Anesthesia information management systems: Workflow engineering and return on investment

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<ul><li><p>A nt Sn Inper, P</p><p>Fsue</p><p>an</p><p>intriesafgivsou</p><p>are</p><p>an</p><p>sysma</p><p>issystimforrieinfwi</p><p>infdifeffincknlismu</p><p>proreflofitivno</p><p>trolenchwo</p><p>witoto the business process analysis and adjustment.Thtroeffins</p><p>temthesom</p><p>poforinfaccar</p><p>are</p><p>pe</p><p>ma</p><p>me</p><p>ou</p><p>gemu</p><p>co</p><p>putiovitan</p><p>tie</p><p>theser</p><p>av</p><p>co</p><p>co</p><p>becapate</p><p>FMicTec</p><p>AparCenter, 1500 E. Medical Center Drive, Ann Arbor, Michigan48109-0048; E-mail: oreilly@umich.edu</p><p>Semerefore, the benefits of implementing an elec-nic perioperative process will depend on theectiveness and efficiency (or lack thereof) of antitutions current paper-based systems.</p><p>* http://www.asahq.org/Newsletters/2002/6_02/subnews_602.htm. 2004 Elsevier Inc. All rights reserved.0277-0326/04/2302-0011$30.00/0doi:10.1053/j.sane.2004.01.005</p><p>151inars in Anesthesia, Perioperative Medicine and Pain, Vol 23, No 2 (June), 2004: pp 151-157nesthesia Information Managemeand Return o</p><p>Michael OReilly, MD, MS, Kevin K. Trem</p><p>ollowing its annual meeting in 2001, the An-esthesia Patient Safety Foundation (APSF) is-</p><p>d the following statement: The APSF endorsesd advocates the use of automated record-keepingthe perioperative period and the subsequent re-val and analysis of these data to improve patientety.* This proclamation notwithstanding,en the competition for scarce healthcare re-rces, keen analysis and persuasive argumentsrequired to advance a project for the acquisition</p><p>d implementation of perioperative informationtems. Return on investment data are central forking those arguments. The purpose of this paperto make the case that an anesthesia informationtem is worth the considerable investment ine, energy, and money and to present a proma financial analysis. Where appropriate, expe-nce from the implementation of an anesthesiaormation system at the University of Michiganll be included.Determining a return on investment (ROI) for anormation technology (IT) project is notoriouslyficult.1 Traditional ROI analyses measure theects of IT on decreased operational costs andreased revenue. However, to the best of ourowledge, such an analysis has not been pub-hed for anesthesia information systems. Sincech of the benefit of IT relates to improvedductivity, a cost and revenue analysis may notect the whole picture with respect to the valueimplementing an information system.2 Intu-ely, it is apparent that paper-based systems are</p><p>t sustainable. However, the transition to elec-nic information systems is a complex and chal-ging endeavor. Much of the work involves</p><p>anging the way people do their jobs; that is,rk process reengineering. The required analysisll reveal benefits that may not be directly relatedthe implementation of an information system butystems: Workflow Engineeringvestment</p><p>hD, MD, and Paul Baumgart, MBA</p><p>The ROI model for anesthesia information sys-s is further complicated by the fact that some ofbenefits will be to the anesthesiologist ande to the institution. But perhaps the most im-</p><p>rtant aspect of implementing an anesthesia in-mation system relates to the intangible benefits;particular, increased patient and provider satis-tion and improved patient safety and quality ofe. Although these are difficult to quantify, theybecoming increasingly important as the com-</p><p>tition for patients and nursing staff increases.The argument for implementation of an infor-tion system can be summed up as if you cantasure it you cant manage it. Everyone knowsr paper systems are inefficient at best and dan-rous at worst. However, more specific benefitsst be described, and if possible quantified, to</p><p>nstruct a business case to advance a project torchase and implement a perioperative informa-n management system. More importantly, it isal to determine the scope of a project and toticipate taking advantage of various opportuni-s that may not be readily apparent.Information systems improve efficiency becausey capture pertinent information at the point ofvice and leverage data already collected orailable from other information systems. That is,mplete and accurate clinical documentation,mbined with other digital data, will drive a num-r of downstream processes. For example, chargeture and quality assurance data can be gener-d as reports from the database. In addition,</p><p>rom the University of Michigan Health System, Ann Arbor,higan, and General Electric Medical Systems Informationhnology.ddress reprint requests to Michael OReilly, MS, MD, De-tment of Anesthesiology, University of Michigan Medical</p></li><li><p>information is collected once and then reconfirmedby others as the data are carried forward during thecar</p><p>besev</p><p>yocu</p><p>askan</p><p>T</p><p>ofcietraopgiseffireqtheeffico</p><p>thema</p><p>sysingpreroo</p><p>tesheces</p><p>icasur</p><p>can</p><p>or</p><p>sca</p><p>patheen</p><p>forcar</p><p>latcan</p><p>tut</p><p>Electronic Advanced Testing DocumentationEnhances Workflow</p><p>advaggingclupoperele(PAme</p><p>thewitodo</p><p>fasres</p><p>ers</p><p>ers</p><p>idetiowiUntiowa</p><p>clitesne</p><p>we</p><p>diftosysthewa</p><p>(W</p><p>dehoon</p><p>thethestaera</p><p>sur</p><p>we</p><p>forspeiss</p><p>152 OREILLY, TREMPER, AND BAUMGARTe process. For example, allergy information canconfirmed; it is better to say, I see you had aere reaction after taking penicillin versus Do</p><p>u have any allergies to medications? In ourrrent paper-based system, the patient may beed this question five times between admitting</p><p>d discharge from the hospital.</p><p>ACTICAL EXECUTION: MOVING PATIENTSTHROUGH THE SYSTEM</p><p>The operating room is a very important sourcerevenue for most hospitals. Increasing the effi-ncy and utilization of the operating room hasditionally been driven by the data available fromerating room scheduling systems. Anesthesiolo-ts and hospitals have vested interests in thecient execution of the OR schedule, and bothuire documentation of sentinel time stamps inperioperative process. This mutual interest in</p><p>ciency and documentation is evidenced by thenvergence of OR scheduling systems and anes-sia documentation systems. Perioperative infor-tion systems help move patients through thetem and therefore provide some ROI by ensur-the required documentation is completed and</p><p>sent at the point of care; i.e., in the holdingm prior to bringing the patient to the OR.</p><p>PATIENT ADVANCED TESTING</p><p>There are three ways an anesthesia advancedting and evaluation clinic can avoid delays andlp move patients through the perioperative pro-s efficiently: (1) by ensuring the patient is med-lly prepared or optimized for anesthesia andgery (and hence the case will not be delayed orcelled because of an unrecognized or untreatedevaluated co-morbidity); (2) collecting andnning the documents that are required for the</p><p>tient to get into the operating room, in particular,consent and surgical history and physical; (3)</p><p>suring the anesthesiologist who will be caringthe patient has all relevant data at the point of</p><p>e. The direct return on investment will be re-ed to the number of cases that are delayed orcelled and for what reason at a particular insti-</p><p>ion.The most significant impact of automating theanced testing process may relate to reducing theravation of those involved in the process. Collect-all existing relevant clinical documentation, in-</p><p>ding labs, consultant reports, and test results at theint of care, is a labor-intensive process in the pa--based world. Prior to the implementation of anctronic system in the Patient Advanced TestingT) Clinic at the University of Michigan, three</p><p>dical assistants were required to assemble all ofrelevant paper documents. Now, the clinic runs</p><p>th one medical assistant and their role has changedcommunicating with other clinics and scanningcuments into the database.Since the patients may move through the systemter than the paper, it is a challenge to make theults of the evaluation available to all stakehold-(nurses, surgeons, and anesthesia care provid-</p><p>). Providers may be in different locations and,ally, would like to have access to the informa-n at the same time. This cannot be accomplishedth efficiency in a paper-based system. At theiversity of Michigan, prior to the implementa-n of an electronic system, one person had tolk over to the Operating Room from the PATnic every day to deliver the paper advancedting forms. These were placed in a filing cabi-t. An audit revealed that 50% of the paper copiesre never retrieved. It was progressively moreficult to find the paper copies since they tendedaccumulate. Implementation of the electronictem was a workflow enhancement for the anes-siologist as well as the clerk whose job it was tolk over with the paper copies and file them.ho likes to file?)</p><p>When a patient is seen in advance, and it istermined they require further tests or evaluation,w do you ensure there is appropriate follow-upthese results by the ordering physician so thatevaluation is completed and reviewed prior tostart of surgery? In our electronic system, out-</p><p>nding issues are identified and the database gen-tes an alert three days prior to the date ofgery. The alert goes to the ordering physician asll as to the anesthesiologist who will be caringthe patient. Electronic notification continues atcified intervals until the flag on the pending</p><p>ue is cleared. This ensures the patient does not</p></li><li><p>show up in the holding room with unresolvedissues.</p><p>ma</p><p>misee</p><p>Motheeffigoscheffi</p><p>TheEva</p><p>24an</p><p>proproua</p><p>introallforlecilatioofprealsfining</p><p>car</p><p>eleser</p><p>Ca</p><p>toan</p><p>ve</p><p>car</p><p>thechCoele</p><p>in real time, the cases for which they are respon-sible. In addition, complete and accurate clinicaldomo</p><p>as</p><p>poco</p><p>widio</p><p>me</p><p>patovidchcliproFoingbe</p><p>W</p><p>topoateelean</p><p>me</p><p>temdocietratoan</p><p>ab</p><p>W</p><p>an</p><p>widocalaleen</p><p>fasme</p><p>increm</p><p>thecas</p><p>153ANESTHESIA INFORMATION SYSTEMSWith an automated system that includes clinicnagement, providers can immediately deter-ne which patients are in rooms and ready to ben as well as how many are in the waiting room.reover, time stamps are applied to each step inprocess and these data can be used to more</p><p>ciently manage the clinic in a manner analo-us to how time stamps generated by surgeryeduling systems are employed to enhance theciency and utilization of the operating room.</p><p>Business of Anesthesia Advanced Testing andluation</p><p>The anesthesia preop evaluation occurs withinhours of the patient going to the operating room</p><p>d is part of the anesthesia professional fee. Thefessional services for patients with complexblems who would benefit from advanced eval-</p><p>tion and testing, that are seen more than 24 hoursadvance of the procedure, are billable. An elec-nic system greatly enhances the ability to collectrequired elements to fulfill payor requirementsdocumentation. In addition, since the data col-</p><p>ted for the advanced testing evaluation are sim-r to those obtained for the preoperative evalua-n, an electronic system enhances the efficiencyhow that information is carried forward into theoperative documentation. An electronic systemo facilitates the requirement of providing thedings of the anesthesiologist back to the request-</p><p>surgeon, via automated email.</p><p>THE OPERATING ROOM: PROVIDINGANESTHESIA SERVICE</p><p>The operating room is where most anesthesiae is provided. There are a number of ways anctronic system provides a ROI for anesthesiavice and associated costs in the operating room.</p><p>pture of All Professional Fees</p><p>Concerns about concurrency may lead providersbe conservative regarding how they documentesthesia start and stop times. In addition, inad-rtent logging of times that reflect overlapping thee of cases can eliminate the ability to bill for all</p><p>cases. In most practices, the concurrencyecks are done after the fact by billing systems.ncurrency problems can be eliminated withctronic systems because they tell the provider,cumentation will identify and capture relevantdifiers such as field avoidance and positioning,well as special techniques such as induced hy-thermia and induced hypotension. In addition,mplete capture of all perioperative proceduresll be captured, such as transesophageal echocar-graphy and invasive monitoring line placement.</p><p>There may also be procedures, such as place-nt of arterial lines, central lines, epidurals, and</p><p>in blocks, that are performed but not billed dueinadvertent omission by the anesthesia care pro-er. Linking the clinical documentation to the</p><p>arge will solve this problem. Ensuring completenical documentation can be accomplished byviding alerts and reminders based on other data.</p><p>r example, if there is an arterial waveform trac-but no arterial line procedure note, an alert can</p><p>generated.</p><p>orkflow: Efficiency of the Billing Office</p><p>The professional fee reflects services providedthe patient; therefore, complete and accurate</p><p>int-of-care clinical documentation should gener-a bill with minimal human intervention. An</p><p>ctronic system should improve the efficiencyd productivity of the billing office. However, asntioned above, the impact of an electronic sys-</p><p>will depend on how well or poorly this is beingne with a paper-based system. Further efficien-s will be realized when systems are able tonsmit these data directly from the point of carethe payor, totally eliminating the billing officed significantly decreasing the accounts receiv-le.</p><p>orkflow: Charge Capture</p><p>The communication between the billing officed the anesthesiologist can be greatly simplifiedth an electronic system. Procedure and othercumentation that are not signed can automati-ly appear in a pending work cue. In addition,rts (email and paging) can be incorporated tosure documentation is completed in a timelyhion. For example, if the preoperative assess-nt documentation is not completed at the time ofision, a page may be sent to the care providerinding them to complete the documentation. Ifdocumentation is not completed at the end of ae, the alert can be sent to the supervisor.</p></li><li><p>Workflow: Clinical Care</p><p>Most surgery management systems provide pa-tietypop(Phthewe</p><p>theau</p><p>inpaWfundusatwa</p><p>atithecu</p><p>thetinpro</p><p>Co</p><p>temspeturcan</p><p>co</p><p>tantatgechchabco</p><p>sca</p><p>admo</p><p>Linproatlin</p><p>Lia</p><p>liatha</p><p>keeper that produces a complete, accurate, andlegible version of events may reduce liability. Howthiinsapthabroan</p><p>gorie</p><p>forcheqelichateabcas</p><p>dathe</p><p>domo</p><p>oloabdecapAnan</p><p>agtolikGiFloreipriua</p><p>ve</p><p>inteas</p><p>are</p><p>Agum</p><p>sho</p><p>154 OREILLY, TREMPER, AND BAUMGARTnt tracking functionality, analogous to airporte displays that provide the status of various</p><p>erating rooms, holding room slots, and PACUase I and Phase II) beds. These systems havepotential to significantly improve efficiency as</p><p>ll as to reduce the aggravation associated withentire perioperative process. Examples include:</p><p>tomated notification that the patient has arrivedthe holding room; the OR is ready for the nexttient; the patient is assigned to PACU slot X, etc.hile it is difficult to put a dollar value on thisctionality, it is likely to result in enhanced pro-</p><p>ctivity as well as enhanced provider and patientisfaction. The same systems can be linked to theiting room so families can follow the perioper-ve process, thus allaying anxiety and eliminating</p><p>many phone calls required to determine therrent location of the patient or the progress ofir procedure. Moreover, the data may be scru-ized to identify bottlenecks and to further im-ve the process and, ultimately, throughput.</p><p>st Per Case</p><p>One significant advantage of an electronic sys-is it provides the a...</p></li></ul>

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