In June 2015, the Department of Health and Human Services honored the Peri-Operative Surgical Home at Phoenix Indian Medical Center with the HHS Innovates Award for its prominent contribution to perioperative care. The award recognized the “Assessment and Planning (A&P)” process [1], which addresses the lack of coordination in perioperative care before, during and after surgical operations.

Perioperative surgical home (PSH) has been proposed as a solution to the underperforming, fragmented, costly perioperative care system. The American Society of Anesthesiologists defines PSH as “a patient-centered and physician-led multidisciplinary and team-based system of coordinated care that guides the patient throughout the entire surgical experience” [2]. It serves the needs of the older patient population in industrialized countries, who often  require extensive perioperative care. [3]

The PSH model aims to improve patient health and experience, and raise cost-effectiveness. The model stresses effective communication, shared decision-making, individualized assessment and perioperative care plan. The PSH model has been shown to significantly improve surgical outcomes in such areas as knee and hip arthroplasty, colonic surgery, and chronic obstructive pulmonary diseases (COPD) [4].

The PSH model is also highly cost-effective compared to current post-operative care.  PSH has been shown to reduce patients’ length of stay, admissions to skilled nursing facilities and costs of care in connection with knee arthroplasty. [5]

Anesthesiologists are the key players weaving together the various components of PSH.  Indeed, as one authority has stated, anesthesiology is perioperative medicine[6]. Although anesthesiology has long been viewed narrowly as a specialty focused on intraoperative processes, it can expand to become the leading specialty in PSH models; it has the potential to deliver significant results in reducing patient morbidity and mortality, and increasing patient satisfaction. [7]

With PSH models, patients and anesthesiologists can establish a trustworthy relationship at the time of admission to a surgical home. Instead of receiving disparate sedation from different anesthesiologists, patients can be looked after by a single provider. [8]

As a consequence, the field of anesthesiology is projected to evolve under the growing adoption of PSH models nationwide. Anesthesiologists may turn into “super-specialists” whose expertise and experience concentrate on fields related to adults, children, critical care, academic research, and pain medicine. [9]

Future anesthesiology education should also aim to integrate the role of the anesthesiologist in PSH models.  Anesthesiology‎ residents can face complex challenges such as patient mistrust, misunderstandings in consenting processes and the questioning of competence [10]. As adoption of PSH becomes more prevalent, more such challenges will arise. These can be preempted and addressed through medical education.

There are two types of challenges in moving towards PSH models: operational and fiscal. Hospitals may be reluctant to change surgical care teams to accommodate PSH models, and anesthesiologists may require additional training and guidance to take up leading roles in coordinating pre-, intra- and post-operative care. Moreover, the extra service provided by anesthesiologists may not be adequately reimbursed. Perhaps a bundle package compensation model may be more adequate than a fee-per-service one. [3, 8]

Though not a panacea, PSH-based models promise to significantly improve healthcare on a large scale. One such model has in fact been successfully implemented within the United Kingdom’s healthcare system.[11]

References:

1. HHS Idea Lab, Peri-Operative Surgical Home, http://www.hhs.gov/idealab/projects-item/peri-operative-surgical-home-posh/
2. Schweitzer M, Fahy B, Leib M, Rosenquist R, Merrick S. The Perioperative Surgical Home Model. ASA Newsl 2013;77: 58–9.
3. Holt NF. Trends in healthcare and the role of the anesthesiologist in the perioperative surgical home – the US perspective. Curr Opin Anaesthesiol. 2014 Jun;27(3):371-6,
4. Kash BA, Zhang Y, Cline KM, Menser T, TR Miller. The Perioperative Surgical Home (PSH): A Comprehensive Review of US and Non-US Studies Shows Predominantly Positive Quality and Cost Outcomes. Milbank Q. 2014 Dec;92(4):796-821.
5. Helwick C. Perioperative Surgical Home Lowers Costs, Optimizes Care. Anesthesiology News. 2014 Dec;40(12)
6. Rock P. The future of anesthesiology is perioperative medicine. Anesthesiol Clin North America. 2000 Sept;18(3): 495-513.
7. Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical Risk Factors, Morbidity, and Mortality in Elderly Patients. J Am Coll Surg. 2006 Dec;203(6):865-877.
8. Kain ZN, Vakharia S, Garson L et al. The Perioperative Surgical Home as a Future Perioperative Practice Model. Anesth Analg. 2014 May;118(5):1126-30.
9. Prielipp RC, Morell RC, Coursin DB et al. The Future of Anesthesiology: Should the Perioperative Surgical Home Redefine Us? Anesth Analg. 2015 May;120(5):1142-1148.
10. Bould MD, Naik VN, Hamstra SJ. Review article: New directions in medical education related to anesthesiology and perioperative medicine. Can J Anaesth. 2012 Feb;59(2):136-50.
11. Knott A, Pathak S, McGrath JS et al. Consensus views on implementation and measurement of enhanced recovery after surgery in England: Delphi study. BMJ Open 2012;2:e001878.

 

Twenty-one million people in the U.S. will receive general anesthesia in a typical year.  But the ability to artificially induce any of the defining components—analgesia (insensitivity to or prevention of pain), paralysis, amnesia, and sedation/unconsciousness—is relatively new. The word anesthesia itself only first appeared in the dictionary in 1751, and was first used to describe the mental state that follows from the inhalation of ether vapor by the prominent physician, Oliver Wendell Holmes, Sr.

Only 300 years ago, surgical pain relief options were limited to the consumption of alcohol or opium (to the point of stupor), or the powers of suggestion or “positive thinking”. Magnets and hypnosis, or ‘Mesmerism’ were used to cure various ailments. Around May 1812, the English novelist Fanny Burney wrote a compelling account of her experience undergoing a mastectomy without anesthesia:

“I saw the glitter of polished Steel – I closed my Eyes. I would not trust to convulsive fear the sight of the terrible incision. Yet – when the dreadful steel was plunged into the breast…I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittingly during the whole time of the incision – & I almost marvel that it rings not in my Ears still [?] so excruciating was the agony. When the wound was made, & the instrument was withdrawn, the pain seemed undiminished..I concluded the operation was over – Oh no! presently the terrible cutting was renewed – & worse than ever”

In contrast, the gratitude felt by the first mother to receive chloroform for the delivery is clearly expressed by the name she gave her baby—Anaesthesia.

 

Anesthesia Through the Ages

 At Xenon Health, anesthesia is our specialty.  But how did our field progress from the prescribing of a few shots of whiskey prior to surgery to the precise science of administering by gas, injection, and infusion drugs that act on different and overlapping sites in the central nervous system? This post reviews the landmark discoveries that led to the evolution of anesthesia over the centuries, and pays homage to the innovators that shaped the field.

400 BC

• Hippocrates recommends opium poppy use for pain-relief.

13th Century   

• Theodoric of Lucca, an Italian physician and bishop, induces unconsciousness prior to surgery by holding sponges soaked with opium, mandrake, and hemlock under patients’ noses.

• In 1275, the Spanish chemist Raymundus Lullius synthesizes ether, which would become the first reliable, general anesthetic—though this would not be recognized for almost 570 years.

 

16th Century  

• Ether is first used on animals by Paracelsus in 1525. Fifteen years later, Valerius Cordus repeats Lullius’ synthesis by distilling ethanol and sulfuric acid.
• In Malta, patients to be operated on were made unconscious with a wooden hammer.

 

17th Century  

• Opium is first administered intravenously.

 

18th Century  

• In 1745, the French explorer Charles-Marie de La Condamine publishes the first written account of curare, a paralytic poison derived from a plant that he observes is used on arrows by South American tribes to kill their prey. Note: This property will become important in 200 years as future anesthesia techniques will require the control of muscle relaxation.

• Nitrous oxide (NO), commonly known as laughing gas, is isolated by Joseph Priestley in 1772. This substance became a heavily researched topic, with Dutch chemist Martinus van Marum publishing 35 papers on his studies and the nitrous oxide experiments performed during the last years of the century by Thomas Beddoes and Humphry Davy demonstrating the gas could be inhaled with analgesic effects.

• The engineer James Watt makes two related inventions—a machine to produce NO and a “breathing apparatus” to inhale the gas.

• In 1778, Antoine Lavoisier discovers oxygen (O2).

 

19th Century  

• In 1805, morphine is discovered by Friedrich Serturner, who names it after the Greek god of dreams, Morpheus. It becomes the first product launched by Merck in 1827.

• Chloroform is simultaneously discovered in 1831 by scientists in three countries. Although frequently used for about 50 years after it is discovered to have anesthetic properties in 1847, a concern about fatalities emerged just 2 months after it is introduced. It was later found to cause death from paralysis of the heart in about 1/3000 patients (and also to be toxic to the liver and to depress most other organs) and by 1940, was replaced by safer alternatives.

• General anesthesia is officially born in 1842, with William E. Clarke administering ether from a towel to a patient about to undergo a tooth removal. Its first documented use as a gas for surgical pain relief is by Crawford W. Long, but since he waited to publish this until 1849, the credit was instead attributed to a Boston dentist, William Morton. A leg amputation and a lower jaw removal followed. Results are first presented to the medical community at the meeting of the Boston Society for Medical Improvements on November 9, 1846. Two days later, patent No. 4848 granted to Morton and his mentor, Charles Jackson, 10% of all profits from the surgical use of ether. This is met with swift opposition from the medical community and is not enforced.

• In 1853, the discovery of the hypodermic needle, the syringe, and the injection of morphine are innovations made possible by Alexander Wood. He invents a hollow needle that fits on the end of a piston-style syringe and uses the device to successfully treat pain by morphine injection. Note: Today, the majority of anesthetic drugs are delivered intravenously—which would not be possible without the invention of the syringe.

• Local anesthesia, in which pain is only blocked in specific locations, comes onto the scene in 1884 with the discovery of injectable cocaine. The renowned Baltimore surgeon William Halsted first injected 4% cocaine into a patient’s forearm and observed that the arm became numb only below the injection site.

• The first spinal anesthesia is also performed that year in Germany when Leonard Corning injects cocaine between the vertebrae of a 45-year-old man and causes the patient’s legs and lower abdomen to become numb. Note: Synthetic drugs will replace cocaine in the next century, with the discovery of Procaine (Novocain) and Lidocaine in 1905 and 1948, respectively.

• In 1891, the German physician Heinrich Quincke introduces the technique of lumbar puncture—later used to administer medications directly into the cerebrospinal fluid (CSF) during spinal anesthesia.

• The blood pressure cuff is introduced by Scipione Riva-Rocci in 1896.

 

20th Century  

Once a patient is anesthetized, there is a critical need to closely monitor the body’s vital signs—pulse, respiratory rate, blood pressure, temperature, and oxygen saturation. This century heralded improvements in patient monitoring techniques, and a wider selection of synthetic anesthesia agents.

• The electrocardiogram is developed in Holland by Willem Einthoven in 1903.

• In 1905, a Russian physician describes the sounds—now bearing his name, “Korotkoff sounds”—heard through a stethoscope placed over a peripheral artery as a blood pressure cuff is deflated. This allows the systolic and diastolic components of blood pressure (BP) to be determined. This measurement gives the anesthesiologist important information during a procedure; a low BP may indicate anesthetic overdose, hemorrhage, or heart dysfunction, while a high BP may be evidence of patient distress due to inadequate anesthesia levels or uncontrolled hypertension.

• In 1913, endotracheal anesthesia is invented when Sir Ivan Magill develops a technique to place a breathing tube into the windpipe, and that same year Chevalier Jackson reports the ease with which using a laryngoscope allowed the insertion of an endotracheal tube.  This was a landmark both for the field of critical care medicine because of its impact on resuscitation, and surgery, as operations of the abdomen and chest would not be possible without the ability to protect and control the airway.

• The cuffed endotracheal tube, which allows positive-pressure ventilation (PPV) into a patient’s lungs, is discovered in 1928 by two University of Wisconsin physicians, Arthur Guedel and Ralph Waters.

• Dr John Lundy changes the standard of care for inducing general anesthesia when in 1934 he introduces the intravenous anesthetic, sodium thiopental. Compared to the pungency of inhaled ether, a Pentothal injection was more tolerable and became the chosen method for sedation.  Propofol, introduced in 1981, has since replaced Pentothal, but the delivery of anesthesia still almost always begins with the intravenous injection of some anesthetic drug.

• The American Society of Anesthesiologists is founded on Feb 13^th, 1936.

• The paralyzing effect of curare became important as muscle relaxation was a necessary step to allow the insertion of endotracheal tubes. This ancient arrow poison was first deliberately applied to surgery by the Canadian doctor Harold Griffith in 1940.

• World War II and the Korean War battlefield medical inventions include shock and resuscitation units used to save the critically ill and wounded. Post-Anesthesia Care Units (PACU’s) and Intensive Care Units (ICU’s) are developed as extensions of these.

• Inhalation anesthesia is forever changed, when in 1956, British chemist Charles Suckling synthesizes halothane. Unlike ether, halothane has a pleasant odor, high potency, fast onset, low toxicity, and is non-flammable. Halothane replaces older “vapors” and is the forerunner to the modern inhaled anesthetics that followed: isoflurane, desflurane, and sevoflurane.

• Stanford anesthesiologist Dr. William New develops the Nellcor, the first commercially available device to allow pulse oximetry monitoring Prior to this date, it was not possible to measure a patient’s oxygen saturation and the first sign of low oxygen levels was often a cardiac arrest. A unique feature is an alarm that lowers the pitch of the pulse tone as saturation drops, giving providers a warning that their patients are in danger of oxygen deprivation.

 

21st Century  

Today, modern anesthesiologists utilize dozens of medications and apply sophisticated high-tech medical equipment, requiring on average four years of training beyond medical school.  What will the next “advance” be?  New drugs, new delivery routes, and new delivery systems are the areas where research is focused. This includes:

• Transmucosal drug delivery—which can be nasal, buccal, ocular, rectal, and mucosal, and is similar to how a patch works, with the advantage that mucosal membranes are thinner and more highly vascularized so the onset of action is faster and the dose needed is lower.

• Intravenous anesthesia evolving towards a continuous drug infusion rather than an intermittent bolus approach. Related to this development is the optimization of Patient-Controlled Analgesia (PCA), a precision drug delivery technology enabled by an electronically controlled infusion pump which allows patients to self-administer (up to a prescribed threshold) until sufficient pain relief has been achieved. PCA has been found to result in less over-or under-dosing and more optimal drug delivery; patients also resume mobility more quickly and can be discharged sooner.

Interested in reading more on the topic? These are the sources referenced:

Anesthesia Fact Sheet. National Institute of General Medical Sciences Web site. http://www.nigms.nih.gov/education/pages/factsheet_anesthesia.aspx Updated May 2015 Accessed October 7, 2015.

Eger II EI, Saidman LJ, Westhorpe RN .The Wondrous Story of Anesthesia. New York, NY: Springer; 2014

Timeline of important dates and events in the development of anaesthesia History of Anaesthesia Society Web site. http://www.histansoc.org.uk/timeline.html Accessed October 7, 2015

The classification of causes of death was first developed in the 1800s[1]. Since then, the classification has been revised 10 times to reflect changes in the medical field. It now includes a list of causes of death and of diseases using a set of codes to allow physicians to provide a high level of detail regarding the injury and the patient encounter. This set of codes is now referred to as the International Classification of Diseases (ICD). In its 10^th revision (ICD-10), the code was implemented on October 1, 2015 in the U.S. health care system and replaced the 9^th revision (ICD-9). ICD-10 includes codes for Clinical Modification (ICD-10-CM) indicating medical diagnoses and a Procedure Coding System referred to as CD-10-PCS. The ICD-10 has more than 76,000 codes[2].

Transitioning from ICD-9 to ICD-10 allows physicians to provide more detailed information about the patient’s injury and about the clinical encounter[3]. For example, ICD-10 allows a provider to indicate which arm sustained an injury and, if the patient was seen subsequently, the code specifies which encounter was initial or subsequent. One disadvantage of the ICD-9 was that it did not allow this level of specificity. Additionally, some of the chapters were full and it was no longer possible to add new codes. Overall, use of the ICD-10’s seven digits will allow the health care system to expand the number of codes, and make it less likely to run out of codes in the future should new illnesses be diagnosed.

Regarding structure, the ICD-10-CM is composed of codes with three, four, five, six, or seven digits. The first three digits are headings that may be further subdivided by digits four to seven to provide more detail regarding the illness. The first digit is alpha, the second digit is numeric, digits 3-7 can be alpha or numeric, and there is a decimal after the third digit. The following examples provide sample ICD-10 codes: A78 for Q fever; A69.21 for Meningitis due to Lyme disease; or S52.131a for Displaced fracture of neck of right radius, initial encounter for closed fracture.

In the future, it will be important for anesthesiologists to master ICD-10 codes in order to improve their chances of being reimbursed for services[4]. This will, in turn, result in increased revenue, less paperwork and improved patient care. For this reason, anesthesiologists should take advantage of ICD-10 training opportunities, especially since many of these trainings are free and readily available online.

Anesthesiologists submitting Medicare claims should note that Medicare no longer accepts ICD-9 codes for services provided after September 30, 2015. Additionally, the system does not accept claims containing both ICD-9 and ICD-10 codes for a service.

Implementation of the ICD-10 system will still require anesthesiologists to report Current Procedural Terminology (CPT) codes for anesthesia and non-anesthesia procedures as many insurers link the CPT code to the diagnosis code to determine medical necessity. The CPT codes include five-digit procedure codes as well as modifier codes[5]. Modifiers are two digits that can either be alpha or numeric. They allow clarification of the services to be billed and do not change procedure codes. Advantages of modifiers include: providing more information by specifying, for example, the anatomical site; eliminating duplicate billing; allowing health care providers to charge for services separately rather than in a bundle; increasing accuracy in reimbursement; improving coding consistency; and enhancing the capture of payment data.

Modifiers that are specific to anesthesia include:

AA – Anesthesia Services performed personally by the anesthesiologist

AD – Medical Supervision by a physician; more than 4 concurrent anesthesia procedures;

G8 – Monitored anesthesia care (MAC) for deep complex, or markedly invasive surgical procedures;

G9 – Monitored anesthesia care for patient who has a history of severe cardiopulmonary condition

QK – Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals

QS – Monitored anesthesia care service

QX – Certified Registered Nurse Anesthetists (CRNA) service; with medical direction by a physician

QY – Medical direction of one certified registered nurse anesthetist by an anesthesiologist

QZ – CRNA service; without medical direction by a physician.

In sum, it is exciting that ICD-10 CM codes have replaced ICD-9 codes. This new system will allow anesthesiologists to report the diagnosis codes and indicate the need for the anesthesia services. To limit denial of claims or the need to resubmit claims that are rejected, anesthesiologists should report codes as accurately as possible.[6] As insurers can deny claims based on the use of diagnosis codes that are invalid, anesthesiologists should verify that patients are eligible for reimbursement and that the services claimed are covered.

[1] https://www.unitypoint.org/waterloo/filesimages/For%20Providers/ICD9-ICD10-Differences.pdf

[2] http://blog.cms.gov/2015/10/01/welcome-to-icd-10/

[3] https://www.unitypoint.org/waterloo/filesimages/For%20Providers/ICD9-ICD10-Differences.pdf

[4] http://www.anesthesiologynews.com/ViewArticle.aspx?ses=ogst&d_id=3&a_id=24050#sthash.rSPbkOkO.dpuf

[5] http://engage.ahima.org/HigherLogic/System/DownloadDocumentFile.ashx?DocumentFileKey=9af2a07d-26e1-4694-b1de-a4c59d0dbc30

[6] http://originhs.com/assets/resources/ICD-10_Anesthesia_Brochure.pdf

A key aspect of anesthesia management is the recruitment of anesthesiologists and certified registered nurse anesthetists. This process begins with identifying the staffing model and the number of anesthesia professionals needed for a surgical facility.  Staffing can be as straight forward as placing a single anesthesiologist or CRNA in an ambulatory surgical center one to two days per week or it can involve providing anesthesia coverage to an entire hospital system twenty four hours per day, 365 days per year.

Recruiting begins with identifying any requisite subspecialty experience. For instance, an ambulatory surgical center with orthopedic cases may prefer an anesthesia provider(s) with expertise in regional anesthesia. Anesthesiologists with sub-specialty training in pediatric anesthesia are preferred for pediatric cases, especially for complex surgeries that are performed in tertiary care hospitals or university-based children’s hospitals.

A search is initiated for board-certified anesthesiologists and/or CRNAs from the community local to the client facility. An anesthesia management company relies on an evolving network of anesthesiology professionals that it cultivates as it grows. If the geographic area is one where the management company has not provided services in the past, it can use one of several industry-specific job boards to post job ads or view curriculum vitaes. Anesthesia management companies frequently contract with staffing companies to assist in the recruiting process. Staffing companies also have an established network of healthcare professionals. They typically compensate the providers directly and invoice the management entity the amount they paid the provider(s) along with a mark-up or margin. This is referred to as a locum tenens arrangement and typically is a temporary staffing model. Staffing companies also engage in permanent placement arrangements where they charge a flat rate to the employer after which the employer is responsible for compensating the healthcare professional directly. It is in the financial interest of the management companies to recruit anesthesiologists and CRNAs directly. However, this may not always be feasible due to a variety of factors (i.e., limited network in a particular geographic area or time constraints.)

Another important facet of the recruitment process involves salary negotiations. This can become an involved process and is impacted by a variety of factors, such as the specific requirements of the position, on-call schedules, potential re-location costs, and the supply-demand ratio for anesthesia professionals for a specific geographic location.

Recruiting also involves finding “coverage” for anesthesia professionals when they take vacations and sick leave. Finding temporary coverage can be challenging for a variety of reasons especially if the coverage need arises suddenly. Anesthesia management companies typically strive to have a back-up panel of anesthesiologists and CRNAs to call upon in urgent coverage situations.

Haroon W. Chaudhry MD

Credentialing involves establishing the qualifications of licensed healthcare professionals and securing the appropriate and requisite documentation concerning their background, experience and licensure. The appropriate precautions are taken to ensure that the anesthesiologist or CRNA has a valid license to practice in the state where the provider will be working. In addition to licensure, the medical malpractice history of the candidate in question must be assessed. If the provider has a malpractice history, a careful assessment and analysis is made of that history. The circumstances and outcome are considered. In an ideal world, all anesthesiologists and CRNAs selected should have an exemplary practice history without any malpractice claims. However, this is not always the case. Some claims are legitimate claims by patients, some are frivolous and many are ancillary – the anesthesia provider is named in the suit but the claimed injury is not directly the result of the administration of anesthesia. The objective is to select an anesthesia provider with as few malpractice claims as possible (ideally none).

Reference checks are an essential step in the credentialing process to ensure that the anesthesiologist’s or CRNA’s qualifications are validated. One can get an assessment of the anesthesia professional’s technical skill as well as bedside manner by speaking to her fellow healthcare professionals.

Additionally, a comprehensive credentialing packet is sent to the anesthesia professional to complete. This has to be completed and shared with the surgical facility where the anesthesia provider will be rendering services. The components of the credentialing packet include:

–         State-specific license to practice

–         National license in the case of CRNAs

–         Board certifications

–         Graduate school or medical school diplomas

–         Proof of malpractice insurance

–         Continuing education certificates

–         Current ACLS certification

–         A self-query from the National Practitioner Data Bank

The National Practitioner Data Bank is a federal data bank created by the Medicare and Medicaid Patient and Program Protections Act of 1987. It was designed to collect and release information concerning the competence and conduct of physicians and other health care practitioners. The Health Insurance Portability and Accountability Act of 1996 resulted in the creation of the Healthcare Integrity and Protection Data Bank (HIPDB). It served as a system to alert users that a review of a provider’s or supplier’s history may be in order. In May of 2013, the NPDB and HIPDB were merged into one data base, the NPDB.

A background check and drug screening are mandatory elements of the credentialing process.

Once all the requisite documentation is collected, it is stored in a secured data base at corporate headquarters and transmitted through a secure mechanism to client facilities.

Maintenance of the files involves updating them periodically with current certifications and licensures as they are renewed and adding proof of continuing education credits as they are accumulated.

In addition to updating each client facility with current documentation pertinent to each credentialed provider, steps to ensure compliance with the credentialing requirements of individual accrediting bodies are taken. Surgical facilities usually choose one of several national accrediting organizations. These include the Accreditation Association of Ambulatory Health Care (AAAHC), the American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF) and the Joint Commission. Each organization has its own specific set of requirements for the credentialing of providers that must be met and maintained.

In summary, credentialing involves the documentation that an anesthesiologist or CRNA is qualified to render anesthesia services and patient care. That documentation needs to meet the requirements of federal and private accreditation bodies and must be appropriately maintained and updated.

Haroon W. Chaudhry MD