Anesthesia management company Archives - Page 15 of 19 - Xenon Health

The electronic health record (EHR) is a longitudinal electronic record of patient health information collected in multiple care delivery settings and includes patient demographics, progress notes, vital signs, problems, medications, past medical history, immunizations, laboratory data, and radiology reports.^[1] The widespread adoption of EHR promises to streamline clinician workflow, provide a more comprehensive, accurate, and convenient overview of a patient’s health history, and allow rapid sharing of records between healthcare providers.^[2] In the 2012 Physician Sentiment Index, 81 percent of physicians believed that EHRs can improve access to clinical data and over two-thirds believed that EHRs could improve patient care.^[3]

One major benefit of EHR usage is that all clinicians involved in a patient’s care can exchange information in a secure manner, improving clinical workflow, hospital interactions, and patient outcomes.^[4] Cues in the EHR software may ensure that essential information is recorded and fewer mistakes are made, provide insight into quality measures and productivity, and increase staff and provider efficiency.^[5] Additionally, patients are able to access their own medical records and view their history, lab results, and medications at any time.

The Meaningful Use program was created by the U.S. government in 2009 as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act. It aims to promote nationwide adoption of EHR systems through a set of financial incentives and penalties. Healthcare providers that demonstrate meaningful use of EHRs, as defined by a set of criteria by the Centers of Medicare and Medicaid Services (CMS), are eligible to receive up to $44,000 through the Medicare Meaningful Use program or $63,750 through the respective Medicaid program. On the other hand, eligible providers who do not demonstrate meaningful use of EHR by 2015 will not receive 100 percent of their Medicare fee schedule.^[6]

There are three distinct stages to the Meaningful Use program which are designed to gradually increase EHR adoption over several years. Stage 1, Data Capture and Sharing, began in 2011 and required providers to establish proper standardized data capture, communicate information for care coordination, and engage patients and families using EHR. Providers were required to attest that they had met nine core objectives and one public health objective in order to receive their incentive payment. Stage 2, Advanced Clinical Processes, required providers to extend EHR to a larger segment of their patient population, increase the amount of patient-controlled data, and provide more rigorous health information exchange starting in 2014. The attestation requirements were the same in Stage Two as in Stage One. Stage Three, Improved Outcomes, intends to simplify the program, increase interoperability between EHRs, improve patient outcomes, and provide greater patient access to self-management tools. However, details of the objectives have not been finalized yet and providers are not required to begin Stage Three until 2018.^[7]

Providers must meet the standards issued by the Officer of the National Coordinator for Health Information Technology in order to receive Meaningful Use certification. They must demonstrate that their EHR system is secure, can maintain data privacy, and share information with other systems in order to qualify for a Medicare or Medicaid incentive payment.^[8]

According to CMS, only 422 anesthesiologists had received financial incentives as of June 19, 2012, less than 1 percent of physicians who identified their specialty as anesthesiology. Under CMS guidelines, anesthesiologists often fall under the category of “eligible professionals” rather than “hospital-based eligible professionals,” who are exempt from financial incentives and penalties. At least 90 percent of services must be performed within the inpatient setting for a physician to be deemed hospital-based, which excludes anesthesiology outpatient and office settings. Thus, many anesthesiologists faced pay reductions beginning in 2015.^[9]

Due to these concerns, CMS created a hardship exemption that would exempt anesthesiologists from payment penalties, recognizing the nature of the patient-anesthesiologist relationship, workflow challenges, and the state of current EHR technology for anesthesiologists. Anesthesiologists may still attempt to become meaningful users and receive incentives, as the hardship exemption only prevents them from being financially penalized.^[10]

The American Society of Anesthesiologists continues to advocate for additional flexibility for physicians who achieve a close percentage of all the Meaningful Use objectives and recommends excluding anesthesiologists from other requirements, including the clinical summary requirement, syndromic surveillance, e-communication with patients, and computerized order entry for transfers of care objectives.^[11]

^[1] http://www.himss.org/library/ehr/

^[2] http://www.athenahealth.com/knowledge-hub/ehr/emr-vs-ehr

^[3] http://www.athenahealth.com/knowledge-hub/ehr/advantages

^[4] http://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference/

^[5] http://www.athenahealth.com/knowledge-hub/ehr/benefits

^[6] http://www.athenahealth.com/knowledge-hub/meaningful-use/what-is-meaningful-use

^[7] http://www.athenahealth.com/knowledge-hub/meaningful-use/stages

^[8] http://www.athenahealth.com/knowledge-hub/meaningful-use/certification

^[9] http://monitor.pubs.asahq.org/article.aspx?articleid=2445240&resultclick=1

^[10] https://www.asahq.org/advocacy/federal-activities/regulatory-activity/electronic-health-record

^[11] https://www.asahq.org/advocacy/federal-activities/regulatory-activity/electronic-health-record

New research on the rare amino acid isovaline shows that it could act as an effective pain reliever with few side effects. Injecting mice with the amino acid inhibits the nervous system’s processing of pain, acting as both an ant nociceptive and an antiallodynic drug. In combination with propofol, isovaline could make procedural sedation significantly more effective and safe.

With potential applications such as these, one might wonder why isovaline’s properties have only recently been revealed. One reason is the amino acid’s unusual origin. Isovaline is extraterrestrial: it first appeared on Earth in 1969 when the Murchison meteorite crashed into Australia. The meteorite also contained common amino acids such as glycine and alanine.

Isovaline works as an analgesic because of its structural similarity to two neurotransmitters responsible for inhibiting pain in the central nervous system: glycine and GABA. These agonists reduce how much pain a person feels by fitting themselves into specially-shaped receptors. Chronic pain arises when there are not enough of these inhibitory agonists, and too many pain signals coming from free nerve endings or other sources. Isovaline can counteract this imbalance by acting as a substitute for glycine and GABA. By activating pain-inhibiting receptors, isovaline is an artificial substitute for the neurotransmitters.

In addition to its effectiveness as an analgesic, isovaline possesses the additional benefit of having no major side effects. Many drugs that relieve pain also cause confusion, sedation, respiratory depression, or addiction. Isovaline is a small molecule that does not cross the blood-brain barrier, and as such produces analgesia without a noticeable effect on the central nervous system. Mice injected with the amino acid both by IV and into the spinal theca experienced no alteration in their spontaneous activity, gait, posture, or respiratory rate.

A study just published in December of 2015 demonstrates isovaline’s potentially significant contribution to medicine as an adjuvant for propofol, the hypnotic agent that is increasingly used in procedural sedation. There is a pressing need to make propofol safer for patients. Sometimes the people who administer propofol are not trained in airway management. Lately the news has published stories about propofol-related respiratory complications, some of which have ended in death.

A mixture of propofol, which on its own causes hypnosis, and an analgesic like an opioid can result in general anesthesia. Under the power of these combined agents a patient both forgets what happened during the procedure and does not experience pain. The combination of opioid and propofol is effective but can lead to respiratory depression relatively easily.

This is where isovaline comes in. As a non-sedating analgesic, isovaline potentially provides the pain-relief of an opioid without the danger of respiratory complications. The recent study shows that isovaline combined with propofol can yield effective general anesthesia: hypnosis, analgesia, and conscious sedation.

If isovaline turned out to be a viable drug for human use, many patients may benefit. Patients would recover from general anesthesia more quickly and experience fewer adverse effects, reducing their health care costs. Medical centers would benefit from the increase in patient and staff satisfaction. And most importantly, the number of sedation-related deaths and complications could potentially be diminished.

References:
http://www.ncbi.nlm.nih.gov/pubmed/20357156

http://www.sciencedirect.com/science/article/pii/S030645221200382X

http://www.ncbi.nlm.nih.gov/pubmed/21906050

http://www.ncbi.nlm.nih.gov/pubmed/21906050

http://www.houstonpress.com/news/going-under-what-can-happen-if-your-anesthesiologist-leaves-the-room-during-an-operation-7842230

http://www.ncbi.nlm.nih.gov/pubmed/26579656

To meet the growing demands of anesthesia practices, there are currently four possible types of anesthesia administration teams, consisting of various arrangements of anesthesiologists, Certified Registered Nurse Anesthetists (CRNAs), and other anesthesia care practitioners. These are the all-physician model, the all-CRNA model, the physician/CRNA model, and the anesthesia care team model. The anesthesia care team model, made up of any combination of non-physician anesthesia providers performing under the guidance of a qualified anesthesiologist, creates a highly supervised and organized environment in a busy surgical facility.

Under the care team model, the anesthesiologist retains virtually all responsibility for a patient, but may delegate tasks to other providers to increase efficiency and improve care. These other team members may include CRNAs, anesthesiologist assistants (AAs), and CRNA or AA students. Anesthesiology fellows or residents may also be part of the care team, operating under the supervision of the lead anesthesiologist.

While the make-up of the team may resemble that of the physician/CRNA model, the responsibilities and specific roles of individuals differ significantly. Although CRNAs who are members of the care team may administer the anesthetic themselves, the anesthesiologist is responsible for prescribing a safe and high quality anesthetic plan and discussing it with the patient. Depending on the procedure and patient’s medical condition, the anesthesiologist may delegate certain anesthetic monitoring tasks to other members of the team, while remaining available for intervention in emergency situations. Non-physician personnel also contribute to collection and documentation of patient data in pre and post-operative evaluations, however the anesthesiologist makes the final decisions regarding the patient’s treatment plan or progress. Through this model, routine post-operative care is usually delegated to post-anesthesia nurses. More detailed information on the organization of the care team, as well as policies set forth by the American Society of Anesthesiologists (ASA) can be found on the ASA website.

The anesthesia care team model has been implemented by many hospitals to increase efficiency and cut down costs. It is less expensive than the all-physician approach and allows anesthesiologists to be available for patient evaluations, consultations, and other essential aspects of patient care. Of course, conflicts may sometimes arise, specifically in determining the roles and responsibilities of anesthesiologists and non-physician practitioners working in the same environment. A study conducted in 2009 by Terri S. Jones et al. found that the main causes of conflict between professionals operating under the care team model were a lack of clarity in role expectations as well as a narrow scope of practice for non-physician providers.

Nevertheless, the anesthesia care team model, with its many benefits, remains highly utilized among surgical centers in the U.S. As detailed in a statement from the American Academy of Anesthesiologist Assistants (AAAA), such a system allows all personnel to work together to focus on providing the highest quality of anesthesia care to patients and in ensuring their safety. Furthermore, as noted in the Jones et al. study, collaboration between anesthesiologists and other anesthesia care providers is maximized through this model, often leading to higher patient satisfaction and an increased number of positive surgical outcomes.

References:

“ASA Statement on the Anesthesia Care Team”: https://www.asahq.org/advocacy/state-activities/core-issues/anesthesiologist-assistants

http://www.beckersasc.com/anesthesia/ins-and-outs-of-4-asc-anesthesia-provider-models.html

https://www.asahq.org/lifeline/who%20is%20an%20anesthesiologist/anesthesia%20care%20team

https://www.aana.com/newsandjournal/Documents/crnacollaboration_1209_p431-436.pdf

https://aaaa.memberclicks.net/assets/docs/position%20statement%20-%20anesthesia%20care%20team.pdf

http://www.aana.com/advocacy/stategovernmentaffairs/Pages/Fact-Sheet-Concerning-State-Opt-Outs.aspx

http://crto.on.ca/pdf/Misc/Anesthesia_Care_Team_Ontario.pdf

With the role of anesthesia becoming ever more crucial to hospital treatments around the globe, ensuring the quality of the anesthetic treatment itself becomes an issue that all healthcare providers must consider in their practices. The Anesthesia Quality Institute (AQI) plays a large role in that capacity, as it manages the National Anesthesia Clinical Outcomes Registry (NACOR), which monitors anesthesia providers that have registered with the AQI, and provides feedback for improvement based on quality gaps that have been identified through performance results and other types of qualitative and quantitative data.

The NACOR is a registered Qualified Clinical Data Registry (QCDR), a designation given from the Centers for Medicaid and Medicare Services (CMS) that indicates that the database relies on a certain reporting mechanism to submit quality reports from qualified healthcare professionals. In 2008, the American Society of Anesthesiologists (ASA) funded the AQI to begin development of the NACOR, to address the lack of a national perspective and the lack of information on procedures that required anesthetics. The AQI began operations in 2009, and the NACOR was then approved and recognized as a QCDR database in 2014, where it was the first anesthesia registry to receive this recognition from CMS.

The NACOR presents a unique solution to the lack of comprehensive information on anesthesiology. The design of the registry itself was aimed to be adaptable for the evolution of healthcare with the development of technology. While most traditional registries for medical records rely on written reports from professionals in the field, NACOR solely collects data electronically, with information directly from anesthesia providers and other healthcare facilities to its database. This information requires a minimum of at least 20 fields of quality measurements, however, the most comprehensive files in NACOR include thousands of data points—including the patient’s vital signs, medication doses, and procedure notes.

The growth of the NACOR and its diversity in reporting anesthesia groups has been rapid. As of 2014, NACOR represented 2534 facilities, ranging from pain clinics to university hospitals and surgery centers. Approximately 317 different anesthesia groups managed these 2534 facilities, 268 of which provided descriptive information on their practices through the NACOR survey. The NACOR provides for a higher level of communication between the AQI, the individual practices, and those involved in the information technology of anesthesia. With the constant flow of information, the AQI can perform a number of tasks, including contracting “with individual practices and hospitals to exchange data” (1). Similarly, the individual practices can use this reported data to “meet various local, state, and federal regulatory requirements”, as well as increase the overall level of quality of their treatments based on the quality measures structured (1).

The NACOR now contains over 16 million records that provide critical information to healthcare providers all over the nation, including information on various types of procedures from different types of facilities. The AQI now hopes to develop a new model for the NACOR that provides a more universal reporting of data, with even more integration of electronic data and expert designed quality metrics. However, the data that is currently provided still serves as a way for anesthesia providers and facilities to identify and fill any quality gaps in their treatments, providing for a more streamlined and patient care oriented experience.

Sites Referenced:

1. https://www.aqihq.org

2. https://www.aqihq.org/introduction-to-nacor.aspx

3. https://www.aqihq.org/qcdr

4. http://repository.edm-forum.org/cgi/viewcontent.cgi?article=1070&context=egems

Anesthesiologist Assistants, or AAs, have played an instrumental role within anesthesia care teams since the creation of the profession in 1969. An Anesthesiologist Assistant is a highly skilled health care professional qualified to provide anesthetic care to patients under the direction of an anesthesiologist, who retains responsibility for prescribing and directing specific treatments in the operating room or intensive care unit. The occupation emerged in order to address the needs of increasingly complex anesthesia practices throughout the 1960s. The American Academy of Anesthesiologist Assistants (AAAA) was subsequently founded in 1975 with the aim of further advancing the profession.

Anesthesiologist Assistants are trained in post baccalaureate programs 24 to 27 months in length following a premedical undergraduate education complete with the necessary science courses. There are currently ten accredited AA certifying programs in the United States at various universities. The National Commission for Certification of Anesthesiologist Assistants (NCCAA) is the organization responsible for the certification process. By contracting with the National Board of Medical Examiners, the NCCAA provides the initial certification examination for graduates of the post baccalaureate program as well as interval examinations to periodically demonstrate qualification throughout their career.

Though specific responsibilities of an Anesthesiologist Assistant may vary depending on state regulations, the hospital environment, or the directing anesthesiologist, AAs generally perform tasks supplementary to those of the anesthesiologist. They are skilled in modern anesthesia monitoring, data gathering, and various therapeutic plans and treatments. Specific tasks may include conducting pre-operative assessments, recording patient progress, and assisting in post-operative rounds. AAs are usually part of comprehensive anesthesia care teams in larger facilities that frequently perform complex operations. Their skills are often crucial to procedures in life-threatening situations such as cardiopulmonary resuscitation. AAs may also hold leadership roles that include training personnel in patient monitor use and management of anesthesia equipment. A full list of typical AA responsibilities can be found on the Commission on Accreditation of Allied Health Education Programs (CAAHEP) website.

Although Anesthesiologist Assistants and Physician Assistants (PAs) hold similar roles as physician extenders, their functions differ due to a separate educational curriculum and certification process. Additionally, while PAs may practice under the supervision of any qualified physician in a number of different fields, Anesthesiologist Assistants are specialized in anesthesia management and administration. However, some AAs choose to obtain dual certification as Physician Assistants and extend their practice to other specialties.

The American Society of Anesthesiologists (ASA) has always strongly advocated for the Anesthesiologist Assistant occupation since its emergence forty years ago, recognizing its contribution to the anesthesia care team. The ASA participates in the training and certification of AAs and supports the expansion of the profession. The American College of Surgeons (ACS) has also recently demonstrated its support in letters to state legislatures on the topic of AA licensing measures. Currently, AAs are authorized to practice in seventeen states and the District of Columbia, as well as all Veterans Affairs hospitals under the TRICARE insurance program. Indiana is the most recent state to recognize the Anesthesiologist Assistant as a medical professional, passing the necessary legislature in 2014. With cooperation and advocacy from the AAAA, ASA, ACS, as well as other health care professionals, the profession is expected to grow significantly in the upcoming years.

References:

http://www.aa-nccaa.org/content/about-nccaa

http://www.caahep.org/documents/ForProgramDirectors/AA_Standards.pdf

http://www.anesthetist.org/faqs#AAsandPAs

http://www.caahep.org/Content.aspx?ID=20

https://aaaa.memberclicks.net/assets/the%20aa%20profession%20overview%20final%20fact%20sheet%20092414.pdf

http://bulletin.facs.org/2013/07/who-is-behind-the-surgical-drape/