Benefit of Electronic Medical Records in the Anesthesia Preoperative Consultation
Center
J.C. Frenzel, M.D., M.S.1, T. Andrabi, M.D. 1, A.A. MacLachlan, M.D. 1, I.T. Powell, R.N. 3, M.A. Rozner, Ph.D., M.D. 1,2

Department of Anesthesiology & Pain Medicine1 and Cardiology2; Division of Management Information Systems3, The University of Texas M. D. Anderson Cancer Center, Houston, TX

Introduction: The practice of anesthesiology is in the early stages of moving from record keeping on paper to the use of electronic medical records (EMRs). Although this transition is well underway in the operating room, it remains uncommon in the preoperative consultation center (PCC). The Department of Anesthesiology and Pain Management at The University of Texas M. D. Anderson Cancer Center (MDACC) recently implemented the use of EMRs in our PCC to great benefit. Anesthesiologists at MDACC’s PCC evaluate more than 1,000 patients per month in anesthesia consultations requested by surgeons; these consultations are billable and reimbursable events (CPT code series 99241 - 5) (1). Because appropriate, defensible billing must be supported by adequate documentation, our coders require that records of all consultations contain the following information to be valid: chief complaint, medications, past surgical history, past medical history, review of systems, physical examination, assessment, and treatment plan. Through November 2003, our process was based on handwritten and dictated notes. Billable consultations averaged 33.2% of patients seen. An analysis of rejected charges revealed a high percentage of incomplete evaluations (i.e., missing required elements), illegible documentation, and lost
work. Because all faculty anesthesiologists rotate through the PCC, a large variability also existed among staff in the depth and quality of the documentation.
Methods: As of November 19, 2002, we started using the PICIS Preoperative Manager EMR product (PICIS Inc., Wakefield Mass). This product follows a structured template that leads the physician through a complete evaluation process. Check boxes exist for common positive and pertinent negative findings. Free text input is allowed so the evaluator can elaborate on specific findings or other data.
Results: The structured EMR format has improved the consistency of evaluations and guides evaluators to include all the required elements. In the month following the installation of the EMR system, the billing percentage immediately increased to 73.2% and has since averaged 78.6%, representing a nearly 100% charge capture. (We do not bill inpatients; patients when the medical necessity of the consultation cannot be justified by the their medical condition [e.g., patients with ASA risk classification 1 and 2] or patients
evaluated on the day of surgery.) As seen in Table 1, professional charges did not increase substantially, but the number of billable encounters did.
Table 1:

Discussion: The effects of using EMRs in the PCC have been felt throughout our practice. The uniformity of evaluations has improved, and problems of illegibility, poor dictation skills, and source document loss are no longer an issue. Because evaluations are in electronic form, they are accessible for reading or printing via a web interface in any hospital location, decreasing the need for back-up office support in record distribution, archiving, and billing. The electronic format also allows physicians within the institution to more easily use preoperative data in clinical studies, supporting the institution’s mission of clinical research. As anesthesiologists make the transition to electronic documentation, we must adapt our
workflow to accommodate these new technologies and alter back office processes to support an electronic format. Effective implementation of the EMR system in the PCC required most faculty to change their personal preoperative interviewing style. Because variation among evaluators was one of the reasons for incomplete documentation, this was expected. As with any change in practice, we encountered some hesitation, but as the clear benefits of using electronic records became apparent, our faculty quickly
adapted.
Conclusions: EMRs will slowly replace paper records during our practice lifetimes. Implementation of EMRs in the PCC presents an opportunity for institutions to improve practice, patient care, and health care delivery, while enhancing charge capture for work done.
References: (1) Arens, J.F., MacLachlan, A. A., 2004, Billing for Off-Site Anesthesia Services, ASA Newsletter, 68: 23 - 27, 2004

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