Happy New Year

I have neglected my blogging since leaving HCA and returning to Hopkins full time. The clinical work seems to take all my time, and leaves little time for writing. Sorry, I know if I want to be taken seriously as a blogger, I need to keep up the writing. Anyway, I will attempt to make a better effort starting in 2013.

When I left HCA, I left a few endeavors unfinished. Primary among them was the development of a pharmacy metric. In my previous published blog, I briefly discussed using a metric such as this to evaluate whether the anesthesia service was being fiscally responsible in their delivery of anesthesia according to pharmacy costs. I had hoped to use actual data from HCA facilities to publish an algorithm and establish some benchmarks. Regardless, I plan on continuing this work most likely as a consultant. I hope to provide some guidance on this in future blogs.

I also feel we are just beginning to look at quality and performance metrics. Most anesthesia groups may have minimal financial bonuses or withholds at risk; however, I expect that to increase. I plan on using a future blog to describe the hospital value based purchasing system, and how physicians need to begin working with their facilities to enhance that facility’s performance. It is important to know that today’s performance on these key metrics will determine the hospital’s reimbursement for 2014. Consequently, there is no time to lag on moving the needle on these metrics.

I am also interested in looking at opportunities to change the current delivery models to reduce costs and improve patient safety. With the advent of using drugs like Propofol for endoscopy and other ‘Remote’ locations (out of OR locations for anesthesia), our anesthesia resources have become extremely stretched. Even employing a care team model (CRNA and MD) will not sufficiently provide enough resources to cover all the requests. I do believe the future will see developments in other models that will need to be vetted for patient safety, but that will ultimately come to bear as reasonable substitutes for anesthesia providers.

Finally, I will continue to look and work on solutions that utilize anesthesia information systems that enhance our patient safety, as well as potentially reduce unnecessary expenses. I am an evangelist for the online patient questionnaire, and the successful incorporation of this information into our existing workflows. We have made some good strides in this arena, but there remains a great deal yet to accomplish.

I do plan on continuing to incorporate my interest in wine into this blog. What started as a lark seems to have become one of the more popular elements of this blog. Though I don’t have time to write a comprehensive review, I do want to let you know that recently I had a 2009 Caymus cabernet that was incredible! This wine tasted phenomenal, which is uncommon for such a young cab. It likely means that the wine will not lay down for a long time without turning, so should be drunk now. Good luck finding this great bottle of wine.

Here is hoping everyone who reads this blog will have a prosperous and rewarding 2013. If you follow me on Twitter (@Jstonemetz), I will update when I publish new blogs. Would really appreciate your feedback and comments. Have a great New Year!

AIMS Market Penetration

For three years I have compiled statistics from current Anesthesia Information Management Systems (AIMS) vendors in an attempt to quanitify the market penetration of  AIMS. I will be publishing this information along with more detailed analysis in an upcoming release of the ASA Newsletter. However, I am going to provide a snapshot of the data here.

By my count there are currently 12 vendors who have at least one installation in US hospitals. Those vendors are:

  • General Electric
  • Drager
  • Philips
  • Picis
  • McKesson
  • Cerner
  • Epic
  • Surgical Information Systems
  • Merge
  • iMDSoft
  • Acuitec
  • Plexus

I asked each of the vendors to provide me with an accounting of hospitals (no surgical centers) where an AIMS is installed, under implementation, or under contract. The ‘under contract’ number also includes numbers of hospitals where an AIMS has been purchased, but not yet installed. Then I divided the vendors into three groups. The first group is vendors who also sell patient monitors and/or anesthesia machines. Typically the AIMS is integrated into the device. The second group also sells Operating Room Management Systems (ORMS). These systems typically provide surgical scheduling, nurse documentation and case-cart inventory. The final group sells exclusively AIMS. The tables below list the vendors and the aggregated number of installations:

 Using an estimation of 5000 hospitals, we can calculate a market penetration. Looking only at numbers of hospitals where there were sales (under contract), we arrive at 33%; however, the real story is looking at the number installed or under implementation. That number is a more realistic 18.2%. The vast majority of sites ‘under contract’, but not implemented are with two vendors – Cerner and Epic. Both of these vendors also sell Hospital Information Systems (HIS), and frequently provide significant pricing incentives to simply add the anesthesia module. It is not clear how many of these sites will actually convert to installations since frequently the anesthesia group is not motivated to use these electronic medical record systems. Future blogs will deal with rationale for moving to an AIMS, and I do believe that there will be continued growth of this market in the near future.







Medication Waste

In a previous blog I discussed Pharmacy Metrics where we are looking to calculate anesthesia drug spend/anesthesia minutes or spend/case to establish a benchmark on drug utilization. This would allow us to determine if the anesthesia providers are using ‘best practices’ such as low gas flows and appropriate drug choices. The dollars spent at hospitals on anesthesia drugs is significant, and if the anesthesia group is not vigilant in using appropriate medications, it can result in much higher expenses to the facility than are justified. Unfortunately, unless there is some analysis of drug utilization, the pharmacy has no ability to even monitor this situation. We anticipate that by looking at this pharmacy metric, we will begin to establish the ability to analyze the practice patterns of the anesthesia group and determine if they are an outlier on medication spend.

The second level of medication usage requires more effort. Even if we look at drug spend, we don’t know if the group is wasting a large amount of medications. I have embedded a photo sent to me by a colleague who practices at a trauma center. This picture was taken the morning they came into the OR and began to prepare their cart for the day. The number of medications drawn up into syringes is staggering, and extremely wasteful.

It is critical that anesthesia providers have medications at the ready for emergent cases, especially trauma. However, if you look closely you will also see syringes for Zofran and other non-emergency drugs. Additionally, did they really need three syringes of propofol? All of these syringes had to be desposed of and represent the second level of waste or muda.

Muda is a Japanese term for waste that can be eliminated without having any impact on the outcome of a process. Described by Toyota’s Chief Engineer, Taiichi Ohno, this concept has become a fundamental component of Lean – a manufacturing improvement process that has made it’s way into Healthcare. Combined with the Six Sigma improvement process, one can become a practitioner of Lean Sigma – a process improvement whereby we ‘lean’ out a process, and then impose ‘six sigma’ improvement to reduce variation.

In the case of wasted medications, we need a metric to be able to quantify the medications used and compare that to the total spend. Therein lies a delta that represents an opporutunity to reduce waste. To obtain the utilization metric, we need actual utilization data, and the typical medication reports we obtain from an AIMS (anesthesia information management system) will not suffice. I could care less if we use 4 mgs of Nimbex or 12 mgs of Nimbex. What I really need is the number of vials used for that case. Since all the medications we use in the OR are single patient use, then if I open a vial, I need to charge it to the patient regardless of how much I use. Reporting back on amount of medication used for each patient is relatively useless unless it can be tied to the number of medication vials.

An ideal way of capturing this information is to use bar coding technology to scan the NDC number from medication vials. Not only will this give me verification of the medication name, but could also provide some drug – drug interactions and drug – allergy concerns if we have clinical data from the patient for reference. Regardless, it would give me an accurate accounting of the medication vials used for each case. By developing anesthesia spend/case (or anesthesia minutes) per provider, we will now begin to be able to look more granularly at individual provider practice, and have metrics on medication management that can potentially change behavior.  

It would require the anesthesia provider to identify each medication drawn up into syringes, which currently is additional documentation; however, it is where we are going in terms of medication management for the operating room. Additionally, the ability to use bar coding for drug – drug analysis would assist us in getting to subsequent levels of Meaningful Use. Do you concur, or disagree? Leave a comment.

Pharmacy Metrics

During anesthesia, we are not able to provide the 5 rights of medication safety – right patient, right medication, right doseage, right route and right time, as described by safe practices. This is primarily because during the anesthetic, the provider decides which drug to give; prepares the medication; and administers the medication without another set of eyes on this process. Consequently, there are drug errors in anesthesia that have been estimated to occur once every 140 anesthetics.

Technology has not provided us with an elegant solution that doesn’t interfere significantly with workflow. There have been some attempts at this solution utilizing bar coding, however, the products have never achieved market acceptance.

In fact, we can’t even determine what or how much medication is actually administered, since the majority of our documentation remains on paper. With the implementation of an AIMS, it might be possible to actually procure medications, however, even in these systems, we do not typically get a comprehensive accounting of all that was drawn up or wasted.

In an attempt to begin looking at this issue, we have determined that we can procure ‘spend’ data per facility. We can look at the dollars spent on anesthetic drugs/by category/per facility/month. What we are attempting to do now, is to match this spend data against anesthesia minutes to arrive at a variable. Using our own internal benchmarking, we hope to shed some light on medication management practices at our hospitals.

For example, if we focus specifically on inhaled agents, we should be able to track the spend/anesthesia minutes and illustrate if our groups are using good practices in the delivery of these agents. Specifically the fresh gas flow rates. It is impossible to determine if providers are using low flow rates; however, by looking at the spend data, we should be able to arrive at a close correlation with usage.

We are hoping that by illustrating this variable as a metric, we can assist our hospitals in reducing unnecessary waste and provide a better environment for our facilities.