North American Partners in Anesthesia CEO John Di Capua, MD, talks about the biggest challenges and latest trends in hospital anesthesia for 2014.
Question: What do you see as the biggest challenge for hospital anesthesia management in 2014?
John Di Capua: Society is struggling to curb the cost of healthcare, and hospitals are feeling the impact of state budget cuts. As physicians, we are challenged to do more with less. The specialty of anesthesiology has to find out how to provide care at a lower cost without compromising the quality of care provided to our patients. As a solution, anesthesiologists are trying to develop ways to become more transparent relatively quickly through data use in order to provide differentiation in terms of quality.
While other disciplines have an edge on this with ready access to large quality outcomes databases, this approach is in its infancy in anesthesia. In 2014, NAPA will commit significant resources in this areas. We will also continue to focus our efforts on enhancing our performance improvement program. Performance metrics aren't just for hospitals. They are a valuable tool for anesthesiologists as well. This data allows our clinicians to have the tools to learn how to improve upon the way they practice medicine and better relate to their patients.
The other challenge for 2014 and beyond has to do with the weight of the consumer, or patient satisfaction, toward anesthesiologists. In the future, satisfaction will play a role in anesthesiologists' reimbursement.
Q: What types of things can anesthesiologists do to improve patient satisfaction?
JD: Anesthesiologists have a short time with patients before and after surgery. Their particular challenge is to overcome the limited interaction they have with the patients to fit into the larger picture of satisfaction.
Our philosophy is that anesthesiologists are supposed to be leaders in the perioperative setting; care begins long before the patient arrives and continues long after they leave. Prior to surgery, our anesthesiologists meet with their patients to ensure they have a thorough understanding of the patient's history and concerns. Through this interaction, we not only educate our patients but our patients educate us, which ultimately leads to reductions in complications and readmissions.
This one-on-one exchange improves the patient's care as well as the perception of anesthesiology. The goal is to create a consistent, high quality, compassionate experience for patients by applying specific systems and processes. However, the transition to this type of leadership is difficult for many anesthesiology practices because they don't have the infrastructure in place for implementation.
Q: Is it a huge infrastructure change or mostly a cultural change for anesthesiologists to become true perioperative leaders?
JD: It's both a cultural change and a capital change. A lot of groups limit themselves to caring for the patient in the immediate postoperative period because they don't see the direct financial benefits of managing the patients before as well as after. As an anesthesia management organization, we put the stress on managing surgical pre-op clinics, which allows the anesthesiologist to analyze all available patient information, including labs and test results to make sure the patient is optimized for surgery, using national best practices for surgical preparation.
That activity has relatively little direct revenue generation for the anesthesiology groups, and sending a physician to the clinic for the appointment is a capital expense. But that's the wrong way to look at it. Even though these visits don't result in direct revenue, they can increase revenue down the line because there are decreased cancellations and litigation.
In the end, it becomes a source of financial help for the group. Getting people to do that when they are a small, local practice is hard because it may take a year or two before you can see the benefit.
Q: For outpatient procedures, how can anesthesiologists ensure quality care when the patient returns home?
JD: We want to see patients at home after they receive regional anesthesia/analgesia. NAPA has a system of call, where we actually take care of patients at home, whether it's answering their phone calls or visiting them. It takes time and a cultural shift to do that as well, but there is a dramatic increase in patient care and revenue. That's where the biggest change will be — moving toward larger, well capitalized groups that can make the financial and cultural leap to provide greater care for patients.
Q: Where are the best opportunities for anesthesiologists and hospitals to improve in the coming year?
JD: All physicians — anesthesiologists included — need to commit to data-driven decisions. You can't improve what you don't measure. In anesthesia, we are beginning to track some quality outcomes databases. There has been some adoption of the Anesthesia Quality Institute from the American Society of Anesthesiologists, but for groups without an electronic medical record, adopting any of these quality database protocols is hard. NAPA participates in the AHRQ PSO and it's our version of a large national anesthesia quality database.
The vast majority of practicing anesthesiologists don't report quality in any database. Given that payers and society want to reward the people who can prove better outcomes, I think anesthesiologists in 2014 will be challenged to adopt some form of quality outcome record-keeping to fit with the national trend.
Q: Is it plausible for anesthesia groups today to acquire an EMR? How will they move forward with data collection if they don't have one?
JD: Anesthesiologists are caught between a rock and a hard place because until recently more than half of their clinical caseload was in the hospital. The hospital-based anesthesiologists use the hospital's EMR and hospitals have been slow to adopt EMR in the operating room. They've done it on the floor and in the emergency room, but the OR is running behind. That's the most challenging and dynamic place where decisions are made quickly, but it's often the last place EMR is rolled out.
In our organization, we've just committed to building our own EMR for those institutions that do not have it. The amount of man hours it takes to design and appropriate the EMR are staggering, given the high costs. However, it helps us improve quality data and collection because we can see the information from a patient's record. It's well worth our time to create that bridge, especially in situations where we need to figure out what went wrong. Smaller groups have a harder time with this due to lack of resources, which is why we are seeing a shift in our industry towards consolidation.
Q: Are there any statistics or benchmarks that are particularly important for anesthesiologists to track?
JD: The most important data that is collected is quality data. Anesthesia practices are challenged not only with quality but also with costs, so we're looking to make the hospitals more efficient. But the priority is always to make sure patients do well.
Q: How will changes in the healthcare landscape, including healthcare reform initiatives, impact anesthesia management and delivery?
JD: There's no doubt that hospitals have reached a breaking point. We are seeing that demonstrated by the number of institutions closing their doors throughout the country. The financial concerns at the hospital level are real. That requires the anesthesia department to become involved in the financial health of the institution.
Examples of how we can help might be by creating standards for purchasing and consolidating in the OR for orthopedics and neurosurgery. If you can save millions of dollars in purchasing costs, it reflects well on anesthesia. It's much more about teamwork now than isolated departments, and it takes non-clinical leadership time to make sure everything is done right.
There is no direct reimbursement for the leadership activities. It's hard to provide non-clinical time because the subsidies are disappearing. Larger groups have an easier time because they can spread the cost of leadership over a larger base and not allow the hospital to go into a spiral. Healthcare right now is all about downward financial pressure and the fact that people are demanding higher quality. That will be the end of many hospitals if we don't figure it out.
Q: How can anesthesiologists truly impact OR utilization to make a difference for the hospital?
JD: In a world where we'll have greater risk with capitated insurance products, managing OR utilization will be critical. Getting patients in on time for scheduled surgery is a huge variable in patient satisfaction. If the OR is inefficient and the patient has to wait, there is unnecessary anxiety and the surgeon's time is wasted. A lot of ORs don't have access to the resources to collect this data. Sometimes, the nurses track data by hand and it's really slow. If you think about how data is collected in other industries, they all have electronic systems and auditing systems to show leaders where to make the necessary change. We have to revolutionize the OR for output.
At NAPA, we've taken the lead in devising a remote video auditing solution to capture 100 percent of throughput and quality data in the OR. The NAPA remote video auditing system is called PeakPerformance2 and we are the only anesthesia provider in the country to offer it.
In the hospitals where we've implemented our program, it's amazing how revealing the information is and how rapidly you can create change by reporting and making data available to the care team immediately. Not only have we seen results with on-time starts and turnover times, it has impacted critical issues related to improved OR protocols and infection control.
Q: What other trends should anesthesiologists look out for in the next year?
JD: Anesthesiologists have to seriously watch how downward financial pressures leading to decreased subsidies for academic and private practices will impact medicine. They must be careful not to scale back the number of practitioners required to manage patients appropriately. Don't fix the budget at the expense of quality.
Additionally, we need to understand what anesthetic techniques and care team models are appropriate to have the best outcomes possible.
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