Improving Anesthesia Information Management

The delivery of anesthesia care is both an art and science. It takes skill, extreme attention to detail and compassion to provide this specific type of care to patients every day. Since the practice of anesthesia necessitates a hands-on approach, the information management aspect of it that happens behind the scenes is rarely thought of by anyone who is not an anesthesia provider. Information management is extremely important when it comes to anesthesia care and there are numerous benefits to ample documentation. 

Benefits of Documented Anesthesia Care 

Just like most medical specialties, proper documentation is paramount to the success of any anesthesia department. Consistent, legible documentation is obviously essential for billing and compliance, but it is also useful for goal setting and benchmarking, quality improvement, risk management and clinical research. A thorough documentation review can even reveal inefficiencies in staffing models. Since documentation is so important, CCI Anesthesia works hard to routinely educate and remind anesthesia providers on proper documentation techniques to ensure the best data quality possible. 

As a comprehensive provider of anesthesia practice management services since 2004, we have learned a few tips when it comes to anesthesia information management that we can share:

Start by Ensuring Clinical Information is Complete

In order to have quality data worth analyzing, the clinical information you are reviewing must be complete. Areas that need to be detailed include drugs and agents utilized, order sets and equipment used. Compare this data to current national patient safety goals, facility accreditation standards and compliance initiatives. Examining this information at least quarterly is best so that any oversights can be corrected in a timely fashion. 

Avoid Time Delays or Lack of Collection

After you have audited your data to ensure completeness, inspect the billing process to make sure all information is sent to your billing system or service. If you are experiencing a delay in reimbursements or a lack of collections, it could be due to gaps in information needed by payors.  

Create an Anesthesia Information Management Checklist 

Checklists are increasingly important in the world of anesthesia care. Whether it is an equipment maintenance checklist or a preoperative, intraoperative or postoperative patient care checklist, anesthesia providers are accustomed to these safeguards and will likely appreciate the implementation of an information management checklist. Creating a checklist of all clinical elements required for documentation will help to ensure the information will be detailed, accurate and complete. Keep in mind that as billing requirements and accreditation standards change, this checklist will need to be updated. 

Consistently Review Documentation Procedures 

Accurate and detailed documentation is an essential element of high quality and safe anesthesia care. Documentation procedures should be regularly reviewed to ensure all applicable regulatory, legal and billing compliance requirements are met. Our team of billing and compliance experts at CCI Anesthesia regularly examine documentation samples at each of our client facilities to ensure accuracy in coding. Our practice management teams monitor operational efficiency in real-time through our tablet-based EMR system while our clinical informatics team maintains a constant watch on quality metrics. The end result for our clients is reduced costs, increased efficiency, improved quality and better clinical outcomes across your health system, hospital or surgery center.

Does your current anesthesia management group emphasize anesthesia information management? If not, you could be leaving money on the table. Contact us today at 844.937.1810 for more information on our approach to using anesthesia information management in ways that reverse inefficiencies and reduce costs. Our anesthesia management and billing experts are eager to help you improve the quality of your data capture and analysis.