ELECTRONIC anesthesia records with anesthesia information management systems (AIMS) continue to grow in prevalence. AIMS have been of interest from the perspectives of anesthesiologists providing clinical care, such as implementing practice guidelines and patient safety, and from the perspective of hospitals or facilities, typically the “clients” actually purchasing the system and who strive for an improvement in cost and charge capture.1–4In contrast, ambulatory clinics have implemented electronic medical records with charge capture modules focused on the professional or physician services. In this month’s Anesthesiology, Dr. Reich et al.  5have demonstrated the successful use AIMS to capture and submit charges for anesthesia professional services. The question for anesthesiology groups is no longer “Is it possible?” but rather “Is this something I need or want to pay for?”

The process of automatic charge capture and submission can be viewed as having four major components: (1) automatic charge capture from data in the AIMS; (2) point-of-care coding, using software implemented by the attending physician; (3) automatic submission of the charge if documentation is complete as determined by software; and (4) automatic notification (via  e-mail) to the attending physician if documentation is incomplete as determined by software. Each component has advantages and disadvantages, as well as varying costs for implementation. Each can also be considered as an independent process that can be used in part or as a whole.

The first component, automatic charge capture, is not a new concept within medicine in general, but it has not been previously used for professional charges for anesthesia services. Its major advantage is that the charge is created without additional effort (paper or electronic) by the physician other than the clinical documentation. Automated charge capture also eliminates the need to reconcile the operating room schedule with the charges submitted, to be certain that none are missing. For academic departments, the system is attractive because it can be used to capture clinical services performed by residents but not currently billed as well as other potential revenue-producing activities. It may also enhance compliance because the charges cannot be created without requiring additional documentation. Also, anesthesia records for insurance appeals can be easily located within the AIMS.

Unfortunately, there are also distinct disadvantages of the automatic charge capture. First, because the AIMS does not have comprehensive software to capture charges automatically, the authors were required to develop their own. This additional software queried the existing AIMS and used a decision tree based on current billing rules. Therefore, IT support is critical to the system, and havoc could occur should such a critical individual depart. Also, billing rules change and system troubleshooting must be readily available. There is no “off-the-shelf” software for professional fees because the purchaser of the AIMS is typically the hospital, not the anesthesiologist or anesthesia group. It is no surprise that these charge capture packages developed for AIMS have centered around hospital billing, coding, and cost capture. However, because many hospitals must help to fund anesthesia staffing costs, any improvement in anesthesiology revenue should translate to an advantage for both the hospital and the anesthesiology group. Perhaps such off-the-shelf packages may become available in the future. Finally, the cost for interfacing with multiple information system platforms can be expensive and should not be underestimated. The system described by Reich et al.  interfaces with many systems, including the AIMS, the hospital’s financial system, the anesthesiology group’s billing software, and the third party payer’s software, which can be unique for each payer.

The second component of the AIMS is point-of-care coding, typically performed by the anesthesiologist with the assistance of drop-down menus and search engines. In a fully automatic system, the surgical procedure code could be automatically completed using the surgeon’s entry. In the system described, the anesthesiologist completed this function, using the software’s drop-down menus and electronic search of codes. Such a system can also be engineered to show the most common surgical procedures performed by a surgeon. To make coding easier, several commercial products currently offer this technology using personal data applications. These allow for coding as well as electronic charge creation. Unlike the automatic charge capture noted above, the personal data application systems require the anesthesiologist to enter the elements of the charge slip, but they do so at the point of care.

The automatic charge submission is the logical next step. For physicians such as pediatricians and radiologists who produce many small charges, an AIMS coupled with automated charge capture is very attractive and fiscally efficient. In contrast, charges for anesthesia services are typically “big ticket” items, and the loss of even one per day can be substantial. The savings are less for anesthesia services because the volume of charges is smaller. The benefits of human oversight may still outweigh the advantages of automatic submission, and careful tracking of submitted charges is necessary to prevent their loss.

The automatic e-mail reminders for incomplete documentation are an attractive feature of the authors’ system. However, it is unclear just where the anesthesiologists can actually access the AIMS to complete necessary documentation. Ideally, the anesthesiologist could do so from any terminal and would not need to be physically present in the operating room or hospital. The use of e-mail reminders could also be implemented with clerical reviews of documentation, but the advantage of automatic reminders may well be more timely.

The study by Reich et al.  showed that this complete charge capture system is possible; however, the cost–benefit of its development and implementation are important. The authors found a one-time benefit from a reduction of “lag days” from 10 to 3. Applying this revenue to the initial costs of the system must be done with some caution. As noted by the authors, at the same time as the system was implemented, a physician incentive compensation system based on charges was also initiated. The incentive system itself could easily reduce lag days and increase charges. Further, if a group’s lag days already range between 3 and 5, little of the one-time revenue gain would be realized.

The costs of developing an automated information system from scratch, in addition to its ongoing maintenance, may well equal any potential savings from the reduction of clerical full-time equivalents. Indeed, the implementation of automated systems do not necessarily reduce labor costs, but rather shift them from clerical staff to staff dedicated to the automated system. If an AIMS is not available, an anesthesiology group can still take advantage of some of the processes studied by using other commercially available products in conjunction with the billing office, perhaps at a fraction of the cost, using e-mail notification for incomplete documentation.

Finally, the strategic costs of having the hospital own the data, giving unfettered access to billing and revenue information, must be weighed carefully. Because the hospital typically owns the AIMS, the hospital, and not the anesthesiology group, owns the data. In our world today, this situation may be less than desirable.

*Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas. aaboulei@utmb.edu†Department of Anesthesiology, Baylor College of Medicine, Houston, Texas.

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