Massachusetts General Hospital, like many other health care facilities, had a number of anesthesia cases that were not billable because of poor documentation. There were missing compliance statements, inaccurate listings of when anesthesia was administered, unsigned records, and other errors. And, of course, claims with overt errors or missing information can't be sent to an insurance company for reimbursement.
"It was ridiculous," says Stephen Spring, the administrative director of finance and information technology for Massachusetts General's anesthesia department, speaking of the hospital's paper-based billing process
But over the past few years, the hospital has done something about the problem. It has built a system that has virtually eliminated documentation errors, helped the hospital recoup hundreds of thousands of dollars annually in lost revenue and may soon prove to be a critical driver of patient safety.
The hospital's effort began in 2002, when it deployed an anesthesia information management system - a computerized recording system that documents events pertaining to the administering of anesthesia during surgical procedures. AIMS serves as a kind of electronic medical record, grabbing information from operating room monitors and anesthesia machines, including blood pressure, gas, and respiration data. Massachusetts General originally deployed an AIMS system from Draeger Medical Inc., Telford, Pa., but has since migrated to a system from iMDsoft, Needham, Mass.
An AIMS can help with records management. But the system depends on doctors or nurse anesthetists manually entering the right data, in the right sequences.
And, at Massachusetts General, documentation errors were still made, many simply because doctors and nurses, for sometimes very legitimate reasons - such as tending to patients - didn't properly document what they were doing.
While recording billing data is not critical for a doctor during a procedure, says Dr. Warren Sandberg, an anesthesiologist at Massachusetts General, it is "critically important to the financial health of an anesthesia department."
So Massachusetts General took another step. In 2004 it built its own software to work in conjunction with its AIMS. The bolt-on technology is designed to help the staff properly record procedures and produce an accurate bill.
Massachusetts General, one of the oldest general hospitals in the country, is a large facility with 900 beds. It offers care in virtually every medical and surgical specialty, including cancer, digestive disorders, heart disease, transplantation and vascular medicine. It has a deep IT bench as well. Its anesthesia department employs a small number of software analysts and programmers.
Led by Spring, the staff set out to write a piece of software, using Microsoft's Visual Basic programming language, that would sit on top of the AIMS system and prompt doctors to enter information about their activities during a procedure.
The result was the Anesthesia Billing Alert System. The system runs on an SQL database, which contains tables on the times and events that are supposed to take place when a patient is given anesthesia and prompts doctors to record their activities. And, in the event a piece of information - such as a timestamp or signature - is missing, the system sends out an alert. The alert may appear as a pop-up on anesthesia system monitors or, if that doesn't elicit a response, through a message sent to the anesthesiologist's ever-present pager.
If, after surgery, doctors and nurses have not in some way corrected the documentation, the system is programmed to e-mail reminders for them to check their records. The reminders keep coming for up to four days.
The system cost about $40,000 to build. But, says Sandberg, billing accuracy has gone up dramatically.
Today, anesthesia procedures are now almost 100% billable - up from 90% before the home-grown system was deployed. The average time it takes to send out a claim has decreased from 13 days to seven. The hospital also is capturing about $400,000 in annual revenue that had been previously lost because claims could not be sent out due to missing information. "The impact has been immediate," Spring says.

Quality Component

Another benefit is that more complete records enabled the hospital to take a close look at what was happening during the course of an anesthesia procedure and identify opportunities for the improvement of patient care and safety.
For instance, Sandberg says, some 6% of all cases had BP "gaps" - times when a blood pressure wasn't taken when it should have. And, he started to wonder if the system could be used to prompt doctors to take actions that would improve patient safety.
"We can do a lot more with this than clean up our billing," Sandberg recalls telling himself.
In January of 2007, the hospital started to build into the system patient safety alerts that prompt doctors when various procedures - such as recording a blood pressure or giving an antibiotic - needed to be done. The alerts, like the billing prompts, run over the hospital's internal paging network.
While the hospital has just set about collecting data on ABAS' impact on patient safety, both Spring and Sandberg believe that the system will improve the hospital's quality of care.
The system, says Spring, "has gone places we never expected."
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