How Electronic Health Records benefit Anesthesia Practices

How Electronic Health Records Benefit Anesthesia Practices Reports indicate that EHRs are helping anesthesiologists function more smoothly and meet government reporting requirements under quality payment programs.

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Consistent, complete, and error-free anesthesia records are crucial to analyze intraoperative events and arrive at accurate conclusions, and medical transcription services have always played a crucial role in ensuring this. Today, electronic health records (EHRs) have been implemented in most hospital systems and anesthesia practices. According to a December 2017 HealthcareITNews report, the software is helping anesthesiologists function more smoothly and meet government reporting requirements under quality payment programs such as MACRA and MIPS. Disadvantages of Handwritten Anesthesia Records Till recently, anesthesia providers documented what happened in the operating room on paper. However, this often resulted in inadequate data and incomplete anesthesia records.

Recordation Perioperative Information Systems notes that handwritten anesthesia records are

time

consuming,

tedious,

inaccurate,

illegible,

and

distracting

and

lists

their

disadvantages as follows:

-

Cannot be validated with regard to accuracy and time of entry of individual documentation elements; much of the information is filled in by the anesthesia provider from memory.

-

Are based on the clinician's viewing and interpretation of the patient monitor

-

The handwritten notes cannot be simultaneously accessed by others

-

Results in loss of clinically relevant information

-

written records may pose legibility and validation challenges

In contrast, EHRs ensure accurate documentation of medical care with automated high resolution physiologic data and provide easily accessible electronic anesthesia information.

Benefits of EHRs in Anesthesia The anesthesia record is designed to document what was done to a patient during the surgery as well as how the patient responded. According to HealthcareITNews, the software mimics what anesthesiologists do with pen and paper� but does so much more efficiently, which greatly improves workflow. When the data is in an electronic format, the information and the process can be analyzed much more quickly. The benefits of EHRs in anesthesia are:

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•

Improves vigilance: A Massachusetts anesthesiologist affiliated with Harrington Memorial Hospital told HealthcareITNews that implementing the platform had improved his practice. The EHR system allows him to work more quickly and efficiently. He does not have to hurriedly write everything down, and unlike handwritten notes, the EHR provided perfectly legible data. As the data is collected electronically, providers can focus on the patient.

•

Provides more information: Anesthesiologists can now get accurate readings about blood pressure, heart rate, oxygen levels, and other vitals by simply looking at the patient’s monitoring screen. Multiple pieces of information are available in the same place.

•

Automation makes reporting easier: EHRs allow providers to report very specific criteria for anesthesia, which is required under MACRA and MIPS to receive their annual percentage of Medicare revenue.

•

Improves the quality of care: Electronic documentation including automatic vital sign documentation and warnings improves the quality of care that anesthesia providers give their patients.

•

Improves medication administration: Electronic systems can check medications for cross-sensitivity and allergies, provide automatic documentation of administration of medications, and document the intake and output of the patient.

•

Helps meet payer reporting requirements: EHRs in anesthesia also improve opportunities for reimbursement by ensuring the ready availability of automated data to prove medical necessity.

To succeed with implementing an anesthesia EMR, experts emphasize that it is important to choose the right system. This brings us to the factors to consider when choosing an EMR for an anesthesiology practice.

Implementation of an Anesthesiology EMR -- Key Considerations Experts recommend that the following points should be kept in mind when choosing anesthesiology-specific technology: •

Comprehensive data capture: The system should meet the requirements of administering anesthesia in a variety of settings and situations. The ideal system would be one that can capture various factors such as body weight, drug

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interactivity,

cardiac

output,

age,

metabolism,

ventilation

and

timing

which

determine what the type of anesthesia and the method of administration. It should also able to seamlessly export and import data from other EMR platforms used by other clinicians in the team. •

Interoperability: The anesthesiology software should ensure interoperability by integrating with the other devices to pull together crucial information on blood pressure, heart rate, oxygen levels, etc. onto one cohesive platform.

•

Robust alert system: The system should provide up-to-date information on the amount of medications being administered and alert the anesthesiologist of any potential adverse drug reactions or allergies prior to an operation.

•

Practice size: There are EMR systems for small and large practices. The selected software should be able to accommodate all the anesthesiologists in the practice.

Robust anesthesia electronic medical records (EMRs) are a necessity for reporting on quality measures and clinical outcomes to support value-based payment strategies and ensuring compliance in a scenario of changing rules and regulations. These factors are driving the implementation of anesthesia EMRs. Anesthesiology transcription companies can meet all EMR/EHR related documentation requirements so that providers can focus on their patients and improve the overall the quality of care delivered inside and outside the operating room.

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918-221-7809