Like all medical records, anesthesia records are destined to transition to an electronic format. “This change will be necessary both to coexist with other systems and to claim the inherent benefits of going paperless,” says Johns. The accuracy and com-
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pleteness of patient records can contribute to the clinician’s ability to optimize care. Paperless records are also important in optimizing pay-for-performance (P4P) initiatives.
Since 2006, Piedmont Hospital’s anesthesia group has used Merge Healthcare’s AIMS solution. Pied- mont is a 450-bed facility with 30 operating rooms. “Our experience has shown that the move to this electronic record has not only brought value in short- term ROI, but has also allowed the hospital to improve both the quality and cost effectiveness of care over the long term,” Johns says.
Enabling P4P documentation at the point of care
Electronic records are natural tools to aid in the capture of pay-for-performance revenue such as DRG (diagnosis-related group) reimbursement, payer re- imbursement for complications and co-morbidities (CC) and SCIP (surgical care improvement project) compliance and measures. These initiatives are data driven. Thus, they rely on information being accu- rately captured at the point of care, with reminders being presented to clinicians at the appropriate time and outcomes being made easily accessible for billing, reporting and review.
An AIMS improves providers’ capacity to comply with these initiatives by enabling accuracy and speed with documentation. “An unobtrusive system can al- low the clinician to care for the patient with complete focus, confident in the knowledge that the system and its reminders will be there when the time is right,” says Johns.
In order to accomplish this, the AIMS must be flexible enough to provide reminders that support hospital-specific initiatives as well as emerging na- tional standards (e.g., Medicare/Medicaid, The Joint Commission).
Piedmont Hospital uses its AIMS to track antibiotic administration at the point of care. For several years, the AIMS has reminded Piedmont’s anesthesia staff to document the location, time and type of antibiotic given. Clinicians select onscreen reminders to directly document this important clinical data. In addition, the AIMS provides automatic reminders to document antibiotic re-dosing at the appropriate time. Re-dosing is an important step in the prevention of surgical in-
fections, and accurate documentation feeds outcome analysis for further improvements.
Electronically aggregating this type of data elimi- nates manual, retrospective data analysis and enables compliance tracking for outcome analysis. “Moreover, the data is more reliable than paper-based data be- cause clinicians are reminded to [document], and have the tools to document at hand,” Johns says. These reminders ensure that clinicians are com- pleting the documentation necessary for SCIP. SCIP data accuracy and compliance impacts reimbursement from many major payers. Piedmont’s AIMS includes tools to track SCIP compliance and identify where improvements can be made to maximize reimburse- ment.
Even if it were fi nancially possible to hire enough staff to aggregate data from hundreds, if not thousands, of paper records, manual data capture will never be as reliable as electronic data.
Dollars saved; safety enforced
Using customized reminders as described above for antibiotics, Piedmont estimated that its AIMS helped capture between $280,000 and $699,000 through improved documentation practices in a single year. The same documentation practices also accounted for an estimated increase in pharmacy charge capture between $340,000 and $680,000. These estimates are a percentage of the overall improvement that year, Johns explains, because the AIMS was only one part of the hospital’s practice changes and improvement initiatives.
This same workflow can be valuable for patient
safety. “Our AIMS on-screen record is designed to present the most important information at every point during patient care,” says Johns, adding that any necessary and incomplete documentation, such as patient allergies, is highlighted, thus prompting the appropriate clinicians to complete it. “In the intense and time-constrained perioperative environment, a system becomes invaluable when it proactively pro- vides reminders and makes important data accessible at a glance,” he says.
Increasing OR throughput and utilization with real-time data
An AIMS not only makes information more ac- cessible to individual anesthesia care providers, but
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