Anesthesia management Archives - Page 16 of 20 - Xenon Health

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/

The Physician Quality Reporting System (PQRS), established under the Tax Relief and Healthcare Act of 2006 by the Center for Medicare and Medicaid Services (CMS), was officially made permanent in 2008 under the Patients and Providers Act. The program was implemented in order to give health professionals a standardized way to report data on the quality of care provided to their Medicare patients.

The purpose of PQRS is to give eligible professionals, EPs, an efficient way of assessing the quality of the care provided to their patients and make sure an appropriate standard of care is being administered. The program allows EPs to quantify how often they meet various health standard metrics and serves as a comparison among peers in a particular field. Additionally, data gathered through PQRS is used to update Physician Compare, a website run by CMS to help patients find health care professionals enrolled in Medicare and make informed decisions in selecting providers. Currently, patients are able to use the website to compare group practices across various specialties. Tools to compare individual physicians and other health care professionals will be available in the future.

Up to this point, PQRS has been implemented through the use of payment initiatives. EPs who meet the necessary criteria receive payment equal to 0.5% of their total estimated Medicare Part B PFS allowed charges furnished during that same reporting period. The types of measures reported change from year to year and vary among specialties. Typically, the measures focus on four key areas: care coordination, patient safety and engagement, the clinical process and its effectiveness, and public health within the targeted population. Professionals have the option of reporting quality information through one of five methods: Medicare Part B claims, the qualified PQRS registry, the Direct Electronic Health Record, CEHRT via the Data Submission Vendor, and the Qualified Clinical Data Registry (QCDR).

Medical professionals are encouraged to choose the reporting method most appropriate for their practice. CMS has made available an implementation guide to assist in the process of selecting a reporting method as well as explain the criteria necessary for each option.

The American Society of Anesthesiologists (ASA) recommends that anesthesiologists in particular carefully review the available reporting mechanisms, as they especially practice in a diverse variety of settings or groups that may benefit from different reporting options. Anesthesiologists must report nine PQRS measures across three different domains. If a provider is unable to adequately report nine measures, he or she will be required to pass the MAV, or Measure-Applicability Validation process, in accordance with several guidelines.

Several important updates have been recently been made to PQRS to modify and improve its efficiency. In 2014, EPs received the opportunity to earn an extra 0.5% in incentives in addition to the PQRS incentive by working with a Maintenance of Certification entity. Details about the program can be found on the Medicare website. Furthermore, starting with the 2015 reports, the Affordable Care Act (ACA) calls for providers who do not participate in PQRS to receive a 2% penalty, or “payment adjustment”. This legislation aims to further encourage physicians to report their quality of information in a timely manner and allows CMS to derive more accurate statistics based on a larger pool of data.

References:

http://www.apta.org/PQRS/

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_OverviewFactSheet_2013_08_06.pdf

http://www.asahq.org/quality-and-practice-management/quality-improvement/physician-quality-reporting-system

https://www.medicare.gov/physiciancompare/staticpages/data/pqrs.html

Although Physiological Closed-Loop Controlled (PCLC) Devices have been readily available in parts of Europe for over ten years now, regulatory obstacles imposed by the FDA as well as medical liability concerns have barred this technology from entering North American markets. On October 13 and 14^th, the FDA held a public workshop to gain further insight into PCLCs and to discuss the benefits and risks of using the device to address technical and clinical challenges posed to clinicians and anesthesiologists in the US.

PCLC devices are an emerging technology in intensive care and emergency medicine settings that use feedback from physiological sensors (i.e. invasive blood pressure, electroencephalogram, cardiac output, respiratory gases) to autonomously manipulate the rate at which medications or fluids are administered, or of ventilator settings. Advances in the technology have ushered in with them the promise of therapeutic and diagnostic capabilities previously unavailable to medical practitioners. However, the automated nature of the device has also caused many anesthesiologists and manufacturers to approach it with a certain degree of caution and uncertainty, as a significant portion of data interpretation and therapy manipulation is shifted from a human practitioner to a medical technology.

During the FDA workshop, Dr. Robert Loeb, a member and incoming chair of the American Society of Anesthesiologists’ (ASA) Committee on Equipment and Facilities, presented on the potential benefits and challenges associated with Physiological Closed-Loop Controlled Devices. Dr. Loeb emphasized that, contrary to previously conveyed fears, the device is not intended to supplant the physician in patient-care settings, but rather to enhance physician capabilities. By autonomously titrating drugs and providing more uniform control, PCLC devices are expected to both reduce clinician workload and allow for more exact control, ultimately decreasing the rate of over-dose and under-dose events and providing the clinician with more resources to effectively carry out treatment in high workload situations.

Alongside these benefits, Dr. Loeb also outlined potential drawbacks inherent in the use of such devices. For example, physiologic sensors exhibit a high potential for artifact, which could result in inappropriate therapy. Most drawbacks, however, center primarily not on device functionality, but on usability and opportunity for human error; the potential difficulty of set-up, the multitude of parameters that must be entered, and the chance that clinicians remain oblivious to complications during use may lead to critical and potentially life-threatening clinical situations. Although PCLC devices may improve clinician and anesthesiologist performance in high-pressure situations, they may also motivate decreased vigilance and situation awareness in low workload circumstances, allowing for detrimental outcomes. For this reason, it is essential that safety features be incorporated into the device and that special attention be paid to user-interface design.

In a letter released by the ASA prior to the workshop, the organization expressed its endorsement for PCLC devices, but takes care to outline measures they recommend the FDA take in order to ensure maximum safety and efficiency during PCLC device use. They suggest that usability tests be carried out early in the design cycle and in real work settings to test clinicians’ abilities to safely use PCLC devices alongside other clinical devices in demanding clinical environments. They also recommend that the FDA begin by approving only closed loop controllers of inhaled anesthetics that feedback directly on anesthetic agent concentrations, as opposed to controllers that act in response to the more indirect signal of processed EEG. Direct indicators of the controlled process in the physiological closed loop (i.e. arterial pressure, pulse oximeter saturation, muscle response to electrical neuro-stimulation, etc.) generate much more dependable feedback loops than signals that are indirect to the controlled process (i.e. processed EEG to estimate level of hypnosis).

Adapting PCLC devices in the American market, operating rooms, and intensive care units would undoubtedly empower the anesthesiologist by bringing a new level of precision and control to the field of patient care. However, the FDA must first ensure that appropriate design strategies, pre-clinical testing, and clinical evaluations be considered to ensure maximum safety precautions be taken before the implementation of PCLC device takes off. Afterwards, as with all automated devices, anesthesiologists and clinicians must take care to maintain utmost awareness and caution when using the technology in order to fully take advantage of the technology’s promise

In today’s 21^st century, technology has come to play a vital role in all facets of the health care industry. Over time, it has seeped into the field of anesthesia, and has come to influence anesthesia management and practice. The latest implementations of technological development in the practice are anesthesia information management systems (AIMS). AIMS serve as a form of electronic health record system (EHRS) that generates an automated, continuous electronic anesthesia database of patient information. These automated anesthesia records gather and store a collection of the patient’s physiological data during the intraoperative period. By collecting basic vital signs and other anesthesia-relevant data, AIMS allow anesthesia providers to access necessary patient information needed for future management, administration, quality assurance, and research purposes. The beauty of an anesthesia information management system is that it has a multi-system interface that combines patient data from pre and post-operative monitors, various hospital clinical data repositories or other EHRS. This provides for a more comprehensive and complete patient record. However, like with most technology in the health industry, the application of AIMS is complex and must be managed with care and consistency to improve patient care.

Anesthesia information management systems are claimed to show improvements in 7 key areas of anesthesia care: cost containment, operations management, reimbursement procedures, quality of care, safety, translational research, and documentation. For patients, AIMS provide more accurate and available recordings of responses to anesthesia that will lead to better health records of treatments. Physicians can also benefit by using the system to improve quality assurance with the help of more accurate and detailed patient reports. AIMS allow anesthesia providers to spend more time focusing on their patients and less time charting information. These systems additionally track provider’s individual performances over time through precise time keeping and measurements. This feature is advantageous for providers because it offers future legal protection in the form of accurate and unbiased recordings. AIMS also offer a tool to control resource management in operating rooms and administration of anesthesia supplies and medications. This tool will enable health care providers to enhance the efficiency of their payment billings and reduce administrative costs. If implemented, anesthesia information management systems can ultimately help decrease health care costs for patients and improve the quality of provider care.

However while the use of anesthesia information management systems boasts many potential advantages, there are still several limitations to be considered due to the complexity of integrating these systems into everyday practice. The problem with depending on information technology in health care is that all providers and users need to be on the same page in terms of procedures and use of the system. One major drawback of AIMS is that there is no standard implementation for providers, leading to major inconsistencies within the practice. If providers don’t know how to use the system, or how to regularly update the database, the resulting incomplete patient records could make it difficult for future anesthesia management and administration. This can prove problematic during vertical integration when providers are transferring patient information from one phase of care to the next. Additionally, some physicians are afraid that the constant training required to update the system will detract from their time spent focused on the patient and result in a loss of personal medical attention. By eliminating providers’ concentration on manually recording and checking of patient information, there creates a chance for missing data due to glitches in the system. Furthermore, if physician anesthesiologists do not receive proper training on how to use AIMS consistently, there opens up more possibilities of incorrect or incomplete information, miscommunication and poor documentation. The use of electronic health records is intended to relieve physician pressure during recordkeeping but, if not integrated properly, can lead to increased liability for physicians. The reality may be that although AIMS provides a solution to an inefficient paper-based system, inappropriate use of the systems can lead to new inefficiency when generating clinical information.

Despite these growing concerns that AIMS may still be underdeveloped for anesthesia practice, many anesthesiologists may soon find themselves pressured into making the switch to these electronic health record systems. The Centers for Medicare and Medicaid Services (CMS) have adopted the Health Information Technology for Economic and Clinical Health Act (HITECH) and will put it into effect in late 2015 to advance the mission of having a national electronic health record system. This means that physicians who provide services on Medicare programs must transition from paper charts to electronic health records or possibly face a 1% cut in reimbursement rates for not complying. Whether or not this mandate applies to them directly, the switch from paper charts to electronic records will become more prevalent for physician anesthesiologists. It is clear that they will soon have to consider the adoption of using systems such as AIMS in their practice to stay involved in patient decision-making processes within clinical care.

Anesthesiologist health care professionals and provider organizations should take cautionary steps to ensure that if they choose to integrate AIMS into their patient care, they select systems that are customized to best fit their practice patterns and therefore minimize user error. After making the switch, organizations should ensure that their staffs are continuously and properly trained on how to correctly apply the electronic system into their routine. If these security conditions are met, the risks associated with lost information from electronic record systems will not outweigh the risks associated with incomplete or inaccurate data in paper records. In the end, AIMS can prove incredibly valuable to patients and providers if the necessary phases are completed to implement them properly. Anesthesia practice could very well soon be saying goodbye to the ancient paper-based system, and welcoming a new era of information technology through anesthesia information management system.

In June 2009, President Obama described his vision for a health insurance marketplace as a one-stop shop for health insurance where Americans can compare prices, and choose the plan best suited for them. In this marketplace, none of the health insurance plans offered would deny people coverage on the basis of preexisting conditions, and all of the plans would be affordable. Such a marketplace would give Americans a better range of health insurance choices, make the health care market more competitive, and improve accountability from health insurance companies.’[i]

To implement the health insurance marketplace, the President signed on March 23, 2010 into law the Affordable Care Act, which was upheld by the Supreme Court. Key features of the Affordable Care Act include: ending exclusions for children under the age of 19 due to pre-existing conditions, allowing coverage for young adults under the age of 26 under their parent’s health plan, ending the possibility that insurers cancel coverage because of mistakes, allowing individuals the right to request reviews of denial of payment, ending lifetime limits on health insurance coverage, requiring insurance companies to publicly justify unreasonable increases in insurance premiums, reducing the costs of administration to ensure health insurance premiums are spent primarily on health care, allowing preventive health services to be offered without copayment, allowing individuals to choose the primary care doctor they want from their plan’s network, and allowing people to seek emergency care in hospitals outside of their health plan’s network.

Today, consumers can now access the health insurance marketplace by going to the federal site at HealthCare.gov in most states. In the health insurance marketplace, there are over 13,000 plans to choose from, and over 180 participating insurance carriers.

The current “Open Enrollment Period” in the health insurance marketplace is from November 1, 2015 to January 31, 2016. People are required to enroll by the 15th of the current month in order to have coverage by the start of the coming month. For example, if one signs up by December 15, coverage will begin on January 1, 2016. However, if one enrolls later than December 15, one has to wait until February 1, 2016 for coverage to begin.

Unfortunately, overall the Affordable Care Act has not been easy to implement; people have been overloaded with inaccurate information, making it difficult for them to know their options, compare plans, and enroll in plans that match their income and their coverage needs. [ii] It is important for individuals to educate themselves about the health insurance marketplace because the new law imposes fines on those who do not have health insurance, determined either as a proportion of one’s income or as a penalty of $695 for each adult in the household. Parents would also be required to pay a penalty of $347.50 for each child. All penalties are applied for each person in the household who was uninsured.

Overall, the health insurance marketplace and the Affordable Care Act have increased the number of newly insured people. Since the Act was launched, there have been an estimated 22.8 million newly insured persons; however, an estimated 5.9 million persons lost coverage, resulting in a net gain of 16.9 million newly insured individuals.[iii]

The increase in new membership in individual plans and in Medicaid plans has expanded the health insurance industry revenue to $743 billion in 2014 up from $641 billion in 2013 before a large part of the law was implemented.[iv] However, much of the growth has not been profitable for all insurers as, overall, the industry experienced an estimated loss of $2.5 billion, or on average $163 per consumer enrolled, in the individual market in 2014. This year, some health care insurance carriers expect to lose money on their marketplace business. It is possible that the losses are due to the increase in the number of people who are not fully healthy and who now have access to insurance. Prior to the Affordable Care Act, only those with high income, perfect health and no pre-existing conditions could obtain coverage,[v] resulting in significant profits for insurance companies.

[i] https://www.whitehouse.gov/blog/2009/06/03/president-spells-out-his-vision-health-care-reform

[ii] http://www.obamacareusa.org/get-quotes/

[iii] http://www.forbes.com/sites/scottgottlieb/2015/05/14/how-many-people-has-obamacare-really-insured/

[iv] http://www.wsj.com/articles/health-laws-strains-show-1446423498

[v] http://www.obamacareusa.org/get-quotes/