLAUpanagenda
Webinar Recording: https://www.panagenda.com/webinars/hcl-notes-and-domino-license-cost-reduction-in-the-world-of-dlau/
The introduction of DLAU and the CCB & CCX licensing model caused quite a stir in the HCL community. As a Notes and Domino customer, you may have faced challenges with unexpected user counts and license costs. You probably have questions on how this new licensing approach works and how to benefit from it. Most importantly, you likely have budget constraints and want to save money where possible. Don’t worry, we can help with all of this!
We’ll show you how to fix common misconfigurations that cause higher-than-expected user counts, and how to identify accounts which you can deactivate to save money. There are also frequent patterns that can cause unnecessary cost, like using a person document instead of a mail-in for shared mailboxes. We’ll provide examples and solutions for those as well. And naturally we’ll explain the new licensing model.
Join HCL Ambassador Marc Thomas in this webinar with a special guest appearance from Franz Walder. It will give you the tools and know-how to stay on top of what is going on with Domino licensing. You will be able lower your cost through an optimized configuration and keep it low going forward.
These topics will be covered
- Reducing license cost by finding and fixing misconfigurations and superfluous accounts
- How do CCB and CCX licenses really work?
- Understanding the DLAU tool and how to best utilize it
- Tips for common problem areas, like team mailboxes, functional/test users, etc
- Practical examples and best practices to implement right away
Pushing the limits of ePRTC: 100ns holdover for 100 daysAdtran
At WSTS 2024, Alon Stern explored the topic of parametric holdover and explained how recent research findings can be implemented in real-world PNT networks to achieve 100 nanoseconds of accuracy for up to 100 days.
In the rapidly evolving landscape of technologies, XML continues to play a vital role in structuring, storing, and transporting data across diverse systems. The recent advancements in artificial intelligence (AI) present new methodologies for enhancing XML development workflows, introducing efficiency, automation, and intelligent capabilities. This presentation will outline the scope and perspective of utilizing AI in XML development. The potential benefits and the possible pitfalls will be highlighted, providing a balanced view of the subject.
We will explore the capabilities of AI in understanding XML markup languages and autonomously creating structured XML content. Additionally, we will examine the capacity of AI to enrich plain text with appropriate XML markup. Practical examples and methodological guidelines will be provided to elucidate how AI can be effectively prompted to interpret and generate accurate XML markup.
Further emphasis will be placed on the role of AI in developing XSLT, or schemas such as XSD and Schematron. We will address the techniques and strategies adopted to create prompts for generating code, explaining code, or refactoring the code, and the results achieved.
The discussion will extend to how AI can be used to transform XML content. In particular, the focus will be on the use of AI XPath extension functions in XSLT, Schematron, Schematron Quick Fixes, or for XML content refactoring.
The presentation aims to deliver a comprehensive overview of AI usage in XML development, providing attendees with the necessary knowledge to make informed decisions. Whether you’re at the early stages of adopting AI or considering integrating it in advanced XML development, this presentation will cover all levels of expertise.
By highlighting the potential advantages and challenges of integrating AI with XML development tools and languages, the presentation seeks to inspire thoughtful conversation around the future of XML development. We’ll not only delve into the technical aspects of AI-powered XML development but also discuss practical implications and possible future directions.
Goodbye Windows 11: Make Way for Nitrux Linux 3.5.0!SOFTTECHHUB
As the digital landscape continually evolves, operating systems play a critical role in shaping user experiences and productivity. The launch of Nitrux Linux 3.5.0 marks a significant milestone, offering a robust alternative to traditional systems such as Windows 11. This article delves into the essence of Nitrux Linux 3.5.0, exploring its unique features, advantages, and how it stands as a compelling choice for both casual users and tech enthusiasts.
Maruthi Prithivirajan, Head of ASEAN & IN Solution Architecture, Neo4j
Get an inside look at the latest Neo4j innovations that enable relationship-driven intelligence at scale. Learn more about the newest cloud integrations and product enhancements that make Neo4j an essential choice for developers building apps with interconnected data and generative AI.
How to Get CNIC Information System with Paksim Ga.pptxdanishmna97
Pakdata Cf is a groundbreaking system designed to streamline and facilitate access to CNIC information. This innovative platform leverages advanced technology to provide users with efficient and secure access to their CNIC details.
UiPath Test Automation using UiPath Test Suite series, part 5DianaGray10
Welcome to UiPath Test Automation using UiPath Test Suite series part 5. In this session, we will cover CI/CD with devops.
Topics covered:
CI/CD with in UiPath
End-to-end overview of CI/CD pipeline with Azure devops
Speaker:
Lyndsey Byblow, Test Suite Sales Engineer @ UiPath, Inc.
UiPath Test Automation using UiPath Test Suite series, part 6DianaGray10
Welcome to UiPath Test Automation using UiPath Test Suite series part 6. In this session, we will cover Test Automation with generative AI and Open AI.
UiPath Test Automation with generative AI and Open AI webinar offers an in-depth exploration of leveraging cutting-edge technologies for test automation within the UiPath platform. Attendees will delve into the integration of generative AI, a test automation solution, with Open AI advanced natural language processing capabilities.
Throughout the session, participants will discover how this synergy empowers testers to automate repetitive tasks, enhance testing accuracy, and expedite the software testing life cycle. Topics covered include the seamless integration process, practical use cases, and the benefits of harnessing AI-driven automation for UiPath testing initiatives. By attending this webinar, testers, and automation professionals can gain valuable insights into harnessing the power of AI to optimize their test automation workflows within the UiPath ecosystem, ultimately driving efficiency and quality in software development processes.
What will you get from this session?
1. Insights into integrating generative AI.
2. Understanding how this integration enhances test automation within the UiPath platform
3. Practical demonstrations
4. Exploration of real-world use cases illustrating the benefits of AI-driven test automation for UiPath
Topics covered:
What is generative AI
Test Automation with generative AI and Open AI.
UiPath integration with generative AI
Speaker:
Deepak Rai, Automation Practice Lead, Boundaryless Group and UiPath MVP
Threats to mobile devices are more prevalent and increasing in scope and complexity. Users of mobile devices desire to take full advantage of the features
available on those devices, but many of the features provide convenience and capability but sacrifice security. This best practices guide outlines steps the users can take to better protect personal devices and information.
Building Production Ready Search Pipelines with Spark and MilvusZilliz
Spark is the widely used ETL tool for processing, indexing and ingesting data to serving stack for search. Milvus is the production-ready open-source vector database. In this talk we will show how to use Spark to process unstructured data to extract vector representations, and push the vectors to Milvus vector database for search serving.
Driving Business Innovation: Latest Generative AI Advancements & Success StorySafe Software
Are you ready to revolutionize how you handle data? Join us for a webinar where we’ll bring you up to speed with the latest advancements in Generative AI technology and discover how leveraging FME with tools from giants like Google Gemini, Amazon, and Microsoft OpenAI can supercharge your workflow efficiency.
During the hour, we’ll take you through:
Guest Speaker Segment with Hannah Barrington: Dive into the world of dynamic real estate marketing with Hannah, the Marketing Manager at Workspace Group. Hear firsthand how their team generates engaging descriptions for thousands of office units by integrating diverse data sources—from PDF floorplans to web pages—using FME transformers, like OpenAIVisionConnector and AnthropicVisionConnector. This use case will show you how GenAI can streamline content creation for marketing across the board.
Ollama Use Case: Learn how Scenario Specialist Dmitri Bagh has utilized Ollama within FME to input data, create custom models, and enhance security protocols. This segment will include demos to illustrate the full capabilities of FME in AI-driven processes.
Custom AI Models: Discover how to leverage FME to build personalized AI models using your data. Whether it’s populating a model with local data for added security or integrating public AI tools, find out how FME facilitates a versatile and secure approach to AI.
We’ll wrap up with a live Q&A session where you can engage with our experts on your specific use cases, and learn more about optimizing your data workflows with AI.
This webinar is ideal for professionals seeking to harness the power of AI within their data management systems while ensuring high levels of customization and security. Whether you're a novice or an expert, gain actionable insights and strategies to elevate your data processes. Join us to see how FME and AI can revolutionize how you work with data!
Let's Integrate MuleSoft RPA, COMPOSER, APM with AWS IDP along with Slackshyamraj55
Discover the seamless integration of RPA (Robotic Process Automation), COMPOSER, and APM with AWS IDP enhanced with Slack notifications. Explore how these technologies converge to streamline workflows, optimize performance, and ensure secure access, all while leveraging the power of AWS IDP and real-time communication via Slack notifications.
Communications Mining Series - Zero to Hero - Session 1DianaGray10
This session provides introduction to UiPath Communication Mining, importance and platform overview. You will acquire a good understand of the phases in Communication Mining as we go over the platform with you. Topics covered:
• Communication Mining Overview
• Why is it important?
• How can it help today’s business and the benefits
• Phases in Communication Mining
• Demo on Platform overview
• Q/A
For the full video of this presentation, please visit: https://www.edge-ai-vision.com/2024/06/building-and-scaling-ai-applications-with-the-nx-ai-manager-a-presentation-from-network-optix/
Robin van Emden, Senior Director of Data Science at Network Optix, presents the “Building and Scaling AI Applications with the Nx AI Manager,” tutorial at the May 2024 Embedded Vision Summit.
In this presentation, van Emden covers the basics of scaling edge AI solutions using the Nx tool kit. He emphasizes the process of developing AI models and deploying them globally. He also showcases the conversion of AI models and the creation of effective edge AI pipelines, with a focus on pre-processing, model conversion, selecting the appropriate inference engine for the target hardware and post-processing.
van Emden shows how Nx can simplify the developer’s life and facilitate a rapid transition from concept to production-ready applications.He provides valuable insights into developing scalable and efficient edge AI solutions, with a strong focus on practical implementation.
Removing Uninteresting Bytes in Software FuzzingAftab Hussain
Imagine a world where software fuzzing, the process of mutating bytes in test seeds to uncover hidden and erroneous program behaviors, becomes faster and more effective. A lot depends on the initial seeds, which can significantly dictate the trajectory of a fuzzing campaign, particularly in terms of how long it takes to uncover interesting behaviour in your code. We introduce DIAR, a technique designed to speedup fuzzing campaigns by pinpointing and eliminating those uninteresting bytes in the seeds. Picture this: instead of wasting valuable resources on meaningless mutations in large, bloated seeds, DIAR removes the unnecessary bytes, streamlining the entire process.
In this work, we equipped AFL, a popular fuzzer, with DIAR and examined two critical Linux libraries -- Libxml's xmllint, a tool for parsing xml documents, and Binutil's readelf, an essential debugging and security analysis command-line tool used to display detailed information about ELF (Executable and Linkable Format). Our preliminary results show that AFL+DIAR does not only discover new paths more quickly but also achieves higher coverage overall. This work thus showcases how starting with lean and optimized seeds can lead to faster, more comprehensive fuzzing campaigns -- and DIAR helps you find such seeds.
- These are slides of the talk given at IEEE International Conference on Software Testing Verification and Validation Workshop, ICSTW 2022.
Winter 2014 Communique From Anesthesia Business Consultants
1. VO L U M E 19, I S S U E 1
Using Big Data for
Big Research: MPOG,
NACOR and other
Anesthesia Registries
Richard P. Dutton, M.D., M.B.A.
Executive Director, Anesthesia Quality Institute
Chief Quality Officer, American Society of Anesthesiologists, Park Ridge, IL
Introduction
A silent revolution is under way
in anesthesiology, one that will have a
lasting impact on our patients and our
practice. I refer to the research potential
of ‘big data’ in anesthesiology, driven
by the rapid uptake of Information Age
technology in our offices, clinics and
hospitals. Electronic healthcare records
(EHRs) are changing the way we care for
patients, the way we document and bill,
and how we understand our practice. In
the long run they will do much more:
they will provide a fundamental ability
to link clinical decision-making in the
operating room with patient outcomes in
a way that lets us learn from every patient
encounter.
This article will provide a brief
overview of existing large datasets describing anesthesia patients, procedures
and outcomes. I will review their current contents and structure, their future
Continued on page 4
➤ INSIDE THIS ISSUE:
Using Big Data for Big Research: MPOG, NACOR and other . . . . . . . . 1
Anesthesia Registries
Another Year of Changes Lies Ahead for Anesthesiologists . . . . . . . . 2
Disruptive Change, Anesthesiologists, and ASCs . . . . . . . . . . . . . . . . . . . 3
Performing High Acuity Cases in ASCs: The Anesthesiologist’s Role . . . . 9
Event Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
AICP
AS
e
Anesthesia Business Consultants is proud to be a
anization C
Org
on
tr
ice
rv
S E R V I C E O R G A N I Z AT I O N S
SOC
rt
s
rm aicpa.org/soc o
erl
p
y SAS 70 Re
Fo
W I N T E R 2 0 14
ANESTHESIA
2014 CPT Coding and Key Reimbursement Changes . . . . . . . . . . . . . . 22
ts
por
Re
ol
BUSINESS CONSULTANTS
Endoscopy: Revisited . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Reporting Postoperative Pain Management in 2014 . . . . . . . . . . . . . . . 18
2. The Communiqué
W i n t e r 2014
P ag e 2
Another Year of Changes Lies
Ahead for Anesthesiologists
As we enter 2014, we expect to see
the term “Big Data” become increasingly
familiar. Wikipedia defines Big Data
as the “collection of data sets so large
and complex that it becomes difficult
to process using on-hand database
management tools or traditional data
processing applications” and notes that
“The trend to larger data sets is due to the
additional information derivable from
analysis of a single large set of related
data, as compared to separate smaller
sets with the same total amount of data,
allowing correlations to be found to
‘spot business trends, determine quality
of research, prevent diseases, link legal
citations, combat crime, and determine
real-time roadway traffic conditions.’
[Citations omitted].”
In healthcare, the value of large data
sets for clinical research and for prevention
of disease is clear. The Multicenter
Perioperative Outcomes Group registry
and the National Anesthesia Clinical
Outcomes Registry noted in Dr. Richard
Dutton’s article, Using Big Data for Big
Research: MPOG, NACOR and other
Anesthesia Registries, are exciting tools for
anesthesia researchers.
Another important concept in our
thinking is “disruptive innovation,” to
which Dr. Michael Hicks introduced
us in his article Disruption and the
Theory of the Anesthesia Business a year
ago, in the Winter 2013 issue of the
Communiqué. Dr. William Hass—a firsttime contributor here—takes the concept
and applies it to anesthesia services in
ambulatory surgical centers in Disruptive
Change, Anesthesiologists, and ASCs.
ASCs are particularly fertile incubators
for disruptive change, according to Dr.
Hass, because they are more cost-sensitive
than other facilities and because their
lower-acuity cases offer opportunities for
staffing and technological innovations.
Combining the cost pressures to which
ASCs are so sensitive with the fact that
personnel is the greatest expenditure in
anesthesia, Dr. Hass predicts that we are
going to see combinations of anesthesia
professionals and clinical technology that
are far different from today’s models. He
is right.
One key facet of ambulatory
anesthesia practice that is changing
rapidly right now is the shift of
certain high-acuity cases to the ASC
setting, which Laura Miller of Becker’s
ASC Review discusses in her article
Performing High Acuity Cases in ASCs:
The Anesthesiologist’s Role. The ability
of anesthesiologists to manage patients’
postoperative pain through nerve blocks
is the deciding factor in many cases. The
practicing anesthesiologists interviewed
by Ms. Miller also point to the specialty’s
role in managing the team that brings the
appropriate patients to the ASC, keeps
them on schedule and discharges them
suitably educated about what to expect
during recovery.
We have been expecting disruption, if
not necessarily innovation, in the market
for anesthesia services for endoscopy for
better than a decade. ABC Vice President
Jody Locke examines the reality through
the combined data of 26 practices across
the country in Endoscopy: Revisited and
concludes that where the revenue yield
per case, combined with the productivity
of the facility, makes anesthesia for
endoscopy profitable, the service is
still a valuable line of business. And
that is the situation for many practices
across the country. Monitoring volume,
payer mix and payer policies, accounts
receivable and productivity by site will
tell each practice whether and when it is
time to revisit providing anesthesia for
endoscopy.
Some of the changes on which we focus
in this issue of the Communiqué are annual
rather than epochal. Coding expert Kelly
Dennis provides a comprehensive review
of a major recurring—and evolving—
topic in Reporting Postoperative Pain
Management in 2014. ABC Vice President
Joette Derricks brings us up to date on
coding and payment developments in
2014 CPT Coding and Key Reimbursement
Changes.
We hope that all of the information
will help ensure a successful year for all of
our valued readers.
With best wishes,
Tony Mira
President and CEO
3. The Communiqué
W i n t e r 2014
P ag e 3
Disruptive Change,
Anesthesiologists, and ASCs
William Hass, MD, MBA
Co-Founder, PhySynergy, LLC, Huntsville, AL
The current upheaval in the business
of anesthesia has been previously reviewed
in various issues of the Communiqué.
While complex forces are involved in these
changes, one aspect of practice management is vitally important for both individual
anesthesia professionals and their anesthesia services: disruptive change.1
Disruptive innovation occurs when
processes are improved and adopters of
these new processes have operational
and financial advantages over their
competitors. Disruptive innovation is
most likely to start in service niches rather
than engulf an entire industry. Anesthesia
professionals in ambulatory surgery
centers (ASCs) are most likely to undergo
disruptive innovation.
Why will these changes occur in
ASCs?
•
With increasing out-of-pocket
expenses, patients are going to
be more cost conscious than ever
before.
•
Demands from patients, referral
sources, and insurers will require
ASCs to provide high quality
services at the lowest possible costs
to survive.
•
ASCs are fertile ground for
disruptive change because their
lower acuity cases and healthier
patients
offer
opportunities
for staffing and technological
innovations.
1
Hicks MR.
Disruption and the Theory of the
Anesthesia Business. The Communiqué (Winter 2013).
http://www.anesthesiallc.com/component/content/
article/45-winter-2013/582-disruption-and-the-theory-ofthe-anesthesia-business, accessed January 3, 2014.
case you haven’t noticed, your
In
patients, potential patients, your referring
physicians, and facility administrators
are already shopping for lower price
services…. including anesthesia services.
ASC services are in the crosshairs of this
new reality.
So, what’s the disruptive innovation
in ASC anesthesia services going to be?
Given that staff expense is the largest
expense in anesthesia services, change will
almost certainly be focused in this area.
Will there be a chain reaction where more
expensive anesthesia professionals are
replaced by those less expensive who are
then in turn replaced by technology and
even less expensive ancillary staff? More
simply, is the plan to replace expensive
anesthesiologists with less expensive
anesthesia professionals who are then
replaced by robots, other technology, or
maybe even trained amateurs? Don’t for a
second think that someone hasn’t thought
of this already.
The viability and utility of anesthesia
services provided with a combination
of anesthesia professionals has been
proven over time. These combined
services constitute the majority of
anesthesia services in the United States
and this format is growing. Fortunately,
the concept has survived despite some
extraordinarily poor implementations in:
• Anesthesia Care Teams (ACTs),
• Collaborative practices and variants,
• Anesthesiologist-only practices,
and
• CRNA-only practices
Continued on page 8
4. The Communiqué
W i n t e r 2014
P ag e 4
Using Big Data for Big Research: MPOG, NACOR and other
Anesthesia Registries
Continued from page 1
development, and their long-term potential for comparative effectiveness and
health services delivery research.
Existing Anesthesia Registries
Table 1 lists several sources for big
data in anesthesia. Two large datasets
supported by the federal government
include information about anesthesia
care. These are the National Inpatient
Sample (NIS) and the Centers for
Medicare and Medicaid Services (CMS)
5% and 100% data files. Both of these
are populated with administrative data,
generated to support Part A (hospital)
and Part B (provider) billing, and then
aggregated by government payers. The
NIS is a statistically-balanced database
constructed from information submitted
by hospitals to state health agencies, and
then passed to the Agency for Healthcare
Research and Quality (AHRQ). NIS
includes information about hospital
inpatients, including those who undergo
surgery. NIS is especially useful for
looking at gross outcomes (in-hospital
mortality, length of stay) and overall
patient characteristics (age, sex, comorbidities). NIS includes International
Classification of Diseases, 9th Edition
(ICD-9) information for each patient.
In theory this includes a number of
codes for postoperative complications,
TABLE 1
Data Set
Types of Data
Address
National Inpatient Sample
Administrative
Centers for Medicare and
Medicaid Services
Premier, Inc.
Multicenter Perioperative
Outcomes Group
National Anesthesia Clinical
Outcomes Registry
Administrative
http://www.hcup-us.ahrq.
gov/nisoverview.jsp
www.cms.gov
Administrative
Clinical
www.premierinc.com
www.mpog.med.umich.edu
Administrative, Clinical,
Quality Capture, Patient
Satisfaction
Clinical, Quality Capture
www.aqihq.org
Clinical, Quality Capture
www.pedsanesthesia.org
Clinical, Quality Capture
www.mhaus.org
Clinical, Quality Capture
http://www.sts.org/
sts-national-database/
anesthesiology-module
Society for Ambulatory
Anesthesia-Clinical Outcomes
Registry
Pediatric Regional Anesthesia
Network
Malignant Hyperthermia
Association of the United States
Registry
Society for Thoracic Surgery
Cardiac Anesthesia Module
www.scordata.org
but in practice the accuracy of this data
is questionable. Different hospitals in
different states have widely differing
incentives for finding this information
in their medical records and reporting
it accurately. Some hospitals have
incentives for caring for sicker patients,
and therefore seek out and document comorbidities more aggressively than those
hospitals which do not; further, some
complications are now associated with
payment withholds or penalties, leading
to an incentive to not find them, or to
code them in other ways.
The CMS datasets are derived from
clinical encounters submitted as claims for
payment by facilities and providers, both
inpatient and outpatient, and have some
of the same shortcomings as the NIS.
CMS data are also heavily skewed towards
older patients, because of the eligibility
requirements of Medicare. These data
include both inpatient and outpatient
surgical procedures and anesthetics.
The 5% sample is readily available for
anesthesia researchers, but includes no
identifying information about each case,
making it impossible to link records for
the same patient for an anesthesiologist, a
CRNA and a hospital. The 100% data are
more comprehensive, but harder to gain
access to. There is no anesthesia-specific
information in the CMS data, other than
the code of the procedure performed, and
no information on long-term outcomes.
Administrative data are also available
from several private insurance companies
and aggregating agencies such as Premier.
These datasets are strong in information
on resource utilization, but less useful
for assessing the specifics of clinical care.
While the Premier database accurately
reflects charges for medications used, for
example, it can shed little light on why
specific medications are chosen.
5. The Communiqué
More specific to the practice of
anesthesiology is the registry of the
Multicenter Perioperative Outcomes
Group (MPOG), built primarily to
facilitate anesthesia research.1 MPOG is
a collaborative effort of more than three
dozen academic anesthesia departments,
coordinated by the University of
Michigan.
The MPOG investigators
developed a common format for
capturing clinical information from
Anesthesia Information Management
Systems (AIMS), and they are working
with their information technology
vendors to map AIMS data and transmit
it to the MPOG registry. To date, MPOG
is collecting every-case data from about a
dozen of the participating departments,
representing five of the ten different
AIMS commonly used in the United
States. Efforts are underway to build
reports in the remaining AIMS, so that
within a few years any hospital with an
AIMS will be able to contribute to MPOG.
Data in MPOG are highly granular for
the anesthetic encounter, capturing
information on anesthesia procedures,
medications, fluids, monitors and vital
signs for every patient the department
cares for. Any academic physician in any
MPOG participant practice can apply to
the Data Use Committee for permission
to analyze the aggregated data.
Similar to MPOG, but including
additional data from anesthesia billing
systems and quality capture software,
is the National Anesthesia Clinical
Outcomes Registry (NACOR), developed
and maintained by the non-profit
Anesthesia Quality Institute (AQI).2,3
This organization was founded by the
American Society of Anesthesiologists
W i n t e r 2014
FIGURE 1
Growth of participation in the
National Anesthesia Clinical Outcomes Registry
(ASA) to improve the quality of
anesthesia practice throughout the
United States. Like MPOG, NACOR
collects data by direct transmission of
digital information; in fact, NACOR uses
the same formats developed by MPOG
for collecting data from AIMS. Unlike
MPOG, NACOR begins by harvesting
information from anesthesia billing
systems, which use relatively simple
formats to capture basic data from
every case. Participation in NACOR is
open to any anesthesia practice in the
United States, whether they have started
using an AIMS or not. The purpose of
NACOR is to provide local feedback to
the anesthesia practice for regulatory
compliance and quality improvement.
NACOR is the largest specialty-specific
registry in anesthesia, including data
from more than 2,100 facilities, 20,000
providers and 250 practices (see Figure
1). Although not primarily intended
Kheterpal S, Healy D, Aziz MF, Shanks AM, Freundlich RE, Linton F, Martin LD, Linton J, Epps JL, Fernandez-Bustamante
A, Jameson LC, Tremper T, Tremper KK; on behalf of the Multicenter Perioperative Outcomes Group (MPOG) Perioperative
Clinical Research Committee. Incidence, Predictors, and Outcome of Difficult Mask Ventilation Combined with Difficult
Laryngoscopy: A Report from the Multicenter Perioperative Outcomes Group. Anesthesiology. 2013 Sep 25. [Epub ahead of
print]
2
Dutton RP, Dukatz A. Quality improvement using automated data sources: the anesthesia quality institute. Anesthesiol Clin.
2011 29(3):439-54.
3
Grissom TE, DuKatz A, Kordylewski H, Dutton RP. Bring out your data: The evolution of the National Anesthesia Clinical
Outcomes Registry. International Journal of Computational Models and Algorithms in Medicine, 2011; 2: 51-69.
1
P ag e 5
for research, the AQI does publish
a Participant User File (PUF) from
NACOR each quarter, presenting a deidentified aggregate dataset for the use of
academic researchers in AQI-participant
practices. The most recent version of
the PUF includes more than 13,000,000
cases collected in NACOR between
January 1, 2010 and September 30, 2013.
The NACOR PUF is heterogeneous in
the data presented; all cases have billing
information, about a quarter have quality
outcome information (usually gathered
at the time of PACU discharge) and only
about 10% have detailed information
from an AIMS. Because of its size and its
national reach, NACOR is a good choice
for descriptions of anesthesia practice in
the U.S., and can serve as the backdrop for
studies using more granular information
collected at a single institution.
There are also a number of
subspecialty registries available for
specific niche practices in anesthesia.
Largest is the Society for Ambulatory
Anesthesia Clinical Outcomes Registry
(SAMBA-SCOR), which focuses on
process and outcomes in outpatient
surgery. SAMBA-SCOR shares data with
Continued on page 6
6. The Communiqué
W i n t e r 2014
P ag e 6
Using Big Data for Big Research: MPOG, NACOR and other
Anesthesia Registries
Continued from page 5
both MPOG and NACOR. All three
registries use identical data formats,
such that the same output files can be
used for submitting data to all three.
Other subspecialty registries include the
Pediatric Regional Anesthesia Network
database, the registry of the Malignant
Hyperthermia Association of the
United States, and the newly-launched
anesthesia component of the Society
for Thoracic Surgery national cardiac
surgery registry. Each of these projects
gathers granular information about a
specific subset of anesthesia patients, and
each is intended primarily for scientific
research.
Future Developments
Although created by different
stakeholders for different purposes,
all databases containing anesthesia
information face common challenges
in recruiting participants, defining
data elements, collecting case-by-case
information, and analyzing and reporting
the results. Older surgical registries have
relied on an “eyeballs” methodology, in
which a professional abstractor reviews
medical records for specific pieces of
information. This model generates good
data in a consistent fashion, but it is
expensive for the hospital to support
and thus limited in the number of cases,
patients and data elements that can be
included. Modern registries, built to
take advantage of the increasing use of
EHR systems, are all seeking to have data
move directly from the medical record
to the registry, without requiring human
abstraction. The difficulty with this
model is the heterogeneity of electronic
data today. Some elements, such as vital
signs and medication doses, are relatively
4
http://www.aqihq.org/qualitymeasurementtools.aspx
standard from one system to another, but
other elements, such as outcomes and
complications, are lacking in consistent
definitions across practices and software
vendors. In 2013 MPOG and the AQI
combined to sponsor a conference
on common measures and common
definitions in anesthesia electronic
records. The first DefCon included two
dozen anesthesia quality management
experts working with an equal number
of EHR vendors to produce consensus
definitions of key elements of the
anesthesia record. Published on the AQI
website, these definitions are serving to
unify data for anesthesia research and
quality management.4
Another goal for the future is to
move from self-reported outcomes,
which require the active participation
of the clinician, to measures that can be
passively calculated from the medical
record. Hemodynamic instability, for
example, will be calculated from the vital
signs in the OR and PACU, as captured
by the AIMS, rather than by subjective
assessment of the provider. An exception
to this principle, but still a necessary
step for the future, will be increasing
collection of outcomes reported by
anesthesia patients. Such measures as
adequacy of pain management, respect
for privacy, quality of communication,
and overall satisfaction with anesthesia
care can only be gathered from the
patient’s perspective. Several commercial
systems have been launched to gather
this kind of data, using tools such as
automated voice-response systems, email,
and text messaging. Data gathered in this
fashion can be linked directly to digital
information in the billing system or EHR,
and can be transmitted automatically to
registries such as NACOR.
Healthcare reform at the national
level will drive an increasing need for
‘shared accountability’ measures, which
assess overall outcomes from an entire
process of care. Rather than reporting
on specific processes at the individual
level—such as the timely administration
of perioperative antibiotics—shared
accountability measures will look at
meaningful outcomes such as mortality,
major morbidity and hospital length of
stay at the level of the entire perioperative
team. Anesthesiologists, surgeons and
hospitals will work together to define
these measures and collect the necessary
data. Large registries such as NACOR are
an obvious source for parts of the data,
especially if granular anesthesia process
information can be combined with longterm outcomes collected in existing
surgical registries. Linkage of data from
one system to another will depend on
accurate patient identification (while still
protecting patient confidentiality) and
common definitions of cases and risk
factors. Shared accountability measures
will be required for public reporting
7. The Communiqué
W i n t e r 2014
on the effectiveness of new healthcare
organization and payment mechanisms,
such as the perioperative surgical home.
There is also an opportunity to
combine structured data in the medical
record with narrative data about specific
cases and events. An example would
be a future state in which the anesthesia
provider completes a quality capture form
at the end of every case, indicating the
absence of any major adverse event. In the
rare case in which something unusual or
unexpected happens, the EHR would shunt
the reporter directly to an online incident
report form that requests a narrative
description of the event. This electronic
data would be kept separate from the
medical record, but would be available
for local quality and risk management
purposes, and for automatic transmission
to national aggregators such as NACOR.
The AQI is pioneering this approach in a
few practices today, and is looking for other
vendors and groups to work with. [Ed. –
ABC is discussing with the AQI methods to
include a narrative incident report feature in
our EHR technology.]
Turning Big D ata
Scientific Research
into
However the data are collected,
the major challenge for any anesthesia
registry is analysis and reporting.
Clinicians are busy and distracted on
a daily basis, and are bombarded with
administrative and educational products.
To effectively turn data into information,
registries must find ways to creatively
analyze what they collect and intuitively
present it to their stakeholders. One
mechanism for doing this is through
publication of scientific papers. Journal
articles maintain a consistent level
of quality through peer review, are
familiar to all physicians, reach a large
audience both inside and outside the
specialty, and are preserved for future
reference through the National Library of
Medicine. Writing scientific papers can
be ‘crowd-sourced’ by providing access
to the data to a large cadre of volunteer
researchers. This model is being followed
by both MPOG and the AQI, who make
their data available with minimal barriers
to any anesthesiologist at a participating
institution. On a larger scale, this is
also the model followed by the federal
government with CMS data and the
National Inpatient Sample.
Availability to researchers of Big
Data from national-level registries is
rapidly spawning a new breed of clinical
scientist with skills in medical informatics,
epidemiology and complex statistical
methodologies. New grant mechanisms
are arising to support these scientists,
with funding from AHRQ, the Patient
Centered Outcomes Research Institute
(PCORI) and organizations within our
own specialty. Both the Foundation for
Anesthesia Education and Research and
the Anesthesia Patient Safety Foundation
now offer funding for healthcare delivery
and comparative effectiveness research.
These grants are directed towards young
investigators, and the funding often
includes specific provisions for training in
operations research, healthcare economics,
or safety and quality. A number of
P ag e 7
anesthesia training programs are following
suit. The anesthesia departments at
Yale, the University of Alabama at
Birmingham, the University of Michigan,
the University of Washington and the
University of California at Irvine all
have dedicated training for residents and
fellows in patient safety, health policy
research, and quality management.
Other institutions, such as Vanderbilt
and Mount Sinai, offer dedicated training
in healthcare information technology.
Academic anesthesiologists of the future
will need to be experts in electronic
data collection, aggregation, and
interpretation; these skills will be just as
important as anatomy, pharmacology and
physiology were to generations past.
Conclusion
Consistent with our specialty’s
long history of advancing patient safety,
the evolution of Big Data registries in
anesthesia is leading all of medicine
into a new era. In the near future we
will learn from every patient we care
for, and will have objective evidence to
guide decisions about drugs, monitors,
and
anesthesia
techniques.
This
advancing knowledge will free us to
take on ever more challenging patients
and operations, and to take our place
as leaders and facilitators of procedural
care of all kinds.
Richard P. Dutton,
MD, MBA is Executive Director of the
Anesthesia Quality
Institute (AQI). He
also serves as Chief
Quality Officer for
the American Society
of Anesthesiologists.
Dr. Dutton is a Clinical Associate at the University of Chicago
Department of Anesthesia and Critical
Care. To contact Dr. Dutton or the AQI,
visit www.aqihq.org.
8. The Communiqué
W i n t e r 2014
P ag e 8
Disruptive Change, Anesthesiologists, and ASCs
Continued from page 3
Anesthesia services with poorly executed
staffing plans will continue to fail because
they recruit and retain the wrong people.
The disruptive innovation in
anesthesia services is the development
and use of aggressive human resource
management (HRM). Anesthesia services
fail or underperform when they are unable
to recruit and retain the right people in the
right places at the right time with the right
leadership to have effective teamwork.
Effective HRM will remedy this
problem. Just slapping some anesthesia
professionals together is no more likely
to provide a high functioning team than
picking random people off the street. An
especially troubling situation occurs when
an anesthesia management company takes
over an anesthesia practice, especially an
all-anesthesiologist practice, and tries to
institute an ACT model using the existing
anesthesiologists who have never worked
with CRNAs. And they double down on
this error by recruiting CRNAs with little
or no input from local staff. This “team”
is a recipe for underperformance or even
outright failure.
What about actual disruptive
technologies? We haven’t seen them yet,
but it doesn’t mean that they are not out
there someplace, possibly in a garage
in Palo Alto or in a business park in
Alabama. When the killer app, program
or device appears, it may spread very
rapidly. Think iPod, iPhone and iPad. It
is easier to adopt a new physical device
than an idea, but it takes the right staff to
adopt anything.
There is another caution for
anesthesia professionals working in
ASCs, particularly those that are owned
by physicians or for-profit corporations.
These entrepreneurial organizations
embrace new ideas and will expect a
similar attitude from their anesthesia
service partners. These organizations may
also be technophiles and will anticipate
reasonable efforts to incorporate
technology that will improve care and
financial performance. In services
focused on performance improvement
through innovation, laggards need not
apply and will certainly not be retained
for very long.
It’s important not to confuse cost
and price. There is an old management
saying, “Beware the cost of the lowest
price.” A mediocre clinical service in an
ASC would be a costly mistake. In an era
of social media and patient satisfaction
surveys, missteps are amplified and
publicized. An innovation might have a
lower price tag for a while, but its success
or failure will depend on its true cost to
the ASC in the long run.
So, what does this mean for ASCs
and anesthesiologists? Some anesthesia
professionals may not be suitable for
the ASC and/or the ACT environment.
Some future combinations of anesthesia professionals and technology will be
far different from the models of today.
Local conditions, payer requirements,
and governmental regulations will
determine the exact composition of the
anesthesia staffs for any ASC. All other
things being equal, an anesthesia service
making aggressive use of HRM and
technology will be the safest and most
economical facility in any locale. With
the right people properly led, almost
anything is possible.
William Hass, MD,
MBA has been actively
involved in anesthesia
practice management
for more than thirty
years. He currently
is
the
medical
service organization
(MSO) evangelist for
PhySynergy, an MSO based in Huntsville,
Alabama. PhySynergy executives had
more than 100 years cumulative service in
anesthesia service management. Dr. Hass
is also the medical director for the Madison
Surgery Center in Madison, Alabama. He
can be reached at whhass@physynergy.com.
9. The Communiqué
W i n t e r 2014
P ag e 9
Performing High Acuity Cases in
ASCs: The Anesthesiologist’s Role
Laura Miller
Editor-in-Chief, Becker’s ASC Review, Becker’s Healthcare, Chicago, IL
Higher acuity cases such as joint
replacement and spinal fusions have
moved into the ambulatory surgery
center setting over the past few years
as minimally invasive techniques allow
surgeons to perform traditionally
inpatient procedures in an outpatient
setting.
The anesthesiologist plays a crucial
role in making these cases successful.
If patients have a great experience,
appropriate pain expectations and
continue to make progress after they
return home, they’re likely to recommend
the center to others and revisit the next
time they need a procedure.
“When a patient says they didn’t
have a good experience and felt sick,
we just can’t cut that person loose. We
have to check up on them and I think
ASCs do a great job of looking at the
patient surveys and following up,” says
Charles Tullius, MD, an anesthesiologist
in Savannah, Ga. “If the patient has one
knee done at the center, they’ll return
when they need the next knee done if the
surgery and postoperative recovery went
well.”
Catherine Schmidt, MD, an
anesthesiologist with Northern Wyoming
Surgical Center in Cody, and Dr. Tullius
discuss some of the biggest challenges
with high acuity cases in ASCs and
their role in making sure these cases are
successful at the center.
Challenges
More complex orthopedic and
spine procedures are now moving
into the outpatient setting, which has
economic and clinical value for the
patients. However, not all patients are
safe for surgery in the ASC and the
anesthesiologist may be the last person in
line to recognize a potential issue before
moving forward with the case.
“Anesthesiologists must be especially
vigilant at ASCs with the higher acuity
cases,” says Dr. Schmidt. “We strive to
maintain hemodynamic stability during
and after these cases. One challenge
we specifically have is that we are not
allowed to administer blood products at
the ASC.”
As a result, patients who are at high
risk of complications are often taken to
the hospital setting. Issues such as obesity
and sleep apnea present huge challenges
to anesthesiologists as well. Obese
patients process anesthesia differently,
which could lead to complications.
However, obese patients also make up a
significant percentage of patients who
will need the orthopedic procedures that
are moving into ASCs today.
“If the patient’s medical problems
aren’t in control and they receive a large
dose of anesthesia, sending them home
right away may be unsafe,” says Dr.
Tullius. “They may look fine while they
are at the center, but they metabolize
their medicine after they go home and if
they don’t have the proper supervision,
there could be unsafe consequences.”
The second big issue Dr. Tullius often
sees among patients is undiagnosed sleep
apnea. Delivering anesthesia to someone
with sleep apnea could have disastrous
results, but many patients claim they
don’t have the time to undergo a sleeping
study to confirm the diagnosis. Nurses
can ask questions about symptoms of
sleep apnea, but without the tests it’s
difficult to pinpoint.
Controlling Patient Pain
The advent of regional anesthesia
allows anesthesiologists to control the
patient’s pain for outpatient procedures
and feel comfortable sending them home
within hours of surgery. Dr. Schmidt has
a team of surgical nurses assist her with
peripheral nerve block procedures and
airway management to ensure everything
goes smoothly.
The anesthesiologist must feel
comfortable administering regional
anesthesia blocks; otherwise they rely on
narcotics to control postoperative pain.
“The patients’ pain control depends
on the skill and speed of the surgeon
and the ability of the anesthesiologist to
mitigate pain,” says Dr. Tullius. “A big
shoulder operation is painful and if the
Continued on page 10
10. The Communiqué
W i n t e r 2014
P a g e 10
Performing High Acuity Cases in ASCs:
The Anesthesiologist’s Role
Continued from page 9
anesthesiologist does a pain block that
lasts 12 to 14 hours, the pain is mitigated.
But if they don’t and the patient is given
narcotics, that could make them sleepy
and they are sent home with the narcotics
in their system.”
Patients at Northern Wyoming
Surgical Center are able to stay up to 23
hours which gives the medical team extra
time to ensure patients have recovered
enough to return home. Dr. Schmidt
uses peripheral nerve blocks to minimize
postoperative pain and educates the
patient about using continuous nerve
blocks after discharge.
“For high acuity orthopedic cases
we do at our ASC, the current trend
includes performing effective peripheral
nerve blocks to minimize the pain
postoperatively. Often this means
sending patients home with continuous
nerve blocks that can keep a shoulder, hip
or knee numb for two to three days after
a shoulder, hip or knee replacement,” says
Dr. Schmidt. “Since these patients can
only spend one night at an ASC, our goal
is to ensure excellent postoperative pain
management so patients don’t end up in
the ER the next day.”
Practicing Efficiency
Surgery center physicians and
administrators want to remain efficient
and fill their schedules with the
appropriate patients.
“Much of the responsibility of
ensuring that high acuity cases run
smoothly and have good outcomes
at ASCs is the purview of the
anesthesiologist,” says Dr. Schmidt. “We
take care of the patient’s medical illnesses
as well as surgical-specific issues while
the patients are at the ASC. We function
much as the internal medicine physician
or pediatrician would in the hospitals and
as anesthesiologists; this is the definition
of perioperative physician.”
Communication between the surgeon,
surgery center and anesthesiologist is very
important to prepare for each patient. This
will prevent cancellations, or worse—
transfers from the center. Dr. Schmidt
outlines the process at her center to
identify issues and promote efficiency:
• Nurses make a preoperative phone
call to obtain a patient history three
to four days before surgery.
–
Nurses go through “Anesthesia
Alerts” with the patients to
identify issues ahead of time.
– They obtain cardiac testing results,
sleep study results, lab work and
x-ray results beforehand.
•
The
nurse
informs
the
anesthesiologist of any pertinent
medical or surgical issues to manage
them before the day of surgery.
“The best quality of care for every
patient is due to great teamwork,” says
Dr. Schmidt. “Our ASC team, from
administrator to housecleaner, works
together to ensure efficiency.”
When anesthesiologists identify a
preoperative issue on the day of surgery,
the case must be cancelled. Canceling
cases throws a wrench in the ASC’s welloiled machine and comes at a financial
loss. However, anesthesiologists must
speak up if they identify a patient they
aren’t comfortable proceeding with at the
center.
“You can fix a lot of that problem by
making preop phone calls far enough in
advance so there aren’t any surprises on
the day of surgery,” says Dr. Tullius. “Find
out a week in advance that the patient
is having chest pain when they walk up
steps so in the intervening time you can
get them to a cardiologist for stress tests
and make sure they are okay before
undergoing the surgery. If you find that
out on the day of surgery, the case has to
be cancelled.”
Future Potential
As procedures and anesthesiology
evolve, there is a potential that more
cases will move from the inpatient
hospital setting to the outpatient surgery
center. Economically, surgery centers
are less expensive than hospitals and
will continue to be a good option for
appropriate cases.
“I am hopeful that in the future we
will continue this trend and it will allow
us to perform other high acuity cases in
the ASC setting,” says Dr. Schmidt. This
may be the case as surgeons currently
performing outpatient procedures in the
hospital setting transition those cases to
the ASC.
However, Dr. Tullius sees surgery
for the sickest patients remaining in the
hospital. “I really think the trend will be
that hospitals will take the sickest cases
and the ASCs will go back to performing
the high volume cases,” he says.
Laura
Miller
is
Editor-in-Chief
of
Becker’s ASC Review
and Becker’s Spine
Review, online and
print publications of
Becker’s Healthcare.
She joined Becker’s
Healthcare in 2010
and has previous experience as a journalist and freelance writer for various online
and print publications. Ms. Miller graduated from Knox College with a degree in
Creative Writing. She is located in Chicago
and can be reached at lmiller@beckershealthcare.com or 312-253-9170.
11. The Communiqué
W i n t e r 2014
P a g e 11
Endoscopy: Revisited
Jody Locke, CPC
Vice President of Anesthesia and Pain Management Services, ABC
Just mention endoscopy at an anesthesia conference and see what happens.
Few topics elicit such strong but disparate
responses. For the anesthesiologist from
the East endoscopy has been, and continues to be, his or her fastest growing and
most profitable line of business. By contrast, the prevailing view of the physician
in the West reflects a very high degree of
skepticism. His experience is that the endoscopists don’t really want to work with
his group. He interprets payer policy as
forcing anesthesia through the same funnel of denial as other services and sees no
meaningful light at the end of the tunnel, especially with regard to endoscopy.
Such is the challenge to today’s anesthesia practice management: sorting out the
realities of facility expectations, surgeon
preferences, payer policies and economic realities and, most of all, rising above
the prejudice of emotions. Cynicism and
the weight of disappointment too often
cloud our ability to make effective management decisions. While the specialty of
anesthesia is at a particularly challenging
crossroads, many are finding opportunity
by reassessing previous assumptions and
digging deeper into the analysis of customer expectations and market trends.
To this end a review of endoscopy is a
particularly fertile field for investigation.
FIGURE 1
These are five questions that should serve
to frame the discussion.
1. How does payment to anesthesia
providers for endoscopic procedures
fit into the broader national debate
about the future of healthcare?
2. Why is there such variability in
practice patterns across the country
as pertains to the role of endoscopy?
3. What do we actually know about
payer policies concerning payment
to anesthesia providers for CPT®
codes 00740 and 00810?
4. What is an effective management
strategy?
5.
What conclusions can we draw
based on what we currently know
about the value of endoscopy as a
line of business?
Total Percentage of Anesthesia Revenue from
Endoscopy by Year and by Region
The following is a review of actual
data for 26 ABC client anesthesia practices, 13 in the Eastern United States and
13 in Western states over a three year
period. Western states include Arizona,
California, Idaho, Oregon and Washington. Eastern clients are located in
Delaware, Florida, Georgia, Illinois, Ohio,
New Jersey, New York, Pennsylvania and
Virginia. These are all moderate to large
practices that have been ABC clients since
2011; 24 of the practices have been clients
since well before 2011. In two cases the
clients joined ABC during the year and so
their data for 2011 have been annualized
to reflect historical production levels.
For purposes of this analysis all claims
billed with CPT codes 00740 (upper
G.I.) and 00810 (lower G.I.) were pulled
for all 12 months of 2011, 2012 and the
first six months of 2013, except as noted
above. Charges and payments were tallied
based on Date of Service. This represented 83,158 claims in 2011, 100,927 claims
in 2012 and 51,072 claims for 2013,
which would annualize to approximately
102,144 cases for 2013 if volumes continued at previous levels. Figure 1 indicates
the total percentage of anesthesia revenue
derived from endoscopy claims by year
and region of the country for the practices included in the study.
Endoscopy for Anesthesia
and the N ational H ealthcare
Debate
The future of payment for anesthesia services for endoscopic procedures
will ultimately be determined by a variety of factors: political, clinical and
economic. As is so often the case in politics, philosophical principles and policy
Continued on page 12
12. The Communiqué
W i n t e r 2014
P a g e 12
Endoscopy: Revisited
Continued from page 11
agendas may have more to do with the
practical reality of clinicians in the field
than clinical relevance or economic realities. Endoscopy is a case in point. If one
assumes that it is desirable for all Americans over the age of 50 to get routine
colorectal screening, then an argument
can be made for the value of making the
procedure as painless as possible. Here
the economic policy argument hinges
on the expectations that spending a little more on anesthesia to ensure that a
higher percentage of patients is screened
costs less than the alternative in which
there is less screening and more colorectal surgery.
Inevitably, the specific realities
underlying such broad policy determinations are far more complicated, but
such assumptions do often drive public and private payer policy decisions.
Apparently, this underlay the interplay
between Aetna and United Healthcare
a few years ago. Aetna decided to deny
claims for anesthesia for ASA physical status I and II patients undergoing
routine colonoscopy procedures. In response United Healthcare reaffirmed
its policy of paying for such services.
Ultimately, Aetna backed off and both
payers now generally cover anesthesia
for endoscopy. In fact, their rates are
some of the best in the industry. How
much insight this provides into the inner workings of other payers is hard to
tell. The fact is that for years the pessimists have been arguing that the end
of reimbursement for endoscopic anesthesia services is imminent and yet, the
payments continue unabated, or so it
would appear.
Clinical realities in medicine are
also subject to their own arcane evolution. The debate as to what categories
of providers are sufficiently qualified to
administer propofol continues at many
levels. Thus far propofol is the agent of
choice for GI procedures and anesthesia
providers are uniquely qualified to manage the risks of its use but this too could
change. The fascinating thing about the
specialty is its ability to develop new
ways to manage patients through the
trauma of surgery with less risk and
fewer complications. It is not unreasonable to assume that some new agent or
technology will similarly transform the
care of endoscopic patients.
Is it true that all such policy decisions are ultimately resolved based on
economics? It is not always clear that
this is the case. Or maybe it is a matter
of how one defines the economics of the
issue. The evidence is that in medicine
it is not always the cheapest option that
wins out. Despite a concerned focus on
the cost of healthcare, costs continue to
rise faster than for any other sector of
the economy. Businesses are continually
striving to provide more service for less
cost and to push their operations to ever
higher levels of productivity and while
we hear the same hope for healthcare,
TABLE 1
the reality does not bear this out.
What appears to happen in healthcare is that the public or policy makers
decide on priorities irrespective of the
economic implications and then the task
that falls to providers is to implement
the policies. Today’s public debate about
healthcare turns on whether it is a privilege or a right. Those that argue that it
is a right seem to be gaining ground,
especially with the recent changes introduced by the Affordable Care Act. How
this general perception will play out in
the specific domain of endoscopic care
is hard to predict but clearly anesthesia
has become a significant stakeholder in
the debate. Curiously enough, while it
used to be that the cost of anesthesia
was 20 to 25 percent of the cost of the
surgery, when it comes to endoscopic
care anesthesia payments are roughly
equal to those of the endoscopists. This
fact alone speaks volumes with regard to
the public perception of anesthesia and
is consistent with the view that two factors have driven most advancement in
healthcare: antibiotics and anesthesia.
Typical Mix of Upper and Lower GI Endoscopy
Procedures, Colonoscopy Practice
13. The Communiqué
D iverse P ractice P atterns
A cross the C ountry
It is important to note that from a
claims processing perspective, endoscopy poses a very specific coding and
billing challenge. Claims are typically
processed based on one of two CPT
codes: 00740 for upper GI procedures
and 00810 for lower GI procedures. We
tend to associate these codes with diagnostic and screening services, but this
is not always the case. Table 1 indicates
a typical mix of services that may fall
under the heading of endoscopy for a
practice that focuses on colonoscopy.
(Under the ASA CROSSWALK®, a wide
variety of surgical procedures all fall under one rather generic category.)
A useful predictor of a dedicated
endoscopy practice, however, is the percentage of colonoscopies performed.
Herein lies the most obvious factor
differentiating practices across the country. Figure 2 compares the impact of
colonoscopy on the various practices
included in the study. As indicated, even
the practice with the highest percentage of colonoscopy cases is under 50
percent. There is an interesting strategic
issue raised by this mix. Some will claim
that the real growth and revenue potential lies in capturing the colonoscopy
business because these are short cases involving healthy patients with potential a
favorable payer mix. Others will look at
these practices with a particularly high
percentage of colonoscopy cases and see
this as a point of vulnerability. This is
the kind of tricky strategic challenge that
anesthesia practices must sort out.
The site of service is another significant factor in understanding the nature
and extent of a practice’s commitment
to endoscopy. For reasons that are not
entirely clear or logical, a higher percentage of endoscopy centers in the East
encourage the participation of anesthesia practices in the management of their
patients. Such situations make it easy to
W i n t e r 2014
FIGURE 2
P a g e 13
2013 Endo Activity by Practice
determine the profitability of the commitment in that all of the key variables
for analysis, volume, payer mix and utilization are easily isolated and defined.
However profitable such arrangements
may be, they pose some special challenges to an anesthesia practice, namely,
if the arrangement is too profitable,
then the center may be interested in
or exploring ways to retain a portion
of the anesthesia revenue itself. There
has been considerable debate in recent
months about corporate models that
attempt to co-opt the role of the anesthesia practice.
While endoscopy centers continue
to be built across the country, these venues are still the exception rather than the
rule for the typical anesthesia practice.
The ideal setting involves the dedication
of one or two rooms in an ambulatory
surgery center or outpatient facility
specifically for the provision of endoscopic procedures. Such arrangements
typically prove to be the most profitable for three reasons: consistent volume
of cases, quick turn-over and favorable
payer mix. From a business perspective,
a service line can best be assessed when
all the variables such as staffing and revenue are clearly identified and logically
integrated. This is what cost accounting
attempts to do and its role in anesthesia
practice management is becoming ever
more relevant. The most complicated
situations to analyze are those where endoscopic cases are mixed in with the rest
of the surgical schedule.
One other question is often asked
about the profitability of endoscopy.
What is the impact of the anesthesia care
team? In theory, the use of CRNAs allows
a practice to reduce its cost of providing
care, a fact that should make it possible
for a practice to be more competitive.
The fact that the anesthesia care team is
more prevalent in the East than the West
may explain part of the regional disparity but cannot be the whole story. Some
notable practices in California have significant stakes in endoscopy centers with
a physician-only model. The real issue,
however, is that the care team only reduces costs when a physician’s salary and
expenses can be leveraged over multiple
rooms. Typically endoscopy suites only
consist of one or two rooms and so the
opportunity for leverage is limited.
What is the ideal arrangement for
the anesthesia practice and when is
endoscopy care most profitable? Quite
simply, it is any situation where the net
financial yield per clinical day of service equals or exceeds that of the other
venues covered by the practice. The two
most important metrics to monitor are
average cases per day and average yield
Continued on page 14
14. The Communiqué
W i n t e r 2014
P a g e 14
Endoscopy: Revisited
Continued from page 13
per case. These are the foundation for
any financial serious analysis and should
be integral to any practice’s ongoing review of its endoscopic activity. Table 2
below lays out the elements of such a
review. While this might be an extreme
example it is based on actual data. The
real point, though, is that even with a
lower yield per case it is the productivity
of the facility that makes the arrangement so favorable, no matter what the
staffing model. This is the aspect of endoscopy that makes it so favorable for
anesthesia practices. The keys to success
are efficiency of the facility and productivity of each anesthetizing location.
More important, however, the ideal
arrangement is the one where the endoscopists believe that the anesthesia
providers will enhance their productivity
and profitability. It is on this point that
there appears to be the greatest disparity
of perceptions across the country. Some
centers and endoscopists are simply more
willing to partner with their anesthesia
colleagues than others. Those anesthesia practices that have been particularly
successful in growing their endoscopy
business claim this is little more than an
educational and marketing challenge.
The Impact of Payer Policies
The impact of payer mix cannot
be overstated; even a slight increase in
TABLE 2
Endoscopy Metrics
29.42
Minutes per case
9.82
Cases per day
4.82
Hours of billable
anesthesia time per day
$384.56
$3,779.79
Yield per case
Yield per Anesthetizing
location day
the percentage of Medicare patients can
dramatically reduce the average yield per
case. Of even greater concern, however,
is the ability of payers to change their
policies such that payments that were
once the norm become the exception, or
where the cost and time associated with
managing denials and the need to justify
the medical necessity of the service
makes the cost of the service prohibitive.
Such changes can completely invalidate
the best laid plans and the most careful
business planning. Such unilateral payer
policy decisions are especially noxious
in that they are completely beyond the
control of the practice. Historically,
and despite the common perception of
many providers, payer policies have not
been an unreasonable impediment to
most anesthesia practices in endoscopy.
Clearly, though, the fear is that this could
change dramatically and very quickly.
Table 3 summarizes average actual
payments per case for the practices in
this study. Not surprisingly, the Medicare
average payment per case is about 38
percent of the average Preferred Provider
Organization (PPO) #1 plan rate with
the Medicaid rate being even lower than
this. Overall about 34 percent of all cases
billed in 2013 were billed to either a
traditional or a managed Medicare plan
but some practices saw more than 45
percent Medicare patients, which has a
material impact on the potential yield
per case.
Based on the data collected for the
practices in this study over a three year
period, the overall yield per endoscopic
case has remained reasonably constant
across the country. There is a slight drop
from 2012 to 2013 but further review
would be required to determine if this
was simply the result of payer mix changes or actual declines in payment per case.
Medicare rates have increased slightly as
TABLE 3
National Average
Payment Rates
2011
2012
2013
Medicare
$164.56 $168.78 $168.65
Medicaid
$138.69 $122.86 $119.20
PPO1
$433.25 $439.14 $442.19
PPO2
$651.69 $692.45 $636.91
PPO3
$519.72 $527.96 $542.89
PPO4
$800.16 $661.94 $552.85
Overall
$331.84 $334.00 $319.10
have those for most PPO and managed
care plans. Those on the front lines of
accounts receivable management complain that there are more denials and
that it is getting harder to get paid, but
based on the results this is more of an
operational challenge than a change in
economic reality. Aggressive accounts
receivable management is an important factor in the success of any practice
and the impact of payer inconsistency
in the adjudication of anesthesia claims
for endoscopic care is more typical than
exceptional.
Given the nature of the service,
though, these rates will still result in a
competitive average daily yield if the facility is well managed and productive.
In general, the conclusion one
might draw from these data is that it
continues to be business as usual for endoscopy. Not indicated here is the fact
that only two of the practices realized
an increase in their net yield per case,
while 12 saw a decrease of anywhere
from 5 to 28 percent. The rest have been
collecting just about exactly what they
were collecting in 2012. As is so often
the case, we should not be too quick to
generalize based on limited data. Each
practice and each line of business needs
to be assessed individually to draw any
15. The Communiqué
meaningful conclusions about underlying patterns or trends.
Given this generally favorable scorecard, then, where is the basis for concern
with regard to the future of reimbursement for these services? It is being driven
by the payers and it pertains to the issue
of medical necessity. Endoscopy has been
a subject of special concern to CMS and
others for many years because such a high
percentage of cases are billed as Monitored Anesthesia Care (MAC) cases. A
MAC case must be specifically flagged on
the claim form with a –QS modifier. This
is not intended to result in a reduction
in payment, but, depending on the payer,
has the potential to increase the likelihood of a denial or request for additional
information. Many Medicare intermediaries also require a separate diagnosis
to justify the payment to the anesthesia
provider. There is a long tradition of
compliance audits following changes in
payment patterns, and anesthesia for endoscopy is no exception. With increased
utilization comes tighter policies in an
attempt to manage the payer’s exposure.
An Anthem-Blue Shield policy that
became effective July 2013 is a case in
point. Of particular note is the following
statement: “The routine assistance of an
anesthesiologist or Certified Registered
Nurse Anesthetist (CRNA) for individuals not meeting the [criteria listed in the
policy] who are undergoing gastrointestinal endoscopic procedures is considered
not medically necessary.” The list of
criteria for medical necessity describes
a common list of risk factors for either
undergoing anesthesia or a surgical procedure. Such policies open the door to
closer scrutiny of endoscopy claims and
are sure to lead to higher denial rates
over time. It is because of such policies
that many practices in California will not
provide anesthesia to ASA I and II patients. It is also why they tend to be so
diligent in confirming documentation of
medical necessity for the anesthesia pro-
W i n t e r 2014
vider’s service in anticipation of a request
for additional documentation.
At the heart of the matter is the ultimate payer litmus test for payment
justification: medical necessity. Unfortunately medical necessity is often in the
eye of the beholder and subject to its own
arcane algorithm of application. What
makes a service medically necessary is not
an easy question to answer. If a patient
has an infected appendix that threatens
to contaminate the perineal space we
assume that it is medically necessary to
remove it because the procedure will restore the patient’s health and avoid other
complications. Does the same logic apply to the 94 year old patient undergoing
coronary artery bypass surgery or the
50 year old executive who is reluctant to
submit to a colonoscopy with moderate
sedation only because it is an uncomfortable procedure? Payers are attempting to
define medical necessity by defining the
necessary diagnostic preconditions for a
service but this is where the process starts
to break down. Maybe the implementation of a new, more specific diagnostic
code set, ICD-10, will make these determinations more rational, but maybe not.
Ultimately an individual must still make
a subjective assessment of the value of the
service and herein lies the ongoing uncertainty of medical necessity.
P a g e 15
The administration of anesthesia to
healthy patients for routine endoscopic
screening is a clear point of vulnerability
and should be monitored closely. This is,
in part, why it is so important to track
endoscopic volume at the CPT level, but
also why diagnosis is so important. The
use of “V” codes for diagnostic screening
has been a point of particular vulnerability in the current diagnosis coding
sequence called ICD-9, and is likely to be
even more so once ICD-10 is implemented next October. Payers use two codes to
adjudicate claims: the CPT surgical or
anesthesia service code and the diagnosis
code. It is only by monitoring the impact
of particular combinations of these codes
that a practice can monitor and gain
insight into payer claims’ adjudication
policies. This is why there is such concern about what are referred to as “Black
Box edits.” Practices that try to anticipate
payer edits by picking payable diagnoses
should be very careful for such practices
will ultimately incur a higher level of risk
for an audit.
An Effective Management
Strategy for Endoscopy
No one can predict the future of
reimbursement for endoscopy with
certainty. No crystal ball is that powerful.
The best we can hope for is to monitor
patterns of payer behavior and policy
changes and infer the implications. Thus
far the pessimists have been proven
wrong, but maybe their day will come.
Those who chose not to participate have
clearly missed a potentially valuable
line of business. The big winners have
been those practices, primarily in the
Northeast, that have aggressively pursued
contracts at endoscopy centers and that
have been fortunate to have very productive
endoscopy suites in their hospitals.
Hindsight is 20/20 but what should we be
monitoring as the market evolves? Where
Continued on page 16
16. The Communiqué
W i n t e r 2014
P a g e 16
Endoscopy: Revisited
Continued from page 15
TABLE 4
Comparing Profitability at Different Locations
Facility A
Facility B
Facility C
Days
Cases
Expected
Allowed
Actual DOS $
NCR
Yield per Case
Yield per Day
Colonoscopies
Cases
% of Total
Average Minutes
Average Yield
Payer Mix
Medicare
PPO
Medicaid
HMO
Other
Commercial
Self Pay
are the particular risk areas? What is the
best way to ensure that today’s silk purse
does not suddenly become tomorrow’s
sow’s ear?
An effective management strategy
for any line of business must be specific to
each site of service. As a general principle,
a cost center model is most appropriate.
The idea is to be able to establish and
monitor the profitability of each venue
(as in Table 4), which would involve
tracking all the factors that determine
both the potential revenue stream, the
overall productivity of the venue and
the cost of providing the care. This is the
direction where most anesthesia practice
management accounting is heading
because of the challenge of unprofitable
lines of business and venues. Today’s
practices must be more vigilant and
willing to take appropriate action when
particular lines of business are identified
as unprofitable because unproductive
venues can be the death of a practice.
Applying this concept to endoscopy
is not always easy, especially when
endoscopy cases are scheduled in surgical
venues, but it is critical in all situations
where the specific focus of a coverage
contract is endoscopic care. Consider the
example mentioned above. A practice
provides anesthesia for endoscopy in
three distinct venues: two hospitals and a
surgery center. Good accounting requires
a clear delineation of the factors affecting
the profitability of each site in order to
assess the actual impact on the practice
as a whole. It may be that one venue is so
inherently profitable that it more than
covers the cost of the others, which is fine.
Suppose, however that the revenue from
the once profitable surgi-center business
starts to slip dramatically. This could be
critical to the overall management strategy
of the practice. The same five factors listed
below will also serve as useful criteria for
the evaluation of potential new venues.
1.
Volume trends are essential to
profitability and it is especially
useful to monitor volume at the
CPT level because the goal is a
preponderance of short cases
involving relatively health patients.
2. Payer mix can be tracked at a fairly
high level for purposes of monitoring the impact of Medicare and
Medicaid on the overall revenue
stream.
17. The Communiqué
3. Payer policies, however, should be
monitored at the individual payer
or plan level because these will
determine the ongoing viability
of the practice and because failure
to identify changes in payer
requirements on a timely basis can
prove both significant and costly to
resolve.
4. Monitoring the accounts receivable
closely is also essential. This would
typically involve a regular review
of the consistency and accuracy of
contractual payments, the impact
of deductibles and co-payments
and changes in payer processing
that can materially alter cash flow.
5. addition, the practice should
In
closely monitor the productivity
of each venue on a normalized
basis by tracking the average cases
per day and the average net yield
per case so that there is always
an accurate determination of the
overall yield per provider day.
There is no one way to achieve this
level of financial accountability but it
should be understood that the data
elements must somehow be combined
to provide a clear and concise dashboard
W i n t e r 2014
that the practice can monitor. Few
billing systems have one report that
brings all the pieces together in a single
report, which is where a spreadsheet
may prove the most useful accounting
tool of all. Visual charting of volume,
payer mix, A/R, productivity metrics
and overall profitability is always an
effective management tool. The key to
effectiveness is the ability to monitor
performance trends at a high level with
an eye to outliers and exceptions, so that
problems and issues can be identified and
analyzed before they become significant.
Conclusions
Anesthesia for endoscopy is not a
new phenomenon. Many of us have been
monitoring the economics of this line of
business for years, wondering whether
or when the market will change. We are
still waiting for the crash that so many
have anticipated for so long. The fact is
that despite all the hype and all the dire
predictions change actually happens
only incrementally in medicine. Payers
adopt more stringent policies and this
impacts the processing of their claims.
This is where payer mix is either a
practice’s curse or salvation. It is all about
the numbers. The sum of the factors
P a g e 17
identified above must be adequate for
the arrangement to be profitable and the
changes over time should be neutral or
positive.
Every anesthesia practice finds
itself covering three kinds of venues:
those that are inherently profitable with
no financial support from the facility;
those that are profitable with some level
of financial support; and those that are
completely unprofitable. Because there
is no evidence that any facility is going
to subsidize an anesthesia practice for
anesthesia for endoscopy coverage then
these arrangements must, by definition,
fall into the first category if they are to
be viable. This is the challenge facing
all anesthesia practices today: knowing
which coverage obligations will meet the
financial requirements of the practice
especially given the reimbursement and
policy changes that have been discussed.
Given the evidence, though, it is safe to
assume that there is likely to be a place for
anesthesia in managing patients through
endoscopic procedures for the foreseeable future. Just as preparation is the most
critical phase of an anesthetic procedure,
so too is rigorous due diligence the most
critical predictor of success in any endoscopic service agreement. Success and
opportunity will come to those who do
their homework and test their assumptions assiduously.
Jody Locke, CPC,
serves as Vice President
of Pain and Anesthesia
Management Services
for ABC. Mr. Locke
is responsible for the
scope and focus of
services provided to
ABC’s largest clients.
He is also responsible for oversight and management of the company’s pain management
billing team. He will be a key executive
contact for the group should it enter into a
contract for services with ABC. He can be
reached at Jody.Locke@AnesthesiaLLC.com.
18. The Communiqué
W i n t e r 2014
P a g e 18
Reporting Postoperative Pain
Management in 2014
Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I
Perfect Office Solutions, Inc., Palmetto, FL
According to Recent Advances in
Postoperative Pain Management (Nalini),
approximately eighty (80%) percent
of patients experience postoperative
(or acute) pain after surgery, and pain
is one of the most common medical
causes of delayed discharge after
surgery. Although there have been
major breakthroughs in postoperative
pain management (POPM), many
factors are considered before deciding
on the type of pain therapy provided
to surgical patients, including comorbidities,
psychological
status,
exposure to analgesic therapies, and
the type of surgical procedure. Studies
indicate postoperative pain is associated
with, but not limited, to gynecological
and orthopedic procedures and have
found recovery is faster and fewer
complications are experienced when the
acute pain is treated aggressively. During
the past twenty years, new technologies
to aid postoperative pain control have
gained widespread use. (Medscape)
Control of POPM is truly a team
effort between the surgeon and the
anesthesia provider. It is important for
anesthesia coders to pay careful attention
to changes regarding coding and
documentation for POPM as changes
may affect an anesthesia provider’s ability
to bill separately for these services. Of
note, there were a number of text changes
in the National Correct Coding Initiative
(NCCI), Anesthesia Services section
found in Chapter II, Pages II-7 through
II-12 in Version 18.0 (effective January 1,
2012) and Chapter II, Pages II-6 through
II-15 in Version 19.0 (effective January 1,
2013). These changes outline under which
circumstances acute pain management is
payable and emphasize the requirement
of documentation from the surgeon
requesting assistance from an anesthesia
provider.
Further, a recent proposed
draft Local Coverage Determination
(LCD) by Noridian Administrative
Services, LLC regarding POPM indicated
“Providers should not expect separate
payment for the establishment of
epidural or other pain blocks unless the
block is placed following discharge from
PACU due to documented inadequate
pain control.” As originally written, the
Noridian LCD would have drastically
changed the way anesthesia providers
are paid for anesthesia services. Both the
American Society of Anesthesiologists
(ASA) and a number of anesthesiologists
who serve on their state Carrier Advisory
Committee (CAC) worked with Noridian
to ensure they had a clear understanding
of acute pain management services and
the significant changes in the original
language of the draft LCD before it
became effective on 11/11/13. In the
final version, Noridian outlines expected
documentation for Medicare Part B as
follows:
Reimbursement for the control or
management of acute pain in the
immediate postoperative period
is generally packaged into the
payment for the surgical procedure.
However, if a need for transfer of
pain management is documented
and ordered by the surgeon and the
accepting provider documents the
need for and acceptance of transfer of
care, separate reimbursement may be
made for the service.
19. The Communiqué
Presumably, both the NCCI changes
and the Noridian LCD are based on the
premise of the Centers for Medicare
and Medicaid Services (CMS) Medicare
Claim Processing Manual, Chapter 12—
Physicians/Non-Physician Practitioners
that postsurgical pain management by
the surgeon is included in the global
surgical package. However, the NCCI
recognizes the ability of the surgeon
to “request the assistance of the
anesthesia practitioner if the degree
of postoperative pain is expected to
exceed the skills and experience of
the operating physician to manage it.”
NCCI also indicates POPM procedures
may be “administered preoperatively,
intraoperatively, or postoperatively.”
Although postoperative pain is
the responsibility of the surgeon and
payment is bundled into the surgeon’s
global fee, anesthesia services may be
reported separately if there is a request
by the surgeon for an anesthesia
practitioner to provide POPM and
anesthesia for the surgical procedure
is not dependent on the efficacy of the
regional anesthetic technique. The ASA
Relative Value Guide® (RVG™) indicates
that the following conditions apply:
1) Anesthesia for the surgical procedure was not dependent upon the
efficacy of the regional anesthetic
technique;
2) Time spent on pre- or postoperative placement of the block
is separated and not included in
reported anesthetic time; and
3) Time for a post surgical block that
occurs after induction and prior
to emergence does not need to be
deducted from reported anesthesia time.
The RVG also suggests documenting the surgeon’s request, however, and
according to the NCCI the “surgeon is
responsible to document in the medical
record the reason care is being referred to
W i n t e r 2014
P a g e 19
TABLE 1
CPT Procedures
Single Injection
64415
64445
64447
64450
Description
Injection, anesthetic agent; brachial plexus, single
Injection, anesthetic agent; sciatic nerve, single
Injection, anesthetic agent; femoral nerve, single
Injection, anesthetic agent; other peripheral nerve or branch
CPT Procedures
Continuous Catheter
Description
62318
Injection(s) including indwelling catheter placement, continuous
infusion or intermittent bolus of diagnostic or therapeutic substance(s)
including anesthetic, antispasmodic, opioid, steroid, other solution),
not including neurolytic substances, includes contrast for localization
when performed, epidural or subarachnoid, cervical or thoracic
62319
Injection(s) including indwelling catheter placement, continuous
infusion or intermittent bolus of diagnostic or therapeutic substance(s)
including anesthetic, antispasmodic, opioid, steroid, other solution),
not including neurolytic substances, includes contrast for localization
when performed, epidural or subarachnoid, lumbar or sacral
64416
Injection, anesthetic agent; brachial plexus, continuous infusion by
catheter (including catheter placement)
64446
Injection, anesthetic agent; sciatic nerve, continuous infusion by
catheter (including catheter placement)
64448
Injection, anesthetic agent; femoral nerve, single continuous infusion
by catheter (including catheter placement)
the anesthesia practitioner.” This provision requires a written request from the
surgeon—which indicates there must be
communication between anesthesia and
surgical staff to ensure the requirements
for POPM are well documented for each
patient on a case-by-case basis.
Procedure coding will depend on the
site of the injection area and placement of
either a block(s) or a continuous catheter.
See Table I for some of the more common
Current Procedural Terminology® (CPT)
codes associated with POPM services.
A -59 modifier should be appended
to indicate that the service or services
were distinct procedural services from
the anesthesia provided for the surgery.
Remember—if the block/catheter was
used for the surgery the procedure
is not separately billable, although
discontinuous anesthesia time may be
reported for the time spent placing the
block/catheter. For example, if a carpal
tunnel procedure is being performed
with a wrist block, a code from the CPT
anesthesia section (01810 + anesthesia
time for both the anesthesia during the
wrist surgery and time related to placing
the wrist block) is reported. No separate
code is reported for the wrist block.
Continued on page 20
20. The Communiqué
W i n t e r 2014
P a g e 20
Reporting Postoperative Pain Management in 2014
Continued from page 19
Coders
should
check
the
documentation carefully and ensure
they understand when POPM is
separately reportable and that there
is an understanding of the procedure
being performed. For example, several
terms are used to describe a “brachial
plexus” block—such as “interscalene,”
“infraclavicular” or “supraclavicular”—
which should not be confused with codes
with a similar sounding description (such
as “suprascapular”). A “popliteal” block
procedure note, without a description of
the anatomy is not helpful in determining
the correct code to report. A “popliteal
fossa” injection is reported with CPT
code 64445 (sciatic nerve), whereas a
“saphenous popliteal” is reported with
CPT code 64450 (other peripheral nerve
block). Also, transversus abdominis
plane (TAP) blocks do not have a specific
procedure code. CPT code 64450 may be
used; however, CPT code 64425 may be
appropriate for TAP blocks performed
for inguinal hernia repair when the
ilioinguinal/iliohypogastric nerves are
anesthetized. (Mariano) If coders are
unclear about the services provided, they
must confirm ALL questionable details!
If ultrasound guidance is utilized
and appropriately documented, CPT
code 76942 [Ultrasound guidance for
needle placement (eg, biopsy, aspiration,
injection, localization device), imaging
supervision and interpretation] may be
reported separately with a -26 modifier
(if applicable). Documentation of the
use of ultrasound alone is not sufficient
—according to CPT Non-obstetrical
ultrasound coding guidelines, “Use of
ultrasound, without thorough evaluation
of organ(s) or anatomic region, image
documentation, and final, written
report, is not separately reportable.” A
retrievable image should be available,
along with a procedure note describing
the use of ultrasound for placement of the
block. It is also important for anesthesia
coders to remember that codes obtained
from the surgery and radiology section
are flat-fee and, although no time is
reported separately, documentation must
support the time the block was placed
(i.e. 7:21 to 7:34) to clearly indicate
that it was separate from the reported
anesthesia time when applicable.
Reporting daily management of
postoperative pain will vary, depending
on the services provided. According to
the NCCI, “CPT code 01996 may only
be reported for management for days
subsequent to the date of insertion of
the epidural or subarachnoid catheter.”
CPT 01996 would not be reported for
other types of continuous catheters, such
as CPT codes 64416, 64446, or 64448.
Coders should determine whether the
documentation supports an Evaluation
and Management (E&M) service,
including the chief complaint (related to
postoperative pain) and at least two of the
three required elements for subsequent
hospital care (History, Examination, and
Medical Decision Making). Keep in
mind that if the surgeon has transferred
responsibility for postoperative pain
management to an anesthesia provider,
only one physician or qualified healthcare
professional should report these services.
Acute pain diagnosis codes are
separately identified in the 338 section
of the International Classification of
Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM), although
there has been some confusion regarding
reporting a diagnosis code from this
section. According to ICD guidelines,
“Routine or expected postoperative pain
immediately after surgery should not be
coded.” However, the guidelines also
state that “If pain control/management
is the reason for the encounter, a code
from category 338 should be assigned
as the principal or first-listed diagnosis”
and “may be reported as the principal
or first-listed diagnosis when the stated
reason for the admission/encounter
is documented as postoperative pain
control/management”. As routine pain
management is provided by the surgeon,
it is my opinion a category 338 code
21. The Communiqué
TABLE 2
Diagnoses Supporting Medical
Necessity for Postoperative Pain
Management (Noridian)
ICD-9CM
338.11
338.12
338.18
338.19
ICD-10- Description
CM
G89.11 Acute Pain Due to
Trauma
G89.12 Acute PostThoracotomy Pain
G89.18 Other Acute
Postoperative Pain
R52* Other Acute Pain
(*Pain Unspecified)
should be reported when anesthesia is
requested to provide POPM. Note in
Table 2, published in the final Noridian
LCD, category 338 is recognized in the
list of ICD 9 codes that support medical
necessity. Since ICD-10 isn’t too far away,
the table has been updated to include
these conversion codes.
Historically, anesthesia practices
have relied on documentation by the
anesthesia provider to support the
surgeon’s request for POPM, such as
a procedure note or anesthesia record
indication of the surgeon’s request. In
the current environment, coders rely on
W i n t e r 2014
the documentation guidelines as outlined
in the NCCI and the recommendations
listed by the ASA. Documentation in the
medical record must support the surgeon’s
transfer of care and this requirement
means that anesthesia practitioners
should request written, rather than verbal,
communication. According to Dr. Peter
Dunbar, who serves on the Noridian CAC
for Washington State, standing orders
from surgeons will be acceptable as long
as they are both surgeon and procedure
specific.
Resources
American Society of Anesthesiologists (ASA) Relative Value Guide® (2013) Reporting Postoperative
Pain Procedures in Conjunction with Anesthesia
(Pages 58 – 65) http://www.asahq.org/For-Members/~/media/For%20Members/Standards%20
and%20Guidelines/2012/REPORTING%20POSTOPERATIVE%20PAIN%20PROCEDURES%20
IN%20CONJUNCTION%20WITH%20ANESTHESIA.ashx
Centers for Medicare and Medicaid Services, Internet Only Manual (IOM), Chapter 12 http://www.
cms.gov/manuals/downloads/clm104c12.pdf
Current Procedural Terminology®, Professional
Edition (2013), American Medical Association
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)® (2013)
Mariano, Ed (MD), Billing for Regional Anesthesia
P a g e 21
http://www.edmariano.com/billing-for-regionalanesthesia
Medscape, CSI: Investigating Acute Postoperative
Pain: Improved Outcomes and Clinical Horizons
http://www.medscape.org/viewarticle/549349
National Correct Coding Initiative, Chapter Two,
Version 19.0, Anesthesia Services https://www.cms.
gov/Medicare/Coding/NationalCorrectCodInitEd/
Downloads/NCCI_Policy_Manual.zip
Nalini V, Sukanya M, Deepak N, Recent advances in Postoperative pain management. Biology and Medicine. Yale J Biol Med. 2010; 83:11–
25
http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC2844689/#!po=70.4545
Noridian Administrative Services, LLC, Proposed/
Draft Local Coverage Determination (LCD):
Nerve Blockade: Somatic, Selective Nerve Root,
and Epidural (DL33188) http://www.cms.gov/
medicare-coverage-database/license/cpt-license.
aspx?from=~/over view-and-quick-search.
aspx&npage=/medicare-coverage-database/details/lcd-details.aspx&LCDId=33187&ContrId=
246&ver=4&ContrVer=1&CntrctrSelected=246*
1&Cntrctr=246&name=Noridian+Administrati
ve+Services%2c+LLC+(02102%2c+MAC+-+Pa
rt+B)&DocType=Proposed_NRTF&DocStatus=D
raft&LCntrctr=83*1%7c242*1%7c246*1%7c241*
1%7c245*1%7c243*1%7c248*1%7c244*1%7c247
*1%7c142*1%7c129*1%7c124*1%7c130*1%7c12
5*1%7c131*1%7c126*1%7c135*1%7c127*1%7c1
33*1%7c128*1%7c134*1&bc=AgACAAIAAAAAA
A%3d%3d&
Noridian Administrative Services, LLC – Link to
LCD L33188 from CMS website
http://www.cms.gov/medicare-coverage-database/
details/lcd-details.aspx?LCDId=33188&ContrId=2
46&ver=10&ContrVer=2&Date=11%2f11%2f2013
&DocID=L33188&SearchType=Advanced&bc=KA
AAAAgAAAAAAA%3d%3d&
Kelly Dennis, MBA,
ACS-AN,
CANPC,
CHCA, CPC, CPC-I,
has over 30 years
experience in anesthesia and speaks
about
anesthesia
issues
nationally.
She has a Master’s
Degree in Business Administration, is
certified through the American Academy
of Professional Coders, is an Advanced
Coding Specialist for the Board of
Medical Specialty Coding and serves as
lead advisor for their anesthesia board.
She is also a certified health care auditor
and has owned her own consulting company, Perfect Office Solutions, Inc., since
November, 2001.
22. The Communiqué
W i n t e r 2014
P a g e 22
2014 CPT Coding and Key
Reimbursement Changes
Joette Derricks, CPC, CHC, CMPE, CSSGB
Vice President of Regulatory Affairs & Research, ABC
The 2014 Current Procedural
Terminology® (CPT) edition will have a
total of 335 changes, including 175 new
codes, 107 revised codes and 47 deleted
codes for specialties.
No Anesthesia CPT codes were
deleted, revised, or added for 2014.
Changes to the 2014 CPT codes may
impact some ASA 2014 CROSSWALK®
CHANGES
determinations or base units. Anesthesia
providers should ensure that they
understand the impact of potential
revenue or compensation changes due to
additions or revisions to the ASA 2014
CROSSWALK (Please refer to Appendix A
– Summary of Additions and Revisions in
the 2014 ASA CROSSWALK for a complete
list of the additions or revisions).
DESCRIPTION
Pain management providers should
take note of the additions and deletions
in the chemodenervation subsection of
the nervous system section of CPT 2014.
Nearly one-quarter of this year’s
CPT code changes resulted from an
ongoing two-year effort to revise
gastroenterology codes to capture
significant advances in endoscopic
COMMENTS
Deleted
64613
Chemodenervation of neck muscle(s) (eg, for
spasmodic torticollis, spasmodic dysphonia)
New
64616
Chemodenervation of neck muscle(s), excluding
muscles of the larynx, unilateral (eg, for cervical
dystonia, spasmodic torticollis)
For bilateral procedure, report 64616 with modifier 50. For
chemodenervation guided by needle electromyography
or muscle electrical stimulation, see 95873, 95874. Do not
report more than one guidance code for any unit of 64616
New
64617
Chemodenervation of larynx, unilateral,
percutaneous (eg, for spasmodic dysphonia),
includes guidance by needle electromyography,
when performed
To report a bilateral procedure, use modifier 50. Do
not report 64617 in conjunction with 95873, 95874. For
diagnostic needle electromyography of the larynx use
95865. For chemodenervation of the larynx performed
with direct laryngoscopy, see 31570, 31571
Deleted
64614
Chemodenervation of muscle(s); extremity and/or
trunk muscle(s) (eg, for dystonia, cerebral palsy,
multiple sclerosis
New
64642
Chemodenervation of one extremity; 1-4 muscle(s)
New
64643
Chemodenervation of each additional extremity; 1-4
muscle(s)
New
64644
Chemodenervation of one extremity; 5 or
more muscles
New
64645
Chemodenervation of each additional
extremity; 5 or more muscle(s)
New
64646
Chemodenervation of trunk muscle(s); 1-5
muscle(s)
New
64647
Chemodenervation of trunk muscles; 6 or
more muscles
Use 64643 in conjunction with 64642, 64644
Use 64645 in conjunction with 64644
Report either 64646 or 64647 only once per session
23. The Communiqué
technology, devices and techniques. In
recent years, miniaturization, powerful
optical magnification and new imaging
technologies have led to a wide variety of
new applications for minimally invasive
upper gastrointestinal endoscopic surgical
procedures and improved diagnostic
capabilities. Coding changes for lower
gastrointestinal services can be expected
for CPT 2015.
While the majority of CPT 2014
changes do not directly impact pain and
anesthesia providers, it is important to
note that changes to the CPT codes may
result in changes in the work, practice
expense, or malpractice relative value
amounts and subsequent Medicare or
other payer’s fee schedules. In 2014,
Medicare made significant and substantial
adjustments in these values that will result
CPT/
HCPCS
Mod
Description
W i n t e r 2014
P a g e 23
in reimbursement cuts beyond the 20.1%
SGR cut. A few examples are shown in the
table below.
A Few Reminders Regarding
Your Clinical Documentation
Moderate (conscious) sedation is
billed based on the intra-service time
which starts with the administration
of the sedation agent(s), requires
continuous face-to-face attendance,
and ends at the conclusion of personal
contact by the physician providing the
sedation. Since moderate sedation is a
time-based code the intra-service time
must be documented in the medical
record. In order to bill for the first 30
minutes of intra-service time, at least 16
minutes must be documented for 99144.
An additional level, 99145, can be billed if
38 minutes of time is documented (each
additional 15 minutes needs a minimum
of 8 minutes).
When imaging guidance is not
bundled in the surgical procedure it
may be reported for the portion of the
service that requires imaging as long as
the documentation supports the medical
necessity for imaging, and explains
how it was used in the procedure, and
that a permanent record of the image is
maintained in the medical record.
Documentation of the patient’s
physical status and any co-morbidities
should be included on all anesthesia
records. Often this information helps to
support the medical necessity of the need
for anesthesia and, more importantly, it
may result in additional revenue.
Joette Derricks, CPC,
CHC, CMPE, CSSGB
serves as Vice President of Regulatory
Affairs and Research
for ABC. She has 30+
years of healthcare
financial
management and business
experience. She is a member of MGMA,
HCCA, AAPC and other associations and
a regular speaker at practice management
conferences. She can be reached at Joette.
Derricks@AnesthesiaLLC.com.
2013
Work
RVUs
2014
Work
RVUs
2013
NonFacility
PE
RVUs
2014
NonFacility
PE
RVUs
2013
Facility
PE
RVUs
2014
Facility
PE
RVUs
2013
MalPractice
RVUs
2014
MalPractice
RVUs
62310
Inject spine cerv/thoracic
1.91
1.18
5.33
1.81
1.17
0.79
0.16
0.10
62311
Inject spine lumbar/sacral
1.54
1.17
4.57
1.78
0.98
0.77
0.12
0.09
62318
Inject spine w/cath crv/thrc
2.04
1.54
4.86
1.46
0.74
0.57
0.16
0.11
62319
Inject spine w/cath lmb/scrl
1.87
1.50
3.07
1.59
0.82
0.65
0.16
0.12
76942
Echo guide for biopsy
0.67
0.67
5.43
1.35
NA
NA
0.05
0.05
76942
TC
Echo guide for biopsy
0.00
0.00
5.18
1.11
NA
NA
0.01
0.01
76942
26
Echo guide for biopsy
0.67
0.67
0.25
0.24
0.25
0.24
0.04
0.04
Reflects decrease in the value which equates to a lower reimbursement in 2014