The document discusses the evolution of anesthesia billing systems towards capturing detailed operational data for better management and performance metrics within hospitals. It highlights the role of innovative technologies, such as the shareable ink anesthesia record system, in facilitating the transition from paper-based records to more efficient electronic systems. Additionally, it emphasizes the importance of using productivity metrics to improve operating room utilization and overall financial health of anesthesia practices.

1. FALL2009 VOLUME14,ISSUE4
ANESTHESIA
BUSINESSCONSULTANTS
The database of an anesthesia billing
system should contain invaluable data
with regard to all that takes place in a
hospital’s operating rooms and delivery
suites. Because there is a charge created
for each and every anesthetic, the level
of detail captured by an anesthesia
department should rival that of the
hospital information system itself. While
the file layouts of many anesthesia billing
systems are defined by the information
necessary to generate a claim, we are
starting to see the emergence of a new
generation of software that seeks to
capture not only what will be necessary
to get paid for anesthesia but also data
that will allow the anesthesia practice not
only to manage itself more effectively, but
to provide the hospital administration
productivity and performance indicators
and metrics that underscore the potential
role of anesthesia in more effective
operating room management.
ABC offers The Communiqué in electronic format
Anesthesia Business Consultants, LLC (ABC) is happy to announce that The Communiqué
will be available through a state-of-the-art electronic format as well as the regular printed
version. The Communiqué continues to feature articles focusing on the latest hot topics for
anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice
administrators. We look forward to providing you with many more years of compliance,
coding and practice management news through The Communiqué and our Monday e-mail
alerts. Please log on to ABC’s web site at 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.
➤ INSIDE THIS ISSUE:
Operating Room Utilization Data Management . . . . . . . . . . . . 1
The Anesthesia Record Powered by Shareable Ink
®
:
A Dialogue with the Inventor . . . . . . . . . . . . . . . . . . . . . . 3
Is your Concurrency Software Compliant? . . . . . . . . . . . . . . 7
The State of AIMS Adoption . . . . . . . . . . . . . . . . . . . . . . . . 12
The Tipping Point for Anesthesia Information
Management Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
The Cost-Cutting Approach To Healthcare Reform . . . . . . . . 18
13 Steps to a Disastrous Anesthesia Information
System Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Anesthesiology Practice Web Sites . . . . . . . . . . . . . . . . . . . 22
HITECH in a High Tech Era . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Event Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Continued on page 4
Operating Room
Utilization Data
Management
Jody Locke, CPC
ABC Vice President for Practice Management

2. The Communiqué Fall 2009 Page 2
The Pace Picks Up in the Development of
Health Information Technology
One theme common to all the different
proposals for healthcare reform in this season
of intense advocacy is the need to increase
both the capabilities and the installed bases
of health information technology. David
Blumenthal, MD, MPP, National Coordinator
for Health Information Technology in the
Department of Health & Human Services
recently noted that:
It would be hard for any health professional
today to escape the conclusion that the an-
tiquated, paper-dominated system we now
have in place isn’t working well for patients,
creates added costs and inefficiencies, and
isn’t sustainable. As we look at our na-
tion’s annual health care expenditures of
approximately $2.5 trillion, there are many
ways our current system fails both patients
and providers. It is clear that change is
necessary.
The need for change from our “antiquat-
ed, paper-dominated systems” to powerful
and flexible information technology has been
clear for quite some time. We generate and
depend on a massive amount of informa-
tion, to which we add more data every day.
Managing all the information that we record
and using it to its maximum capabilities are
major challenges for anesthesiologists and
other professionals.
ABC invested in powerful custom-
built anesthesia practice management
software, F1RSTAnesthesia™, several years
ago. This system goes far beyond claims
and revenue cycle management, of course.
Jody Locke illustrates the use of data on
the time and units billed and the actual
collections per anesthetizing location, by
hour, to analyze utilization and identify
opportunities for increases in productivity
in his article “Operating Room Utilization
Data Management.” While Jody’s graphs
and charts come from F1RSTAnesthesia™,
which he helped to shape, he acknowledges
that “there is no one best way to capture and
present operating room utilization data.”
To look at some of the ways in which
other developers and organizations manage
data, we invited several such developers to
describe their systems in this issue of the
Communiqué. The digital pen-and-paper
method of completing an anesthesia record
marketed under the name Shareable Ink
Anesthesia Record™ represents brand-new
technology about which we are very excit-
ed – so much so that we have entered into
an exclusive agreement with the company
that developed the system under which, for
a certain time, we will be the sole anesthesia
billing company to sell the digital pen under
the F1RSTAnesthesia™ Record.
Several third party systems represented
in this issue are already quite familiar to most
anesthesiologists. Readers will immediately
recognize the name Docusys®. Teecie Covad,
VP for Product Management at Docusys,
Inc. has written a comprehensive descrip-
tion of the features and benefits of a true
AIMS in “The Tipping Point for Anesthesia
Information Management Systems.” Picis®
Anesthesia Manager is another system used
by many anesthesiologists every day. It has
a large installed base in hospitals across the
country. Dr. Carlos Nunez, Chief Physician
Executive for Picis®, gives an excellent his-
torical overview of the changing industry
needs and adaptations, and the Picis® so-
lution, including a synopsis of the federal
Stimulus Package that will reward hospitals
for demonstrating the “meaningful use” of in-
formation technology starting in 2011.
The nearly $20 billion in Stimulus
funds to promote the adoption of elec-
tronic health records was one aspect of the
American Recovery and Reinvestment Act
of 2009 (“ARRA”). Another part of ARRA
significantly alters and supplements HIPAA
privacy and security provisions. Abby
Pendleton, Esq. and Jessica Gustafson, Esq.
review the HITECH (Health Information
Technology for Economic and Clinical
Health Acts) provisions of ARRA per-
taining to patients’ privacy rights, breach
notification, and the consequences of breach-
ing private information.
ASA has created a new organization,
the Anesthesia Quality Institute (AQI),
to develop a national data registry for
anesthesia. To achieve similar goals of
collecting data from multiple operating
rooms to support benchmarking and
quality improvement initiatives, SouthEast
Anesthesiology Consultants of Charlotte,
NC, launched its own Quantum Clinical
Navigation System™ in the 1990s and
reports that Quantum is now installed in
25 hospitals. John Kunysz, Quantum’s chief
operating officer, describes the system and
its value in his article “The Cost-Cutting
Approach to Healthcare Reform.”
Joe Laden, a name very familiar to
participants in the MGMA-Anesthesia
Administration Assembly (AAA) and other
members of the anesthesiology community,
has synthesized everything he learned from
studying and comparing multiple exam-
ples in his write-up entitled “Anesthesiology
Practice Web Sites.” His checklists and brief
descriptions will be invaluable to readers
contemplating creating or expanding their
own websites.
Having read of the amazing capabili-
ties of anesthesia information management
systems in the first half of this issue, do not
miss the wonderful warning “13 Steps to a
Disastrous Anesthesia Information System
Implementation” by AAA officer and VIP
Phil Mesisca.
The changes that have taken place in
anesthesia practice since I founded ABC
thirty years ago are staggering — and the
constants are equally amazing. We are all
privileged to work in an area that asks us to
learn new technologies and new practices,
or at the very least, new approaches, all the
time. As with every quarterly issue of the
Communiqué, I am most grateful for the
willingness of experts like those noted above
to share their knowledge with us.
With best wishes,
Tony Mira
President and CEO
ABC is very proud to be the exclusive sponsor of a major new event at the Annual Meeting of the American Society
of Anesthesiologists: A Celebration of Advocacy, the opening session of the 2010 meeting which will be held in at
the Morial Convention Center in New Orleans, Louisiana from October 17th through October 21st.

3. The Communiqué Fall 2009 Page 3
In this issue, Communiqué
interviews Dr. Vernon
Huang, Founder and
Chief Medical Officer
of Shareable Ink and
inventor of their
Anesthesia Record prod-
uct. The Shareable Ink Anesthesia Record
allows immediate capture of information
written on paper anesthesia records. Dr.
Huang is also a practicing anesthesiologist
in the San Francisco Bay Area with an ex-
tensive background in medical informatics
and technology. Dr. Huang can be reached
at vhuang@shareableink.com. ABC will
market the product under the name
F1RSTAnesthesia Record™.
Question: Dr. Huang, what is the
Shareable Ink Anesthesia Record?
The Shareable Ink Anesthesia Record
is a product that enables anesthesiolo-
gists and CRNAs to take advantage of
the benefits of electronic medical records
without disrupting their workflow. Using
the system, anesthesia providers fill out a
paper form — that is nearly identical to
their current anesthesia record — using
a “digital” ballpoint pen. Essentially, they
chart on a paper anesthesia record just as
they have always done.
But now, when they drop off the pa-
tient in the PACU, they simply dock their
pen in a cradle, and all the information
is immediately and securely transmitted
to our servers. Then, the Shareable Ink
system creates actual computerized data
from the pen strokes — capturing times,
signatures, diagnoses, procedures, and
anything else written on the form. All the
information in the pen is encrypted and
transmitted to our secure servers where
all the computing is done.
The Shareable Ink system can even
automatically conduct rule checks and
immediately notify providers if they
forget to provide required informa-
tion, such as a signature or anesthesia
end time. Alerts can be sent via pagers,
text messages or emails — before the
anesthesiologist has even left the PACU.
An immediate notification means that
a provider can fix the record while it’s
still in front of him or her, resubmit the
record by docking the pen, and avoid
callbacks and rework.
Question: The system’s simplicity
is intriguing. How is the data utilized
after it’s captured?
After the data is captured from the
paper record, it is immediately “elec-
tronic” and we can do all sorts of useful
The Anesthesia Record
TM
Powered by
Shareable Ink®
: A Dialogue with the
Inventor
Vernon Huang, MD
San Francisco, CA
Continued on page 8
Shareable Ink®
Anesthesia Record™

4. The Communiqué Fall 2009 Page 4
Operating Room Utilization Data Management
Despite the potential of an anesthesia
practice database to enhance operating
room efficiency this aspect of practice
management is in its infancy. The most
common use of productivity data con-
tinues to be the evaluation of potential
stipend requirements. Anesthesia prac-
tice managers are coming to understand
the correlation between operating room
utilization and the need for financial
support. The financial analysis seeks to
assess whether the revenue potential of
each location covers the cost of provid-
ing the care. Having a reliable handle on
the profitability of each location covered
has been proven to be a consistently ef-
fective means of both justifying stipend
requests and encouraging administrators
to reconsider adjusting coverage require-
ments. The key, of course, is the ability to
produce and present the data and calcu-
lations in a manner that is both clear and
compelling.
Forward-looking practices also use
similar types of productivity metrics to
evaluate each line of business on a regu-
lar basis. Such forms of analysis provide
an important means of assessing the rea-
sonableness of continued coverage. The
result of such service-line specific review
may result in requests for additional
financial support or they may inspire cre-
ative thinking about alternative ways of
providing coverage more cost effectively.
A classic example involves a practice that
had believed it was important to tie up
every surgery center in town to keep out
the competition; once the group assessed
its actual yield per location day, however,
it quickly realized that a number of the
coverage contracts were significantly im-
pacting the compensation of the average
shareholder. A careful assessment of the
data led to the elimination of some of
the less productive contracts and a much
more realistic book of business.
Rare is the anesthesia practice that
is not challenged by the economics of
coverage and reimbursement. The con-
ventional approach to the enhancement
of practice profitability tends to focus
on revenue enhancement, either through
more aggressive contracting or accounts
receivable management. The fact is that
such efforts have limited ability to re-
solve significant profitability shortfalls.
Typically, the only real solution involves
matching staffing to revenue, which may
involve adjusting coverage. It is one thing
to work on ways on increasing the size of
the revenue pie, but if the pie is divided
too many ways then none of the slices
will support the income expectations of
the providers.
The use of productivity data and
metrics to assess the profitability of cov-
erage is leading to a view that an even
better strategy would be to use the same
kinds of information more pro-actively
to actually help hospitals and surgi-cen-
ters manage rooms more effectively on a
prospective basis. This is opening doors
of opportunity for anesthesia practices
to be seen more as problem-solvers in the
tricky business of operating room man-
agement. Some practices have been so
successful in their education of hospital
Continued from page 1
Table 1: An example of Operating Room Production Metrics by Room

5. administration that key stakeholders have
come to rely on the anesthesia metrics
and scorecards as the most reliable means
of measuring operating room efficiency.
Key to all of these strategies is the
ability to produce normalized produc-
tivity metrics by anesthetizing location.
The value of being able to drill down to
the specific anesthetizing location is be-
coming increasingly clear. To this end
developers of billing software are making
the necessary modifications to file layouts.
Having the capability to capture such
data and actually being able to gener-
ate reliable reports on demand, however,
are two quite different issues. Not only
must forms be designed to encourage the
practitioner to indicate where the case
was performed, but there must be a clear
logic and structure to the labeling. Minor
inconsistencies in provider labeling can
greatly impact the quality of the informa-
tion reported. Operating Room #1 must
be reported and entered the same way for
every case or the performance indicators
will not make sense. It does not matter
what the labeling convention is, so long as
it is consistent.
Once this is accomplished the
results can be invaluable. ABC’s
F1RSTAnesthesia allows for perfor-
mance data to be tracked in a variety of
ways. Standard performance metrics are
a very useful starting point. It is espe-
cially useful to be able to track average
case production, units billed, hours of
anesthesia time and actual collections
by operating room. Even more useful is
the ability to look at these same metrics
by shift or time of day. Perhaps the best
mechanism for monitoring utilization is
the ability to plot activity by hour of day.
Four typical examples of utilization data
are included in the tables accompanying
this article. These represent actual report
data for two ABC clients.
Table 1 presents key performance
metrics in summary for calendar 2008.
This table allows for the assessment
of comparative productivity among
locations as compared to standard bench-
marks. Most practices try to achieve an
average productivity of 50 ASA units per
location day, which should be sufficient
to cover the cost of coverage given a rea-
sonable payor mix. Ideally, each location
should generate at least 7 hours of bill-
able anesthesia time. This is considered a
sustainable level of production.
Table 2 compares activity by shift for
the same locations. Here the view is his-
torical. Conventional wisdom holds that
in an 8 hour shift there should be 6 hours
of billable anesthesia time. It is also true
that 75-80% of the revenue per anes-
thetizing location should be generated
during the day shift.
Table 3 shows the number of loca-
tions in use by hour of the day. Here
production data is aggregated and aver-
aged for eight months. Most observers
are interested in the point at which the
level of activity starts to drop off. This
The Communiqué Fall 2009 Page 5
Continued on page 6
Table 2: An example of a typical shift utilization assessment
Table 3: An example of a typical Utilization graph

6. type of graph also allows for the compar-
ison of activity by day of week.
The last chart, Table 4, presents pro-
ductivity metrics for day shift versus
overall productivity over time and allows
for the identification of downward trends
or seasonal variations in productivity.
This type of analysis is especially useful
for the assessment of staffing needs and
will sometimes be incorporated into a
staffing budget.
Anesthesiologists intuitively recog-
nize the value of timely and accurate data
in the management of their activities.
There is no question that the use of high
tech digital monitors has greatly enhanced
the quality of care provided in the oper-
ating room. There is no reason to believe
the same concept will not prove equal-
ly as valuable in the management of the
operating rooms themselves. Anesthesia
providers just need to get over the precon-
ceived notion that they are captive to the
system. There is no question that the pos-
session of such data and the ability to use
it effectively in the education of the hos-
pital administration represents a new role
for many practices. The case for a more
active role for anesthesia in the manage-
ment of operating rooms is being made
daily across the country. It will not be a
wholesale transformation of the specialty
but a gradual evolution from quiet ob-
server to active participant. As in so many
things, the best advice is to identify oppor-
tunities to demonstrate small examples of
process improvement and build on suc-
cesses one by one.
It is easy to look at these types of
charts and graphs and to say, that is in-
teresting but it would not be too useful in
my hospital. Such an attitude, however,
will inevitably be a self-fulfilling propo-
sition. There is a reason why so many of
the largest anesthesia practices are in-
vesting in technology and data capture
devices to be able to reliably measure and
monitor patterns of operating utilization.
They have long since learned that having
the tools to manage manpower and staff-
ing more effectively is the key to their
cost-competitiveness and survival. This
may not be the kind of technological ap-
plication that captures the imagination
with its sophistication or innovation but
it is clearly one that ensures profitability.
While there is no one best way to
capture and present operating room uti-
lization data there are clearly systems
that are more user-friendly and flexible
than others. ABC is especially proud of
its F1RSTAnesthesia software and the
various ways clients have been able to use
its data to manage their practices more
effectively and to provide unexpected
value added service to their hospitals.
The Communiqué Spring 2009 Page 6
Continued from page 5
Table 4: An example of utilization trends over time
Operating Room Utilization Data Management

7. The Communiqué Fall 2009 Page 7
Anesthesia groups that practice in
a “care team” setting use concurrency
software to calculate the maximum
number of cases that an anesthesiologist
is medically directing at any given
time. This software ultimately assigns
concurrency modifiers to each claim
being billed, thus influencing the
expected allowable that an insurance
company will pay. The biggest flaw
with such concurrency programs is
their inability to properly handle intra-
operative handoffs, or relief.
For example, Anesthesiologist A
begins medically directing a case at
2:00pm. Anesthesiologist B takes over
the case at 3:00pm and the case ends
at 3:30pm. Unless your concurrency
software has the ability to input multiple
anesthesiologists with multiple start/stop
times on the same case, the software is
not giving you accurate data.
From a billing standpoint,
relief cases are billed under one
anesthesiologist’s name with the total
case time. This anesthesiologist’s name
billed is typically the physician with
the greatest amount of time in the case.
However, from a compliance perspective,
each physician’s start/stop times need
to be analyzed for concurrency in order
to properly select the correct medical
direction or medical supervision
modifier.
In the example given above,
Anesthesiologist A may have a maximum
concurrency ratio of three CRNA rooms
from 2:00-2:59pm. Anesthesiologist
B may have a maximum concurrency
ratio of five rooms from 3:00-3:30. If
the concurrency analysis is run only on
Anesthesiologist A from 2:00-3:30pm,
the concurrency modifier assigned
will be incorrect, which will result in a
potential overpayment from the payer, as
shown in Figure 1.
In conclusion, intra-operative
handoffs should be well documented on
the anesthesia record and concurrency
should be run on each anesthesiologist’s
individual times in order to properly
calculate the modifier assigned on the
claim form. Since Medicare medical
direction (1-4 concurrent CRNA
rooms) pays 50% of the allowable
to anesthesiologist, while medical
supervision (5+ rooms) pays a maximum
of only 4 units to the anesthesiologist, it
is crucial that your concurrency reports
be able to substantiate the modifier billed
on each case.
As part of our desire to keep both clients and
readers up to date, the Communiqué has been
printing compliance information since its
inception. In the Compliance Corner, we will
now formally keep you abreast of the various
compliance issues and/or pick out a topic that
would be of interest to most of our readers.
Is Your Concurrency
Software Compliant?
Hal Nelson, CPC
ABC Director of Compliance and Client Services
Figure 1. Is This Case Medically Directed (QK) or Supervised (AD)?
2:00pm 3:30pm
Anesthesiologist A Anesthesiologist B
1:3 1:5

8. The Communiqué Fall 2009 Page 8
The Anesthesia Record
TM
powered by Shareable Ink®
:
A Dialogue with the Inventor
Continued from page 3
things with it. This is a key capability of
the Shareable Ink Anesthesia Record.
We can “slice and dice” the data and
push it out to various stakeholders of the
anesthesia record. For example, informa-
tion required for billing can be sent to the
billing company without the delay and
cost associated with scanning or mail-
ing. Because our system conducts rule
checking and can immediately notify the
provider about errors, we can eliminate
sending the chart back to the provider for
rework that would normally add weeks to
the A/R cycle.
We can also send information about
narcotics used during the case to the
pharmacy. Sometimes, we take the data
from many forms and build “dashboards,”
web pages that give a view into data ag-
gregated from many cases. Institutions
can use these dashboards to monitor
SCIP measures such as antibiotic admin-
istration time and patient temperature on
PACU arrival.
As another example, my group has
always recorded anesthesia ready time in
addition to surgery start time. This way,
we can measure how efficiently the OR is
running. If the hospital asks us to provide
an extra anesthesiologist to staff a room,
we may be able demonstrate that anoth-
er room is not necessary by bringing at-
tention to this OR “downtime.” If there
is sufficient downtime, the resource issue
can be addressed by scheduling existing
rooms more efficiently.
Unfortunately, my group never had
an easy mechanism for collecting and
analyzing the data. The exercise would
have been too tedious to retrospectively
enter that data from all the paper charts.
But now, using the Shareable Ink system,
the data is available electronically and
anyone with a spreadsheet can analyze it.
The system can even attach time stamps
to checkboxes, signatures, or any other
data collected from the form. This allows
groups using the Shareable Ink Anesthesia
Record to do detailed data analysis with
regard to CRNA supervision.
Question: How does the technology
by Shareable Ink compare to scanning?
First, information is immediate and
actionable with the Anesthesia Record.
Scanning is not as timely because the pro-
cess requires someone – usually not the
anesthesiologist – to physically obtain
the record, put it in a work queue, and
then scan it. Scanned information is also
less actionable. For example, if some-
one scans a record with no anesthesia
end time or no signature, and then, sub-
mits it for payment, days or weeks would
pass before the anesthesiologist is notified
about the missing information.
Second, all you get is a “picture” of
the record with scanning. You don’t really
obtain any discrete data. You can’t easily
answer questions like, “what percentage of
my patients are ASA 4E?” or “how many
central lines did I put in last year?” from an
archive of scanned records.
Question: What made you come
up with the Shareable Ink Anesthesia
Record?
I’ve always been fascinated with tech-
nology. That’s probably why I chose anes-
thesia as a specialty. I took a break from
clinical medicine before residency to
manage the healthcare market for a divi-
sion within Apple Computer. I remember
giving a talk in 1993 in which I predicted
that someday all doctors would be car-
rying PDAs. Since medical school, I’ve
known that healthcare providers were
mobile professionals with their own spe-
cific computing needs.
The digital pen is the ultimate ex-
tension of mobile computing. Finally,
we have a technology that fits our work-
flow. Previously, in order to use an EHR,
we had to modify our workflow to fit de-
cades-old technology. With the Shareable
Ink technology, we just do our jobs as we
have for years. Only now, we seamlessly
capture our information digitally in the
background.
Question: How did you start
Shareable Ink?
During residency, in the middle
of the “dotcom” boom, I took a sab-
batical to join a start-up company called
PatientKeeper. PatientKeeper was one
of the first companies to allow clinicians
to use PDAs and smartphones in their

9. The Communiqué Fall 2009 Page 9
workflow. The company has grown tre-
mendously over the years, and now, they
have signed contracts with about 12% of
US hospitals.
I reached out to my friend Steve
Hau, the founder of PatientKeeper, and
was able to convince him to become the
CEO and a co-founder of Shareable Ink.
Steve has a proven track record of build-
ing new companies in healthcare IT and
making customers successful. He quick-
ly assembled a terrific team of industry
veterans.
Question: Who is using the
Shareable Ink Anesthesia Record?
Anesthesiologists from coast to
coast are using our system, and we are
also working with physicians in other
specialties, in both the inpatient and
outpatient settings. Our anesthesiologist
clients aren’t limited to any particular lo-
cation or sub-specialty. We can take any
existing anesthesia record and make it
work with our system.
Question: What are the benefits
of using the Shareable Ink Anesthesia
Record?
There are numerous benefits that
accrue to both the individual anesthe-
siologists as well as to the institutions at
which they practice. The main benefit
to the providers is that they get almost
all of the advantages of having an EHR
– but without the hassles associated with
changing workflow.
With our system, there is virtually
no learning curve or training involved;
everyone already knows how to fill out
an anesthesia record with a pen. Because
of immediate rule checks, anesthesiolo-
gists know that they are filling out their
records completely and won’t be asked
weeks later to recall, for a particular case,
what time they transferred care in the
PACU. Taken together, this positively
impacts job satisfaction and the bottom
line.
The benefit to the institution is that
they get access to data that they have
always wanted but never had before —
and without having to scan or key enter
the records. Also, there is essentially no
burden on the IT staff. No Shareable Ink
software is installed on site. All the infor-
mation from the pen is encrypted and
transmitted to our servers where all the
computing is done. Administration and
providers can optionally access the data
using a standard web browser and the
data is always owned by the client.
Question: What benefits does it
bring to the anesthesia provider?
The benefits are multiple. From an
administrative and workflow perspec-
tive, the Shareable Ink Anesthesia Record
eliminates lost records, cuts down on
the number of records that need to be
reworked and decreases days in A/R.
Providers no longer have to fill out bill-
ing tickets and carry around anesthe-
sia records until they reach some critical
mass that reminds them to do their bill-
ing and send in their paperwork.
From a clinical perspective, it en-
courages more complete and accurate
charting since it can notify us if we’ve
submitted a record with a required el-
ement missing, such as an unsigned
Continued on page 10

10. The Communiqué Fall 2009 Page 10
CRNA compliance statement or missing
signature.
From a practice management stand-
point, the Shareable Ink Anesthesia
Record allows you to capture all sorts of
new data that was never easily available
before. One of the first things my group
implemented was recording our position
on the call schedule on our records. With
the Shareable Ink system, it’s easy to col-
lect all this data so we can actually ana-
lyze how much a particular position on
the call schedule works over time. This
will allow us to staff more efficiently.
Finally, from a financial perspec-
tive, we now have all the data we need in
order to qualify for pay by performance
or to report a new PQRI measure. If a
new performance measure is initiated, we
don’t have to do a lot of computer and
data entry work, we just have to intro-
duce a new field on a form.
Question: How does Shareable
Ink technology compare to current
Anesthesia Information Management
Systems (AIMS)?
Anesthesia Information Management
Systems have been commercially avail-
able for over a decade yet they have been
installed in less than five percent of the
marketplace. I believe this lack of adop-
tion is due to two primary factors: cost
and difficulty of use.
The Shareable Ink Anesthesia Record
costs only a fraction of the amount an
AIMS costs, and we can capture all of
the salient data that the institutions that
pay for these AIMS want. The Shareable
Ink Anesthesia Record is also incredibly
easy to use. Training is minimal and the
workflow of the user doesn’t change.
In addition, AIMS require provid-
ers to use a keyboard, mouse, or other
data entry device, and thus modify the
way they work in order to accommodate
data entry. I think this is the main reason
that there has not been more widespread
adoption of these systems. The approach
that we’ve taken with Shareable Ink
allows providers to practice the way they
do now, input data in a way that is natu-
ral and familiar, and still get the benefits
of an electronic system.
Question: How does the cost com-
pare to AIMS?
Current AIMS systems require new
computer hardware to be installed in
every operating room, sometimes even
requiring the replacement of anesthesia
machines! The Shareable Ink Anesthesia
Record not only costs a fraction of the
cost of an AIMS in implementation, it
also saves the institution ongoing costs
related to training and support. Our phy-
sicians report that they require about
half an hour of training. CRNA users,
who don’t need to take advantage of the
alerting or reporting functions, report
that their training took just five minutes!
On the support side, we’re not asking
the providers to do anything new other
than place the pen in a cradle. There’s not
much that can go wrong so ongoing sup-
port costs are miniscule.
Question: What about automated
vitals signs capture?
The Anesthesia Record
TM
powered by Shareable Ink®
:
A Dialogue with the Inventor
Continued from page 9

11. The Communiqué Fall 2009 Page 11
We don’t automatically capture
vitals signs, and I believe that that is one
of our strengths. Using the Shareable Ink
Anesthesia Record, providers are still en-
gaged with the case and record the vital
signs every five minutes. This means that
every five minutes the vitals have to go
from our eyes, through our brains, and
then be written on the anesthesia record.
It’s been suggested that while using
an AIMS, providers have a tendency
to let the record go on “autopilot,” and
they can actually be less vigilant to the
vital signs. I know some controversy sur-
rounds this.
What we know for a fact is that cases
have been litigated where the automat-
ed anesthesia record failed to record the
vital signs for extended periods. Also,
many providers are concerned about
AIMS systems capturing spurious data,
such as recording an abnormally high
pulse because the cautery is in use. They
fear that these data might increase their
liability and lead to increased documen-
tation burdens to edit the readings. The
Shareable Ink approach still allows for
the human filtering of inaccurate vital
signs so that the record reflects what ac-
tually happened during the case.
Question:What are the challenges of
implementing the technology?
The main challenge is in educating
the institution. Hospitals are often re-
luctant to start new IT projects because
of their history of being over budget
and behind schedule. Normally, once
we show the parties involved how little
training is involved and how minimally
disruptive it is to their workflow, things
go very fast.
The only requirement to deploy
the system is that the location have an
Internet connection. As I mentioned,
we don’t install any software on site.
All we leave behind is a docking cradle
for the pen and a driver to allow that
cradle to communicate with our servers.
Computing is done securely and remote-
ly by Shareable Ink’s servers.
Another challenge is interfacing to
the wide range of hospital IT and OR in-
formation systems that exist. Fortunately,
the interface work isn’t required to get
started. And the team at Shareable Ink
has a deep knowledge and significant ex-
perience at this task.
Question: How does the Shareable
Ink Anesthesia Record work with OR in-
formation systems?
We can interface into the OR
information system. Often, the
anesthesiologist keeps the most
accurate and up to date record. This
is especially true if the circulating
nurse is expected to enter data into an
OR system while performing clinical
duties. By extracting data from the
anesthesia record, powered by Shareable
Ink and uploading it into the existing
OR information system, Shareable Ink
relieves physicians and nurses from the
mundane, distracting and expensive
task of data entry. The Shareable Ink
Anesthesia Record is very complementary
to traditional information systems
because it draws on their strengths
of storing, retrieving, and displaying
data. Data entry is a limiting factor on
all existing systems, and now, we’ve
made that process a part of the existing
workflow nearly effortless.
Question: Why did you choose ABC
to be your partner?
I’ve been an ABC customer from
within two busy anesthesia practices.
Every few years, we re-evaluate the mar-
ketplace and consider changing billing
vendors and every time, we return to
ABC for our business.
We chose ABC to be Shareable Ink’s
reseller in the anesthesia marketplace
because of their market share, focus on
the anesthesia market, their expertise in
anesthesia billing and practice manage-
ment, and their willingness to embrace
new technologies.
Reference: Vigoda, M.M., Lubarsky, D.A.
Failure to Recognize Loss of Incoming Data
in an Anesthesia Record-Keeping System
May Have Increased Medical Liability. Anesth
Analg 2006;102:1798-1802

12. The Communiqué Fall 2009 Page 12
Although still far from achieving
mainstream adoption, anesthesia infor-
mation management systems (AIMS)
have made significant strides in market
penetration over the last five years.
Commercially viable AIMS solutions
have been available for more than two
decades, but it is only recently that the
notion of implementing an automated
anesthesia record has become widespread
within the practice of anesthesiology.
Perhaps the federal government’s push
to increase the adoption of electron-
ic health records (EHRs) as a part of
the recently passed “stimulus package”
will lead to near universal acceptance of
AIMS, but there are other forces at work
that have moved AIMS from being an
interesting experiment to a vital tool for
the management of anesthesia patient
information.
First and foremost, the leading
AIMS solutions have matured in ways
that reflect not only the progress of tech-
nology, but also the realities of modern
clinical practice. Even the most basic
systems can recreate the paper anesthe-
sia record; capturing data from moni-
tors and anesthesia machines, as well as
input from the user to document things
such as medications, fluids and clinical
notes. However, more advanced systems
such as Picis®
Anesthesia Manager have
moved beyond simple record keeping,
and now offer decision support tools and
remote access that extend the usefulness
of the electronic record. There have also
been advances in configurability, usabil-
ity and stability that have made AIMS
easier to implement and more transpar-
ent to the workflow of the average user.
Probably the most significant technologi-
cal advance that has directly increased
adoption of AIMS has been the integra-
tion and interoperability of these systems
with the information infrastructure of
the hospital.
The most successful AIMS solu-
tions are those that allow the electronic
anesthesia record to operate seamlessly
with the other information systems in-
stalled in the hospital. The interopera-
bility begins in the operating room and
extends as far as the outpatient areas.
In fact, the event that led to the larg-
est market expansion of AIMS was the
availability of the first commercially
viable suite of perioperative automation
solutions, Picis CareSuite, in 2003. By
combining a traditional operating room
management system (ORMS) with the
clinical solutions for preoperative evalu-
ation, anesthesia automation, and recov-
ery room (PACU) documentation, AIMS
adoption in the United States jumped in
one single year from a handful of sys-
tems to almost 100. Vendors offering
stand-alone systems began to suffer and
in some cases disappear, while the tradi-
tional hospital information system (HIS)
vendors attempted to enter the market.
While interoperability of AIMS
solutions was a welcome development
for the IT management of the hospital,
it was the gains in usability that began to
turn the tide with anesthesia providers
in terms of user acceptance. For
example, the availability of patient data
from outside the perioperative period,
The State of AIMS Adoption
Carlos M. Nunez, M.D.
Chief Physician Executive, Picis®
Wakefield, MA

13. The Communiqué Fall 2009 Page 13
such as allergies, medications, lab and
other test results, has helped drive the
acceptance of anesthesia automation
and streamline workflow. One of the
most important immediate benefits is
the ability to quickly access a patient’s
previous anesthesia management details
without sifting through paper charts.
This is especially useful for patients who
have difficult airways or other notable
pathology that could affect the delivery
of anesthesia. The ability to copy forward
portions of the patient’s previous pre-
anesthesia evaluation(s) also saves a great
deal of time and eliminates redundancy.
As a result, the pre-anesthesia
evaluation and immediate preoperative
preparation of the patient became less
of a paper chase and improvements in
the reliability of data captured from
medical devices helped make anesthesia
providers more comfortable with the
automation of clinical record keeping.
Advanced user interface design and
flexible configuration options pushed
the acceptance of AIMS even further.
The evidence is clear in the marketplace:
those AIMS solutions that offer
comprehensive interoperability beyond
the four walls of the OR and integrate
well into the unique workflow of
anesthesia have established themselves as
the leaders.
The final inherent trait of AIMS
that provides tremendous incentives to
hospitals is the ability to use their col-
lected data to facilitate both clinical and
administrative functions. The growing
use of decision support is an excellent ex-
ample of how vast amounts of data col-
lected across the perioperative period can
be available to the end users of AIMS, at
the point of care. AIMS-based decision
support systems enable users to create
their own rules, providing clinicians with
timely notifications based on patient
data that can help the clinician guide the
course of care. Imagine the AIMS screen
displaying a colored icon or sending a
text message to an anesthesiologist when
a patient with a history of Malignant
Hyperthermia has a recorded body tem-
perature that is rising. The collection
of data at the point of care also makes
remote access to the anesthesia record
possible, so that clinicians have access
to patient information from any OR or
PACU bed, anywhere they happen to be.
Then, after the episode of care is com-
plete, all of that data is available to gen-
erate billing (professional fees, supplies,
pharmacy, etc.) as well as research and
quality reporting. The ability to generate
reports with AIMS data, as required by
the Surgical Care Improvement Project
(SCIP), is vital in today’s healthcare en-
vironment. The information that is doc-
umented in an AIMS, such as time from
antibiotic dose to incision, appropriate
sterile technique, use of beta-blockers,
insulin use and glucose levels, and the use
of intraoperative warming devices, can
also be used to justify improved contract
rates for insurers that are willing to com-
pensate for proof of improved quality of
care.
The American Recovery and
Reinvestment Act of 2009 (ARRA)
included nearly $20 billion to stimulate
the adoption of electronic health
records. Beginning in 2011, the federal
government will reward hospitals with
incentive payments for demonstrating
the “meaningful use” of information
technology. After 2015, the incentive
payments go away; they replaced with
financial penalties for those hospitals
that do not meet the government’s
goals. A large part of the meaningful
use criteria center around the established
and growing requirements for quality
reporting as mandated by the Centers
for Medicare and Medicaid Services
(CMS). The perioperative care areas
of the hospital are where a great deal
of the data that CMS requires for its
quality measures reporting program
are collected, such as SCIP. ARRA may
provide the final push necessary to arrive
at near universal adoption of AIMS in
the coming years. For more information
on getting to meaningful use in high
acuity areas of the hospital, such as the
perioperative suite, Picis invites you
to visit http://www.picis.com/Picis-
Advocacy and download our position
papers.
Carlos Nunez, MD, is
Picis’s Chief Physician
Executive. He can be
reached at Carlosnunez
@picis.com

14. The Communiqué Fall 2009 Page 14
Although Anesthesia Record Keepers
have been available for nearly 30 years,
it has only been in the last decade that
broadly featured Anesthesia Information
Management Systems (AIMS) have been
available. In this comparison, I have de-
fined an Anesthesia Record Keeper as an
electronic system that produces a paper
printout of a legible, complete anesthesia
record at the end of a case; my definition
of an AIMS gets closer to the ideal – an
electronic anesthesia medical record that
maintains integrated communication
with other hospital and provider systems
throughout the perioperative period
(such as clinical information systems
used by nurses, clinical data repositories
used by hospitals and professional fee
billing systems in place for the group).
As AIMS mature to the stature of
information systems, they are gaining
acceptance. Yet, market penetration for
this product is still, by nearly all esti-
mates, less than 10%. Ultimately, one of
the most limiting factors of widespread
adoption has been the requirement to
win over two groups to purchase and
implement an AIMS: facility administra-
tors who typically provide the budget,
and physicians, who need to use the tech-
nology. A confluence of factors aimed
at both potential buyers, however, is
moving the AIMS industry to the tipping
point of widespread adoption.
Federal Initiatives
First, a national emphasis on health
IT through the federal economic stimu-
lus package, although not directed to spe-
cialty systems such as AIMS, will likely
leave such specialty groups as lone users
of paper records in an electronic envi-
ronment – a situation that will hasten
conversion. A secondary push toward
health IT has been proposed through the
national health care reform proposal re-
cently introduced by Senator Baucus and
others, encouraging health providers to
use IT to coordinate care, curb Medicare
abuse and fraud, improve care quality
and reduce duplicate tests.
Second, in the national debate sur-
rounding healthcare reform, reduc-
ing costs through the elimination of
Medicare abuse and fraud is a primary
focus when discussions turn to paying
for such proposals. Those discussions
generally lead to scrutiny of health pro-
viders who bill for their services and the
RAC (Recovery Audit Contractor) pro-
gram is the latest permutation of that
The Tipping Point for
Anesthesia Information
Management Systems
Teecie Cozad
Vice President, Product Management, DocuSys, Inc.
Atlanta, GA

15. The Communiqué Fall 2009 Page 15
examination. As advised by Pendleton
and Gustafson in ABC’s Summer 2009
Communiqué (“What Anesthesiologists
and Pain Management Physicians Need
to Know About the RAC Program”),
improved demonstration of medi-
cal compliance and documentation of
start and end times, invasive lines, post-
operative pain services, medical neces-
sity for monitored anesthesia care cases
and chronic pain management are wise.
The case completeness checks provided
by a robust AIMS such as DocuSys® will
perform real time concurrency checks
and prevent a provider from closing a
case until all billing requirements are
complete.
Safety and Quality – Hand in
Hand
The continued emphasis on patient
safety and quality embodied by CMS’s
Physician Quality Reporting Initiative
(PQRI) will also drive AIMS adoption.
The more anesthesiology quality mea-
sures are adopted by payers, the more
technology will play a role in prompting
the clinician to document their evalu-
ations and actions and to report their
performance effectively. While relatively
small bonuses are held out to stimulate
participation in these measurement pro-
grams now, the general consensus is that
physician payments will go the route of
hospital payments where bonuses for re-
porting became bonuses for performance
before becoming reductions in payments
for non-reporting. A good AIMS should
have a decision support engine that
allows the anesthesiology group to design
prompts to achieve 100% compliance
with both performance and reporting
on quality measures. It should assist the
anesthesiologist by selectively prompting
at the appropriate time for an appropri-
ate subset of patients to avoid message
fatigue.
Wrong site surgery is another in-
stance where one can imagine the an-
esthesia provider with a widening
downside potential. Although surgeons
and anesthesiologists are still getting paid
when “never” events such as this occur,
Bierstein suggested in the Winter 2009
issue of the Communiqué (Health Care
Quality and Measuring Performance),
…“it is not hard to imagine…[a system
that allocates] a pro rata share of respon-
sibility for perioperative injury.”1
An
AIMS can offer checklists to the user that
assist in documenting anesthesiology’s
part in the important “Time Out” for
confirmation of patient demographics
and surgical site.
Other safety measures that can be
enhanced with an AIMS include verifica-
tion and reporting of adverse medication
reactions. Utilizing an AIMS that incor-
porates a drug information database can
Continued on page 16
1
A recent Medicare MLN Matters article (MM6405) indicates that Medicare no longer covers any hospital or
other services provided in connection with a wrong site/wrong patient/wrong procedure episode, stating spe-
cifically that “All providers in the operating room when the error occurs, who could bill individually for their
services, are not eligible for payment..”

16. The Communiqué Fall 2009 Page 16
standardize allergy and home medica-
tion documentation, eliminate dupli-
cate documentation through inbound
integration of codified allergy and drug
information from nursing information
systems and can enable selective decision
support at the point of care around al-
lergy alerting and potential drug-to-drug
interactions.
Capturing postoperative complica-
tions is a required and necessary part of
the provision of anesthesia. A feature-
rich AIMS of today should allow the pro-
vider to document any events that are
noted during or after the case and track
them for Quality Improvement purposes.
Some AIMS, such as DocuSys, permit the
separation of Quality Improvement doc-
umentation from the generally available
Anesthesia Record. Additionally, there
are active projects aimed at building
multi-institutional clinical anesthesia da-
tabases for benchmarking and outcomes
research to which groups may wish to
contribute. These databases are built on
the output of various AIMS. Enterprise-
level reporting databases may contain the
clinical data repositories of related infor-
mation systems as well as AIMS data.
An important benefit of technolo-
gy highlighted by the advent of Personal
Health Records (PHRs) is a concept that
the Cleveland Clinic and others imple-
mented a decade ago – that of having
the patient participate in their preopera-
tive care by completing a computerized
health questionnaire. An AIMS that can
incorporate a triage methodology for
presurgical testing and pre-anesthesia
evaluation based on the patient’s health
history can provide extensive patient
safety benefits by communicating the
patient’s surgical risk to the entire medi-
cal team for optimization well in advance
of the day of surgery. Using technology
in this way permits the primary care pro-
vider, surgeon, anesthesiologist, preop-
erative nurse and the patient to work in
concert to improve care and eliminate
duplicate testing – additional goals of na-
tional health care reform proposals.
An AIMS at the Point of Care
Adoption of an AIMS is dependent
on two buyers and both have to be con-
vinced of the value of an AIMS for a pur-
chase decision to be made. Let’s start
with the problems that an AIMS can
solve for the provider at the point of care.
First, after years of development and
feedback from the anesthesiology market,
it is understood by AIMS manufactur-
ers that systems have to be easy to learn
and easy to use. No one in the fast paced
arena of anesthesia delivery has time to
grapple with a user interface that is not
intuitive. Some systems require less han-
dling than others to thoroughly docu-
ment a case, but a primary requirement
of any successful AIMS implementation
is that the anesthesia providers must be
able to focus on the patient and not on
the tasks of using a computer or docu-
menting physiologic data. Some sys-
tems, like DocuSys, have minimized the
work involved in supply and drug utili-
zation by accepting bar code scanning to
replace drop down lists, and by sending
utilization data to materials management
and pharmacy systems automatically so
that anesthesia providers do not have to
manage charge forms.
Second, the fear on the part of anes-
thesia providers that erroneous vital signs
will be entered into the record has largely
receded as more and more clinicians have
gained the understanding that a legible,
complete record is far easier to defend in
The Tipping Point for Anesthesia Information Management Systems
Continued from page 15

17. The Communiqué Fall 2009 Page 17
court than an incomplete hand-written
record. Most providers utilizing AIMS
now enter a quick note to explain aber-
rant physiologic data recordings.
The federal Drug Enforcement
Agency (DEA) has made additional func-
tionality of some AIMS, like DocuSys, a
real benefit. With requirements for anes-
thesia providers to document narcotic use
and wasting, the AIMS that can provide
complete electronic narcotic reconciliation
can save significant time for anesthesia
providers as well as hospital pharmacists,
both of whom are in short supply. Many
hospitals have implemented dedicated
medication dispensing carts in each oper-
ating room because of the difficulties en-
countered and the resources consumed in
reconciling anesthetic narcotic usage. A
comprehensive AIMS should eliminate
the duplicate documentation required to
dispense the medication from the cart and
document its administration in the record
by communicating bi-directionally with
the cart and with pharmacy.
Other efficiencies can be brought
to the point of care by a well designed
AIMS. Access to previous medical re-
cords in a manual world can be slow and
inefficient. Immediate access to AIMS
records means that the anesthesiolo-
gist can quickly review a patient’s previ-
ous airway management techniques in
preop to assist in planning. A strong
AIMS should automatically post com-
plications during a case to the patient’s
future PreAnesthesia Evaluation record
to extend safety to upcoming visits and
maintain links to images of the airway, if
available.
For those anesthesiologists who serve
as managers of the OR, an AIMS system
can help to streamline traffic through
the OR with the use of patient and pro-
vider tracking systems. Most AIMS utilize
the work station monitor and/or plasma
screens to provide boards that document
a patient’s progress through the perioper-
ative process. The best AIMS also provide
tools that allow the anesthesia manager
to assign anesthesia providers to add on
cases without phone calls and pages. The
OR/Anesthesia utilization reports avail-
able in an AIMS can permit anesthesia
managers to gather data for underuti-
lized FTEs that can successfully result in
needed stipends or produce the proof
sources for additional manpower when
there is high utilization.
Those with departmental responsi-
bilities to support professional fee billing
and physician compensation recognize
manual systems as inherent sources of
errors and omissions. A primary benefit
of an AIMS is the elimination of missing
charge sheets and the automatic trans-
mission of billing data – either in image
or data formats – at the close of each
case. A good AIMS will provide reports
to verify that all cases made it to the bill-
ing destination, reporting on closed,
opened but not completed, and cancelled
cases. Those who have successfully im-
plemented AIMS with billing support
have seen their “Days to Bill Drop” de-
crease by 10 or more days.
The Bottom Line is Still the
Bottom Line
Finally, returning to the second buyer
for an AIMS, it is the hospital or facility
executive who makes the final purchasing
decision. For the anesthesia group who
desires to implement an AIMS, the group
needs to operate at a strategic level to ac-
complish their wish. Hospitals lose mil-
lions of dollars every year because many
co-existing diseases are not adequately
documented. No other physician group
is better positioned to provide the docu-
mentation that can result in accurate
identification of co-morbidities for surgi-
cal patients than anesthesiologists. Using
an AIMS that can separate the healthy
from sick patients; start a PreAnesthesia
Evaluation with a patient’s personal
health record, and bring in preopera-
tive nursing documentation to validate
it, allows the anesthesiologist to spend
a couple of minutes on identifying co-
morbidities on a subset of surgical pa-
tients. This strategic use of an anesthesia
resource can significantly improve the fi-
nancial status of the hospital. More ac-
curately capturing charges on all items
used for a particular patient and provid-
ing information that allows the hospital
to more accurately track inventories of
drugs and supplies provides even more
ammunition in convincing hospital ex-
ecutives that an Anesthesia Information
Management System is an investment
that cannot wait.
Teecie Cozad is Vice
President, Product
Management at
DocuSys, Inc.
in Atlanta, GA.
Questions may be
sent to tcozad@
docusys.net; readers
may also find further information at
www.docusys.net.

18. The Communiqué Spring 2008 Page 18The Communiqué Fall 2009 Page 18
You cannot open a newspaper or
turn on the television today without
hearing about healthcare reform and
healthcare quality. The driving force
behind healthcare reform is that it is
currently 18.4% of our gross domestic
product. Despite the amount of money
being spent on healthcare, hospitals and
practices alike are concerned with what
may happen to already diminishing mar-
gins and therefore are looking to decrease
costs.
Quantum Clinical Navigation
System™ has been quietly working in the
background for more than twelve years
providing proof of quality and help-
ing hospitals, physicians and practices
decrease costs and implement pay for
performance models.
By capturing 50 perioperative in-
dicators Quantum CNS can measure
numerous types of outcomes:
1. Efficiency measures such as case
delays and cancelations;
2. Practitioner performance, includ-
ing measuring complications or
incidents and answering the fol-
lowing two questions:
a. Which doctor is not per-
forming according to best
practices or industry guide-
lines for evidence based
medicine?
b. How can we mentor the
doctor to become a better
practitioner?
3. Critical quality indicators that
assist in meeting JCAHO stan-
dards, SCIP initiatives and PFP
initiatives. Quantum CNS also
produces reports that allow clients
to measure the CQI data by loca-
tion, physician and comparative
benchmarks. Numerous best prac-
tices have been instituted based on
CQI results;
4. Patient satisfaction through patient
satisfaction surveys administered
after surgery or once the patient
has returned home, and
5. CQI data captured throughout the
continuum of care: patient check
in, holding room, operating room,
post-op, hospital floor, home, and
reported back to the physician,
surgeon and hospital.
Southeast Anesthesiology Consultants,
the founding company of Quantum
CNS, has been using the system since its
creation. “We wanted to be able to mea-
sure, analyze and continuously improve
our processes and performance,” said
Dr. Richard Gilbert, President and CEO
of Southeast Anesthesiology Consultants
and Quantum CNS.
Quantum is designed to flow natu-
rally with the patient care models already
in use throughout physician groups and
hospitals. Unlike expensive healthcare
IT systems which force clinicians to bear
the burden of cumbersome interfaces
and extra steps, Quantum CNS provides
a very high “return on clinician time” in
The Cost-Cutting Approach To
Healthcare Reform
John M. Kunysz
FACHE, Chief Operating Officer, Quantum Clinical Navigation System™
Charlotte, NC

19. The Communiqué Fall 2009 Page 19
addition to the standard “return on in-
vestment” model.
One example of the way
Quantum CNS’s real time report-
ing helped Southeast Anesthesiology
Consultants occurred in their Obstetrics
Anesthesiology division. One of SAC’s
physicians always received patient sat-
isfaction scores of 98% or better. A few
months ago, for no particular reason,
this physician’s score began to drop
dramatically. In less than two weeks he
went from patient satisfaction scores of
99% to scores below 70%. Because of the
real time reporting that this physician’s
hospital chief received, SAC was able
to quickly intervene, discuss the results
with the physician and see immediate
improvement with the scores rebound-
ing to 99% in a matter of days. “It was
remarkable,” commented John Kunysz,
COO of Quantum CNS, “This particular
physician’s scores dropped dramati-
cally and then rebounded in less than
24 hours due to the data Quantum pro-
vides on a real time basis.” Actions like
this have kept SAC’s overall patient satis-
faction 98% or better for over five years.
This kind of real time reporting and im-
mediate focused intervention is not pos-
sible with most traditional QA programs
using retrospective chart review.
Another way that Quantum CNS’s
reporting data is invaluable for physi-
cians and hospitals is that it can aid in
payer negotiations. Instead of having
to rely on payer data, SAC can proudly
showcase their own data, prove that they
are able to beat all national benchmarks
and ultimately use it as a tool to negotiate
better reimbursement rates.
Finally, Quantum Clinical
Navigation System aids in cost re-
duction. If you were to achieve the
level of benchmarks that Southeast
Anesthesiology Consultants can achieve
with antibiotic administration, lower-
ing of myocardial infarction and stroke
incidences nationwide the United
States would save more than $5 bil-
lion in healthcare expenses each year.
(See “Proper Antibiotic Administration
Savings”, inset) These cost savings
would allow hospitals and practices to
begin implementing expensive technol-
ogy, such as EMR systems, and could
lessen the burden of healthcare reform
on an already weak economy.
Proper Antibiotic Administration Savings
The national incidence of surgical site infection is 3-5% of all patients. Incidents of SSI
cost approximately $3,000 for an additional 7-9 hospital days per patient. Appropriate
administration of antibiotics decreases SSI 40-80%. The current benchmark for appropriate
antibiotic administration is 50-75% of the time. If SAC administers antibiotics 90% of the
time appropriately they will save $6.48 million dollars a year on 100,000 patients. Being able
to increase the percentage of time that proper antibiotic administration occurs would result
in a multi-million dollar savings nationwide.
*Cost & Benchmark source: Barnard, Bonnie MPH, CIC “Fighting Surgical Site Infections”
Myocardial Infarction # Patients % Patients
SAC 19 0.02%
National Benchmark* 205 0.19%
Number of patients undergoing anesthesia annually:
SAC- 95,205 patients/year US approx. 40 million patients/year.
Average cost to traditional health insurer for first 90 days after heart attack
per patient $ 38,501**
Total cost SAC patients $ 731,519
Total cost National Benchmark $ 7,892,705
Estimated savings to health plans/patients resulting from SAC reduced events = $7,163,236
Estimated national savings if benchmark reduced to SAC benchmark levels = $2.618 Billion
*Benchmark Source: Chung, Dorothy and Stevens, Robert, “Evidence-based Practice of Anesthesiology,” page 379.
** Cost Source: NBER Working Paper No. 6514, nber.org/digest/Oct 98, National Bureau of Economic Research.
Stroke # Patients % Patients
SAC 19 0.020%
National Benchmark* 476 0.5%
Number of patients undergoing anesthesia annually: SAC-95,205 patients per year, US
approximately 40 million patients per year.
Cost at discharge for inpatient care per patient $ 9,882**
Total cost SAC patients $ 187,758
Total cost National Benchmark $ 4,703,832
Estimated savings to health plans/patients resulting from SAC reduced events = $4,516,074
Estimated national savings if benchmark reduced to SAC benchmark levels = $1.897 Billion
*National benchmark is <1%, so .5% is used for calculation.
*Benchmark Source: Fleisher, Lee; ”Evidence-Based Practice of Anesthesiology, page 163.
**Cost Source: Neurology, Vol 46, Issue 3, 854-860, 1996, American Academy of Neurology, “Inpatient
costs of specific cerebrovascular events at five academic medical centers”
John M. Kunysz,
FACHE, is a licensed
CPA formerly with
Pr i ce w a te r h o u s e
Coopers and KPMG.
He received his MBA
from the University
of California, Los
Angeles, and Bachelor of Science degree
from San Diego State University. For ad-
ditional information regarding Quantum
Clinical Navigation System visit www.
quantumcns.com or call 1.800.354.3568.

20. The Communiqué Fall 2009 Page 20
13 Steps to a Disastrous
Anesthesia Information System
Implementation
Phil Mesisca, MBA, CMPE
University of Pennsylvania Health System, Philadelphia, PA
Implementing an Anesthesia
Information System (AIS) is a major un-
dertaking for an anesthesia practice. The
question is less about “should we” and
more about “when or how should we” as it
is inevitable that most practices will even-
tually make the move. This article will
review the steps to be avoided for a suc-
cessful AIS implementation.
1. Purchase Vaporware.
Ignore any discussion with a vendor
that includes “… not now, but we will
be able to handle that in our next ver-
sion …”.
2. Assume The Ais Will Fix All
Your Operational Problems.
In the words of Bill Gates “The first
rule of any technology used in a busi-
ness is that automation applied to an
efficient operation will magnify the ef-
ficiency. The second is that automation
applied to an inefficient operation will
magnify the inefficiency.” If you have
someone constantly tracking down
missing anesthesia records now, you’ll
probably have someone tracking
down incomplete or open electronic
anesthesia records later.
3. Under-Estimate The Time
And Resources Needed For
Implementation.
Most large capital investment projects
come in late and over-budget. There
will be significantly more issues than
you will anticipate and make sure you
prepare for the time devoted to the
one out of every 5 clinicians who will
offer significant resistance.i
4. Only Consider The Costs
And Resources Needed To
Implement.
You can’t prepare for every future
problem so prepare for your response
to a problem. Think about on-going
issues and future needs such as tech-
nical support, upgrades, training,
record security, interfaces, on-going
fees, data mining, expansion licenses,
backup processes, etc. There is an
enormous amount of work in prepar-
ing for the implementation, but many
practices don’t properly plan for the
continued resources and time needed
for the months/years after the go-live
date.
5. Let The Administrative Team
Take Complete Responsibility
For Implementation.
Key physicians and CRNAs must be
involved for a successful implemen-
tation. These individuals must also
be given the needed time to properly
plan and implement – and remember
“implement” is beyond the day the
system goes live.
6. If The Hospital Is Funding The
AIS, Make Sure You Allow It
To Dictate What System You
Will Implement Even If You
Know That It Will Not Meet
Your Needs.
You certainly need to be reasonable,
but implementing a system that isn’t
going to do the job properly will be a
lose/lose for both your group and the
hospital.
7. Modify The Ais To Accommodate
How You Do Things Today In
Your Practice.
The more willing a practice is to be
flexible and modify work processes to
take advantage of the technology, the
higher the probability that the poten-
tial benefits will be realized.
8. Ignore The Research That
Documents The Enormous
Difficulty For People To
Change And Just Assume That
Everyone Will Embrace This
New Technology.
Consider a recent study that showed
that despite the real possibility of
death if patients did not change their
lifestyle, fewer than 15% of heart

21. The Communiqué Fall 2009 Page 21
attack survivors were following their
doctor’s advice to adhere to a healthy
diet just one year after their heart
attack.ii
Even if things go perfectly,
few people embrace change.
9. Don’t Fill The Open Clerical
Position In Your Practice
Since You Are About To
Implement Your New Ais And
You’ll Surely Have Much Less
Need For These Positions Once
You Go Live.
Before, during and for months after
implementation you will have more
need than ever for administrative
support. This is also a critical time
to have stability in key positions.
President Abraham Lincoln believed
that his nomination as the Republican
candidate for his second term had not
come because he was the best man,
but rather because the party had con-
cluded that it would be best to “not
swap horses while crossing the river”
since they were in the middle of the
war. Good advice to remember.
10. Set Unrealistic Expectations.
No system will meet all your needs
and wants. Forget about your wants.
Prioritize your needs.
11. Be An Eternal Optimist And
Avoid Conflict.
It is imperative to confront the issues,
debate them, fix them, and move on.
Consider the Stockdale Paradox as
noted by famed author Jim Collins
in his landmark book Good to Great.
It’s named after Admiral James
Stockdale, who survived 7 years as a
POW during the Vietnam War. You
can listen to a brief audio on this on
Collins’s web site (http://www.jimcol-
lins.com/media_topics/brutal-facts.
html#audio=59), but the key quote
from the book is “You must never con-
fuse faith that you will prevail in the
end – which you can never afford to
lose – with the discipline to confront the
most brutal facts of your current reality,
whatever they might be.”iii
12. Worry That This Will Be
Bad For Billing Compliance,
Malpractice Claims, Or
Patient Care.
Billing compliance documentation
will be much better as long as your ac-
tions are compliant. Non-compliant
actions will be duly noted in the elec-
tronic system (e.g. If you note at 11:00
that you were present for induction
but induction actually occurs at 11:42
you will have a problem). So if you
do the right thing the documentation
proving that will be better than ever.
A survey published in Anesthesia &
Analgesia showed that departments
using an AIS for anesthesia record
keeping believed that these systems
were useful for managing malpractice
risk and did not increase malpractice
exposure.iv
A study at the University of Michigan
showed that the use of electron-
ic reminders improved procedure
documentation compliance and pro-
fessional fee reimbursement.v
Another
study at Massachusetts General
Hospital showed that real-time
checking of electronic records for doc-
umentation errors and automatically
text messaging clinicians greatly im-
proved the quality of documentation.vi
13. Underestimate The Value Of
An AIS.
An MGMA survey across all medical
practices reflected that after the first 6
to 24 months, the benefits of electron-
ic health record adoption generally
increasingly exceed the cost, and most
practices eventually wonder how they
ever conducted business without an
electronic record.� vii
Although anes-
thesia is certainly very different from
other specialties, similar results can be
expected.
So the good news is that eventually
you will have better documentation for
billing compliance. Eventually charge cap-
ture will be more accurate. Eventually the
billing cycle will be faster. Eventually mal-
practice risk will be reduced. Eventually
patient care will be better. Eventually
you’ll be telling stories to the residents and
SRNAs about life before the AIS imple-
mentation and how paper was used. They
will stare at you in disbelief.
i
MGMA Information Exchange – Electronic Health
Records, November 2006.
ii
University of Massachusetts Medical School (2008,
February 1). Patients Diagnosed with Coronary
Heart Disease Continue Poor Diets, Study Shows.
ScienceDaily. Retrieved August 28, 2009, from http://
www.sciencedaily.com
iii
Collins, Jim. Good to Great: Why Some Companies
Make the Leap…and Others Don’t. Harper Business;
Edition 1, October 16, 2001.
iv
Feldman JM. Do Anesthesia Information Systems
Increase Malpractice Exposure? Results of Survey.
Anesthesia & Analgesia. 2004; 99: 840-843.
v
Kheterpal S, Gupta R, Blum JM, Tremper KK,
O’Reilly M, Kazanjian PE. Electronic reminders im-
prove procedure documentation compliance and
professional fee reimbursement. Anesthesia &
Analgesia. 2007 March; 104(3):592-7.
vi
Sandberg WS, Sandberg EH, Seim AR, Anupama S,
Ehrenfeld JM, Spring SF,Walsh JL. Real-time checking
of electronic anesthesia records for documentation
errors and automatically text messaging clinicians
improves quality of documentation. Anesthesia &
Analgesia. 2008 January; 106(1): 192-201.
vii
MGMA Electronic Health Records: Perspective
from the Adopters, October 2007.
Phil Mesisca, MBA,
CMPE is the Chief
Operating Officer
for the Department
of Anesthesiology
& Critical Care and
the Department of
Otorhinolaryngology –
Head and Neck Surgery at the University
of Pennsylvania Health System in
Philadelphia. He can be reached at mesis-
cap@uphs.upenn.edu

22. The Communiqué Fall 2009 Page 22
Virtually all large anesthesiology
practices have a corporate website. Some
are quite detailed and complex. Fewer
medium and small practices maintain
a web presence. Should every practice
consider creating a practice website or
upgrading its current site?
After examining a number of
anesthesia practice websites, one can see
that most have common elements and
purposes. Before considering website
design, the practice should seriously
consider the purpose of the website and
its intended effects.
The reasons given by anesthesia
practices for expending the time and
money needed to produce an effective
website are to implement one or more of
the following:
1. Establish a “web presence”
2. Recruit anesthesia personnel via
the website
3. Provide patient information
4. Assist in the patient billing process
5. Schedule anesthesiologists via
surgeon preference
6. Internal uses such as maintaining
call schedules, document retrieval
and communications.
7. Marketing to patients, surgeons
and facilities seeking anesthesia
coverage.
Web Presence
Currently, almost every business
has a website, so anesthesiology practices
may believe that they too should
have one. However, many surgical
anesthesiology practices with exclusive
hospital contracts do not experience
competitive pressure and have not yet
seen the need for a web presence. Pain
management practices are more market-
driven and usually maintain a web site
that can help promote their services
to patients and referring physicians.
Although a web presence alone may not
be the motivating factor to establish a
website, practices should consider the
fact that most businesses are found
these days via internet searches. A
simple but well designed website may
be an alternative to a costly listing in the
business pages of the local telephone
book.
Recruiting
Some anesthesia practices
state that their website is mainly for
recruiting purposes. This is especially
true of practices that employ CRNAs
and experience difficulty with hiring
and turnover. A properly designed
and maintained web site can appear
at the top of search results that are
run by physicians or CRNAs seeking
employment in your area. Some
practices post jobs and allow resumes to
be submitted through their website. If
your local competitors are doing this and
you are not, you are at a disadvantage.
With proper search engine placement
and a long term strategy for recruitment,
the anesthesia website can reduce or
eliminate the need for outside recruiters
as well as for recruiting and advertising
fees.
Patient Medical Information
Many practices place extensive
patient education information on
their web site. This information may
be generic such as the description of
the types of anesthesia and anesthesia
complications. Specific information
Anesthesiology Practice Web Sites
Joe Laden
Anesthesia Associates of Louisville, PSC
Louisville, KY

23. The Communiqué Fall 2009 Page 23
such as the anesthesia group’s
preoperative testing requirements can be
available on the website. The ASA has
patient information on its website that
can be linked to.
Patient Billing
In addition to billing and collection
policies and procedures, some practices
have links to the practice’s billing
company. It may also be possible to
provide a mechanism for patients to view
and pay their bills on the practice web
site with credit cards and PayPal.
Anesthesia and Surgery
Scheduling
In some areas of the country,
anesthesiologists compete within hospitals
and are scheduled by surgeon preference.
A web presence and scheduling system are
vital to these practices.
Marketing
Beyond a simple “web presence”,
some anesthesiology groups market their
skills and experience to the community
and to prospective facilities in need
of anesthesiology services. To do this
the website could describe the group’s
accomplishments and special services
it delivers to the facilities at which it
operates. If the group is involved in
community activities and charities, these
can be promoted on the web site.
Practices with office-based pain
management divisions usually describe
these services on the website and provide
contact, location and hours of operation
information.
Internal Use
Some practices maintain a website
only for internal use and some include a
private section with password access on
their public website.
Internal uses include: call and
vacation schedules, posting of clinical
and business documents and internal
communications. Practices that use a
commercial web-based scheduling system
can post a link to their system here.
Hosting and Cost
A website can be hosted on your
corporate network or via a web hosting
service. Hosting should not cost more
than a few hundred dollars per year.
The cost of designing and implementing
a web site can range from zero for a
simple web page hand-coded by someone
in the practice to tens of thousands of
dollars for the elaborate web site of a
large anesthesiology practice.
Website Placement
If you want prospective employees
and local patients to find your website
by searching using Google, Bing, Yahoo
and other search engines, you need
to take some steps to assure that your
site will be retrieved high in the search
engine results lists. This is called Search
Engine Optimization and the techniques
to do this will be known by your website
designer.
Implementing Your Website
An anesthesiology practice will
most likely use a professional website
design company to product a website or
upgrade its current website. However,
before the website design work is
done, the practice manager and one or
more physicians should examine the
websites of many local and national
anesthesiology practices to obtain ideas
about the website elements the practice
would like to emulate.
Having a good idea as to the layout
and features of one’s website before the
implementation process starts can save
the practice time and money and make it
much more likely to produce an effective
result.
Continuing Relevance
After the anesthesiology website
is implemented, it should be updated
frequently with current information
Continued on page 24

24. The Communiqué Fall 2009 Page 24
about the practice. If you scan the web looking for anesthesia group web sites,
you will find ones that look like they have
not been updated in years. Someone in
your practice should be designated to
keep the website up-to-date. One way
to make your website look current is to
include frequently updated news items or
a patient information blog on the front
page.
Anesthesiology Practice Web Sites
Continued from page 23
Website Main Sections
Information about the Practice
History
Mission Statement
Group makeup
Message from group leader(s)
Services Provided: (e.g.: Surgical
Anesthesia, Ambulatory Anesthesia,
Chronic Pain, Acute Pain, OB
Anesthesia, Neuroanesthesia,
Cardiac Anesthesia, Critical Care
Anesthesia)
Special Services
Quality Assurance Program
Practice Divisions (OR, OB, Pain, Critical
Care, Office Based)
Facilities Covered
Description and pictures of facilities
Links to facilities
Location/Directions/Maps
Self-promotion & differentiation from
competing groups
Information about group in video format
Providers (MD,CRNA,AA)
Names of providers
Provider biographies/qualifications
Provider photographs
Links to articles and accomplishments of
group members
Patient Information
Medical Information
Description of types of anesthesia
OB anesthesia considerations
Fasting Guidelines
Preoperative testing
Pre-anesthesia questionnaire
Recruiting
CRNA opportunities
MD opportunities
Administrative positions
Ability to email or upload resume
City, state and community information
Links to area attractions, real estate and
schools
Administration/Billing
Billing Information
Insurance accepted
Billing policies and procedures
Link to billing company
Online Payments: Credit Card/PayPal
Support staff names and contact
Information
Private Access Sections
MD/CRNA Call Schedules
Vacation Schedules
Link to scheduling software
Internal Communication / Private Email
Link to group’s intranet
Access to Company Documents
Policies and Procedures
Medical Information
Links to anesthesiology clinical sites
Access to patient billing information
Access to Quality Management/Assurance
System
ASA’s Lifelineto
ModernMedicine.com
TheAmericanSocietyofAnesthesiologists
(ASA) recently launched a website, http://
www.LifelinetoModernMedicine.com to
help educate and inform patients and
the public at large. Among the important
tools on this site are the Anesthesia&Me©
checklist, a form to be filled out with
an individual’s medical history, current
medications, allergies and additional
items necessary for proper anesthesia
care. LifelinetoModernMedicine.com
also gives patients details about what to
expect before and after surgery from an
anesthesia perspective. In the September,
2009 issue of its Newsletter, ASA asked
all members to post a link to the new
website from their own websites and to
help spread the word by other means.
Joe Laden has served
as the Business
Manager for Anest-
hesia Associates of
Louisville, PSC since
1981. He has written
many articles about
anesthesia business topics and has made
presentations at MGMA, ASA and other
business conferences. To contact Joe with
any questions or comments about infor-
mation in article: joeladen@aalouisville.
com. More lists of academic and private
practice websites can be found at http://
sites.google.com/site/joeladen/Home
Private Practice
http://www.valleyanesth.com/
http://www.amg-group.com/
http://www.gasdocs.com/
http://www.wacmdpa.com/
http://www.northeasternanesthesia.com/
http://www.anesthesiapmc.com/
http://seanesthesiology.com
Pediatric
http://www.napdocs.com/
Academic
http://www.anes.ucla.edu/
http://anesthesia.duhs.duke.edu/
http://my.clevelandclinic.org/anesthesia/
default.aspx
Pain
http://www.michiganspineandpain.com/
Some examples of Good Anesthesia Practice Websites:

25. The Communiqué Fall 2009 Page 25
The Health Information Technology
for Economic and Clinical Health Act
(“HITECH Act”), included as part of the
American Recovery and Reinvestment
Act of 2009 (“ARRA”), significantly
alters and supplements provisions of
the Health Insurance Portability and
Accountability Act of 1996 (“HIPAA”)
protecting the privacy and security of
individuals’ protected health information
(“PHI”). Subtitle D of HITECH—
pertaining to patients’ privacy rights,
breach notification, and consequences
of breaching private information—
significantly expands the HIPAA privacy
and security provisions. This article will
summarize some key aspects of the privacy
and security portions of the HITECH Act.
Liabilities of Covered Entities
and Business Associates
In one of the most significant
expansions of HIPAA effectuated by the
HITECH Act, the HITECH Act expanded
certain requirements, which previously
only governed covered entities,1
to also
govern business associates of covered
entities.2
Specifically, Section 13401 of
the HITECH Act directly applied the
administrative, physical and technical
safeguard requirements of the HIPAA
Security Rule to business associates,
and mandated that business associates
maintain policies, procedures and
documentation of security practices. In
addition, pursuant to Section 13404 of the
HITECH Act, the privacy requirements
addressed by the HITECH Act (and
summarized in this article) are made
applicable not only to covered entities, but
also to their business associates.
Whereas HIPAA specifically
governed covered entities, and thus made
only covered entities liable for HIPAA
violations, both covered entities and
business associates are liable for HIPAA
violations based on the HIPAA amendments
in the HITECH Act. Prior to HITECH, it
was the covered entity’s responsibility to
ensure the business associate complied
with HIPAA standards. If a business
associate committed a HIPAA violation,
the consequence was termination of
the contract if the business associate
remained non-compliant. Now, if a
business associate is non-compliant,
then that business entity is subject to
consequences directly from the HHS,
including criminal and civil liabilities.
Required Notification for
Information Breaches
Effective September 23, 2009,
both covered entities and their business
associates will be liable for breaches of
a patient’s unsecured protected health
information.3
The HITECH Act requires
a covered entity or its business associate
to notify an individual of a breach of that
individual’s unsecured protected health
information within 60 days of discovering
the breach. When a breach involves
individual consumers, depending on the
number of individuals who are involved,
an individual notification or media
notification will be utilized. Notification
must also be made to the Department of
HHS immediately if the breach involves
500 or more individuals. If the breach
involves less than 500 individuals, the
provider can maintain such information
on a log, which must be provided annually
to HHS.
Guidance from HHS Surrounding
Breach Notification
On April 29, 2009, HHS published
additional guidance regarding the
HITECH Act’s requirements regarding
the breach notification requirements for
unsecured protected health information.4
Note that the breach notification
requirements apply only to unsecured
protected health information, which is
defined as protected health information
that is not unusable, unreadable
or indecipherable to unauthorized
individuals.
The additional guidance was
mandated by Section 1302 (h) (2)
1
A covered entity is defined as “(1) [a] health plan. (2)A health care clearinghouse. (3) A health care provider who transmits any health information in electronic form in connection
with a transaction covered by this subchapter.”
2
A business associate is “a person or organization, other than a member of a covered entity’s workforce, that performs certain functions or activities on behalf of, or provides certain
services to, a covered entity that involve the use or disclosure of individually identifiable health information. Business associate functions or activities on behalf of a covered entity
include claims processing, data analysis, utilization review and billing.” http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html
3
Unsecured protected health information is defined as “protected health information that is not secured through the use of a technology or methodology specified by the Secretary….”
HITECH § 13402(h)(1)(A).
Continued on page 26
HITECH in a High Tech Era
Abby Pendleton, Esq.
Jessica L. Gustafson, Esq.i
The Health Law Partners, P.C.
Southfield, MI

26. The Communiqué Fall 2009 Page 26
of the HITECH Act, which required
HHS to issue guidance “specifying the
technologies and methodologies that
render protected health information
unusable, unreadable, or indecipherable
to unauthorized individuals ….”
Although compliance with this guidance
is not mandatory, HHS emphasized that
following the guidance will serve as a safe
harbor, resulting in “covered entities and
business associates not being required
to provide the notification otherwise
required by section 13402 in the event of
a breach.”
On August 24, 2009, HHS published
an Interim Final Rule,5
which clarifies
guidance specifying technologies
and methodologies that render PHI
unusable, unreadable or indecipherable
to unauthorized individuals, and further
outlines new regulations governing
covered entities’ and business associates’
responsibilities under the HITECH
Act to provide notification to affected
individuals and to HHS following the
discovery of a breach of unsecured PHI.
The new regulations will be codified at
45 C.F.R. § 164.400 et seq.
The Stakes Are Raised –
Increased Enforcement
As noted above, the HITECH Act
contains provisions so that penalties that
apply to covered entities for violations of
HIPAA also apply to business associates.
Further, the HITECH Act revises and
expands current penalty provisions for
violations of health privacy and security
regulations. The HITECH Act contains
new provisions related to noncompliance
due to “willful neglect” and requires the
government to formally investigate any
complaint of a violation if a preliminary
investigation of the facts indicates a
possible violation due to willful neglect.
The HITECH Act also replaces the
current penalty of $100 per violation
with a new tiered-penalty system.
Of particular importance, the
HITECH Act also includes a provision
authorizing enforcement by State
Attorney General Offices if the attorney
general of a State has reason to believe
that an interest of one or more residents
of that State has been or is threatened
or adversely affected. In such cases, the
Attorney General can bring a civil action
on behalf of the state residents to enjoin
any continuing violation or to obtain
damages on behalf of the residents.
The court may also award costs and
reasonable attorney fees to the State. 6
Required Accounting
of Disclosures Involving
Electronic Health Records
As many providers are aware,
under HIPAA, covered entities are
not required to provide individuals
with an accounting of disclosures of
their protected health information if
the disclosure is related to treatment,
payment, or the health care operations
of the covered entity. Per the HITECH
Act, providers who use or maintain
electronic health records will be required
to account for disclosures related to
treatment, payment, or the health care
operations of the covered entity. In such
cases, the accounting period is limited
to three (3) years prior to the date on
which the accounting is requested. The
effective date for this new requirement
is dependent upon whether the provider
acquired an electronic health records
as of January 1, 2009 or after January
1, 2009. For users of electronic records
4
74 Fed. Reg. 19006 (April 17, 2009), available at http://edocket.access.gpo.gov/2009/pdf/E9-9512.pdf
5
74 Fed. Reg. 42740 (August 24, 2009), available at http://frwebgate6.access.gpo.gov/cgi-bin/PDFgate.cgi?WAISdocID
=282472267445+0+2+0&WAISaction=retrieve
6
Section 13410 of the HITECH Act.
HITECH in a High Tech Era
Continued from page 25

27. The Communiqué Fall 2009 Page 27
as of January 1, 2009, the HITECH Act
applies to disclosures made on and after
January 1, 2014. For users acquiring
electronic health records after January
1, 2009, the HITECH Act applies to
disclosures made on and after the later
of January 1, 2011 or the date the entities
acquires the electronic health record. 7
The Minimum Necessary Rule
With regard to non-treatment
situations, HIPAA requires providers to
only use the minimum amount of PHI
necessary to accomplish permitted tasks.
Section 13405 of the HITECH Act clarifies
that a covered entity will be seen as having
complied with this “minimum necessary”
standard if it limits the disclosed PHI to
the “limited data set.” The limited data
set excludes identifying information such
as names, addresses, telephone numbers,
social security numbers, etc. However,
if the limited data set is not sufficient,
the minimum necessary standard
applies. By August 2010, HHS will issue
guidance surrounding the definition of
minimum necessary. Until this guidance
is issued, the Act requires “in the case
of the disclosure of protected health
information, the covered entity or business
associate disclosing such information shall
determine what constitutes the minimum
necessary to accomplish the intended
purpose of such disclosure.”
Prohibitions on Sale of
Electronic Health Records
or PHI
Unless one of six (6) specified
exceptions apply, the HITECH Act
prohibits a covered entity or business
associate from directly or indirectly
receiving remuneration in exchange
for any protected health information,
unless the entity obtained a valid HIPAA
authorization that specifies whether the
protected health information can be
further exchanged for remuneration.
The exceptions to the general prohibition
include the following:
• The purpose of the exchange is for
public health activities;
• The purpose is for research and
the price charged reflects the costs
of preparation and transmittal of
the data for such purpose;
• The purpose is for treatment,
subject to additional protections
promulgated by regulation;
• The purpose is in connection with
the business operations of the
entity;
• The purpose of the exchange is
for remuneration that is provided
by a covered entity to a business
associate for activities involving
the exchange of protected health
information that the business
associate undertakes on behalf
of and at the specific request of
the covered entity pursuant to a
business associate agreement;
• The purpose of the exchange is to
provide an individual with a copy
of his or her own protected health
information.
HHS is authorized to develop
additional exceptions. Notably, the
effective date for this provision is
six (6) months after the date of the
promulgation of final regulations
(HHS is responsible for promulgating
regulations no later than 18 months after
the enactment date of the Act).8
Access to Information in
Electronic Format
The HITECH Act states that where
a covered entity uses or maintains an
electronic health record with respect
to protected health information, the
individual shall have a right to obtain
from the covered entity a copy of such
information in an electronic format.9
Conclusion
The HITECH Act significantly
alters and supplements provisions of
HIPAA protecting the privacy and
security of individual’s PHI. Providers
and their business associates are well
advised to familiarize themselves with
such requirements in order to remain
in compliance with the expanded
health information privacy and security
requirements.
i
The authors would like to thank Neda Mirafzali,
a 3L law student at Michigan State University Law
School and a law clerk currently working with The
Health Law Partners, P.C., for her contributions to
and assistance with this article.
7
Section 13405 (c) of the HITECH Act.
8
Section 13405 (d) of the HITECH Act.
9
Section 13405 (e) of the HITECH Act.
Abby Pendleton and Jessica L. Gustafson
are partners with the health care law firm
of The Health Law Partners, P.C. The firm
represents hospitals, physicians, and other
health care providers and suppliers with
respect to their health care legal needs.
Pendleton and Gustafson co-lead the firm’s
Recovery Audit Contractor (“RAC”) and
Medicare practice group, and specialize
in a number of areas, including: RAC,
Medicare, Medicaid and other payor audit
appeals, healthcare regulatory matters,
compliance matters, reimbursement and
contracting matters, transactional and
corporate matters, and licensing, staff
privilege and payor de-participation
matters. Pendleton and Gustafson also
regularly assist attorneys with their health
care legal needs. They can be reached at
(248) 996-8510 or apendleton@thehlp.
com and jgustafson@thehlp.com.
Abby Pendleton Jessica L. Gustafson

28. Professional Events
ANESTHESIA
BUSINESS CONSULTANTS
255 W. Michigan Ave.
P.O. Box 1123
Jackson, MI 49204
Phone: (800) 242-1131
Fax: (517) 787-0529
Web site: www.anesthesiallc.com
Date Event Location Contact Info
Oct. 17-21, 2009 ASA Annual Meeting Morial Convention Center,
New Orleans, LA
www.asahq.org
Oct. 11-14, 2009 MGMA Annual Conference Colorado Convention Center,
Denver, CO
www.mgma.com
Oct. 26-30, 2009 CSA Fall Hawaiian Seminar Grand Hyatt Kauai Resort & Spa,
Poipu Beach, Kauai
trowe@csahq.org
Nov. 6-8, 2009 Association of Anesthesiology Program
Directors/Society of Academic
Anesthesiology Chairs Annual Meeting
Boston Park Plaza,
Boston, MA
www.aapd-saac.org
Dec. 11-15, 2009 New York State Society of Anesthesiologists
Postgraduate Assembly in Anesthesiology
Marriott Marquis,
New York, NY
www.nyssa-pga.org
Jan. 17-22, 2010 Clinical Update in Anesthesiology,
Surgery and Perioperative Medicine
Paradise Island, Bahamas Helen.phillips@mountsinai.org
Jan. 18-22, 2010 CSA Winter Hawaiian Seminar Hyatt Regency Maui Resort & Spa,
Ka’anapali Beach, Maui
trowe@csahq.org
Jan. 29-31, 2010 ASA Conference on Practice Management Marriott Marquis,
Atlanta, GA
m.teister@asahq.org