Business Logistics
19.1 Staffing for Preoperative Assessment
Ronald P. Olson
There are many staffing models for preoperative assessments. Each institution will need to develop a process to serve patients with a balance of proportion and depth of preoperative assessment for its unique needs.
One end of the spectrum is from a perhaps mythical age when every patient had a primary care physician (PCP) who could quickly summarize the patient’s current medical, psychological, and social status, as well as expeditiously and knowledgably discuss the risks and benefits of contemplated interventions with the surgeon, anesthesiologist, and patient. Consultations required for optimization would have already been arranged as part of routine care. There may be some communities which are close to this Nirvana, in which case perioperative assessment and optimization can be deferred to the PCP, and the hospital needs only to gather information. In this case a nurse screening call or perhaps just a clerical collation of the information will be satisfactory, as long as the information gets to the operating room on time.
The other end of the spectrum is where patients arrive the morning of surgery with no knowledge or documentation of previous health status, and little idea of what is about to occur. Admittedly, if the patient had to climb a flight of stairs to get to the operating suite, and the procedure does not involve significant physiologic stress, all will probably go well, thanks to the large margin of safety that current anesthesia and surgery provide.
Increasingly, however, patients present with multiple comorbidities which may or may not have been recently optimized or even assessed. Anesthesiologists may be pressured to accept small risks in the name of patient convenience. But these may be preventable. Even if surgery can proceed with little change in medical care, the perioperative period presents an opening to improve long-term health, which may not happen otherwise. It is an opportunity to clearly demonstrate the institution’s interest in the patient’s overall health, which has ethical and public relations justification.
Comprehensive preoperative assessment and optimization (1,2) involves the following: (1) information gathering; (2) reviewing and evaluating the adequacy of that information; (3) determination of need for further assessment, investigations, and treatments to optimize perioperative health; and (4) actually doing the optimization. All of these should be documented in a concise, structured, and available format.
INFORMATION GATHERING
If patients have had good comprehensive health care, and documentation of that care is available, there is little need for further preoperative assessment (3). If most patients in a healthcare system are in this category, have a PCP who knows them well, or can easily be seen by a consultant preoperatively, information gathering can be done by clerical staff. The few questionable cases can be deferred to an advanced practice provider (APP) or preoperative physician. As the proportion of cases with uncertain medical care increases, it will become necessary for a clinician with a higher level of training and certification to be the primary information gatherer.
DETERMINATION OF ADEQUACY OF INFORMATION
As health care has become more fragmented, collating accurate medical records has become more difficult. Electronic health records (EHRs) are making it easier to share records across institutions, but extricating useful information from auto-populating templates becomes challenging. It is not fair to expect clerical staff to discern if the content of the information is adequate. Nursing staff are likely better able to make this assessment. If there is a large proportion of complex, suboptimally managed patients, an APP may be needed to make medical decisions about the adequacy of patient information.
Some patients can be assessed remotely (e.g., telephone, EHR, telemedicine) without an in-person visit (4). The problem is determining which patients can be assessed from afar. In some communities, surgeons are familiar enough with their patients, to triage appropriately. When many patients are referred from afar with inconsistent information, other triage methods will be needed. One option is for all patients to receive an initial remote (typically by phone) assessment, which can determine who needs a clinic assessment. This requires enough lead time for the phone call. If further care is needed, the next question is how will this be accomplished and by whom.
DETERMINATION OF NEED FOR FURTHER ASSESSMENT
The simplest approach may be to refer patients to their local provider. Another option is to refer to an internal medicine service. This may be inconvenient for the patient, especially if it represents a duplication of care. If services are included in a global surgical fee, it may be advantageous to utilize an anesthesiology-directed preoperative clinic. This will likely minimize overinvestigation, as preoperative care directed by anesthesiology limits unnecessary testing (5,6). While experienced nurses often make these determinations, there is a concern that they do not exceed their scope of practice. APPs, with training and support of anesthesiologists, may represent the best balance of skills.
PERIOPERATIVE OPTIMIZATION
It may be necessary to refer the patient to the appropriate consultant when there is a complex medical issue. But many medical issues can be easily managed by preoperative specialists. Examples include prescribing medications to optimize asthma or hypertension, treating infections, or instructing on perioperative anticoagulants and chronic medications. Similar to preoperative investigations, medical optimization may increasingly be considered part of a global fee, and referring the patient to a consultant adds inconvenience and cost, as well as reducing income.
While some certified registered nurse anesthetists (CRNAs) may have the training and interest to do perioperative optimization, many institutions find it is not the most efficient use of their skills. PCPs are well suited if they have guidance from anesthesiology. Consultants and anesthesiologists certainly can do it. However, as described previously, APPs working with anesthesiologists may be the ideal balance of skills and availability. If only a very few patients require additional evaluation and intervention, it may be more efficient to use nurse screening with involvement of a part-time anesthesiologist or consultant for those few cases.
ROLE OF THE SURGEON
An obvious omission from the potential staff for perioperative assessment and optimization is the surgeon. There are some surgeons who know their patients well, have maintained some knowledge of medical conditions, and continue to make time to attend to medical preparation. It is commended and encouraged when possible. However, it is increasingly an unrealistic approach. Surgeons have their own increasing demands on time and expertise, and preoperative medical evaluation and care may not have high priority.
DOCUMENTATION
EHRs can provide the benefit of a standard document that increases the likelihood that relevant information is gathered and recorded, regardless of who gathers it. EHRs can also provide a surplus of unneeded trivia and information that is not useful for preoperative care. Institutions must keep system-wide programs relevant to the perioperative period. The preoperative clinician must be empowered to produce a selective synopsis, not an unfiltered anthology.
CONCLUSION
No one system of preoperative assessment and optimization will be ideal for all institutions. The intersection of patient complexity, accessibility of patient records, staff training to provide perioperative care, and the institution’s investment, will all influence the best processes to provide comprehensive perioperative care. The goal is to utilize staff to practice at the “top of their license,” to avoid duplication of assessments done elsewhere, and to improve each patient’s health for both the perioperative period, and for years to come. As much as possible, it should be done within the jurisdiction of the anesthesiology department (Table 19.1).
TABLE 19.1 Perioperative Assessment Staffing Options | ||||||||||||||||||||||||||||||||||||||||||||||||
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REFERENCES
1. Cohn SL. Preoperative evaluation for noncardiac surgery. Ann Intern Med. 2016;165(11): ITC81-ITC96.
2. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. J Am Coll Cardiol. 2014;64:e77-e137.
3. Keay L, Lindsley K, Tielsch J, et al. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev. 201214;(3):CD007293.
4. Olson RP, Dhakal IB. Day of surgery cancellation rate after preoperative telephone nurse screening or comprehensive optimization visit. Perioper Med (Lond). 2015;4:12.
5. Finegan BA, Rashiq S, McAlister FA, et al. Selective ordering of preoperative investigations by anesthesiologists reduces the number and cost of tests. Can J Anaesth. 2005;52(6): 575-580.
6. Fischer SP. Development and effectiveness of an Anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology. 1996;85:196-206.
7. Goldman L. Cardiac risks and complications of noncardiac surgery. Ann Intern Med. 1983;98(4):504-513.
8. Wijeysundera DN, Austin PC, Beattie WS, et al. Outcomes and processes of care related to preoperative medical consultation. Arch Intern Med. 2010;170(15):1365-1374.
19.2 Remote Evaluation
Ben Boedeker
Advances in telemedicine have made it practical for anesthesiologists to provide virtual preoperative care to remote sites. Advantages of tele preoperative evaluation include improving the preoperative assessment for patients to decrease surgery cancellations after travel for the operation. Telemedicine services are useful for education, instructions, planning for further care, postoperative evaluations, and for special patients with a high cancellation rate such as patients with high comorbidity or poor primary care from remote areas. Numerous studies have reported high patient and physician satisfaction survey rates for tele preoperative services (1,2,3,4,5).
ESTABLISHING A PREOPERATIVE TELEMEDICINE SYSTEM
When a tele preoperative system is established, metrics should be tracked to monitor quality indicators of the process. Example quality indicators which can be measured are outlined in Table 19.2. Other metrics to track include identification of difficult airways, incomplete records, and rate of surgical delays and cancellations.
COMMUNICATION SYSTEMS
The telemedicine system used for the virtual preoperative evaluation should be HIPAA secure. A good resource to guide your information technology department in HIPAA compliance is the Office for Advancement of Telehealth: http://www. telehealthresourcecenter.org/
TABLE 19.2 Possible Quality Assurance Measurements for Tele Preoperative Evaluation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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EQUIPMENT
Equipment to support a tele preoperative clinic includes a camera to assess the airway, neck excursion, and overall view of the patient. An electronic stethoscope is used for auscultation of bruits, and pulmonary and cardiac examination. Dental cameras may be used to provide a more advanced assessment of the airway. Spirometry can also be supported by telemedicine. Preoperative pulmonary function testing using lung spirometry has been found to be effective for the screening of abnormal pulmonary function and predicting postoperative surgical complications. Tele spirometry can allow detection of this pathology early in the preoperative process allowing pulmonary function optimization to be performed preoperatively and continued through the postoperative period to prevent complications (6).
SUMMARY
Telemedicine provides an opportunity to improve the perioperative process by performing patient anesthesia evaluations prior to patients reporting for surgery, thereby
ensuring they have been optimally prepared before traveling. This can decrease surgical delays or cancellations which save healthcare dollars and improve the patient experience. Improved quality can be accomplished by tele perioperative medicine by increasing the patient’s access to anesthesia providers throughout the perioperative period without the need to travel to major hospital locations.
ensuring they have been optimally prepared before traveling. This can decrease surgical delays or cancellations which save healthcare dollars and improve the patient experience. Improved quality can be accomplished by tele perioperative medicine by increasing the patient’s access to anesthesia providers throughout the perioperative period without the need to travel to major hospital locations.
REFERENCES
1. Galvez J, Rehman M. Telemedicine in anesthesia: an update. Curr Opin Anesthesiol. 2011;24:459-462.
2. Wong DT, Kamming D, Salenieks M, et al. Preadmission anesthesia consultation using telemedicine technology: a pilot study. Anesthesiology. 2004;100:1605-1607.
3. Dick P, Filler R, Pavan A. Participant satisfaction and comfort with multidisciplinary pediatric telemedicine consultations. J Pediatr Surg. 1999;24:137-142.
4. Zetterman CV, Sweitzer BJ, Webb B, et al. Validation of a virtual preoperative evaluation clinic: a pilot study. Stud Health Techno Inform. 2011;163:737-739.
5. Burton R, Boedeker B. Application of telemedicine in a pain clinic: the changing face of medical practice. Pain Med. 2000;1(4):351-357.
6. Jeong O, Ryu S, Parks Y. The value of preoperative lung spirometry test for predicting the operative risk in patients undergoing gastric cancer surgery. J Korean Surg Soc. 2013;84(1):18-26.
19.3 Business Model for Preoperative Process
Thomas R. Vetter
BACKGROUND, RATIONALE, AND A COMMON FUNDAMENTAL QUESTION
In the United States and other developed countries, there is an ongoing evolution away from volume-based toward value-based healthcare payment models. This is being driven by a confluence of governmental policies, federal statutes, market forces, and consumerism. It reflects a strong multi-stakeholder mandate to optimize outcomes and reign in unsustainably increasing healthcare expenditures (1,2).
Value in health care has been defined as health outcomes achieved per dollar spent (3). This simple quotient can be expanded to include several specific outcome domains:
Value = [Quality + Safety + Patient and Provider Satisfaction] ÷ [Cost]
Value-based health care is not some quixotic notion, which will eventually fade away like previously attempted healthcare reform in the United States—rather it is a major redesign that is well underway (4). The US Centers for Medicare & Medicaid Services (CMS) expect that 90% of Medicare payments will be value based by 2018, with commercial payers beginning to follow suit (4).
Practically speaking, at least in the United States, traditional fee-for-service is giving way to alternate payment models, whereby financial gain-sharing and risk-sharing are equally realized by payers and providers—including individual clinicians (5).
Such value-based alternate payment models (e.g., bundled payment for total joint replacement) are an increasing focus for CMS, private insurers, and self-insured regional and national employers (4,5).
Such value-based alternate payment models (e.g., bundled payment for total joint replacement) are an increasing focus for CMS, private insurers, and self-insured regional and national employers (4,5).
Delivering such value-based health care requires effectively managing not only the long-term but also the short-term health of populations. This includes managing the short-term health of the surgical population, which certainly begins in the preoperative phase of care (2).
To effectively contribute to perioperative population health management and to successfully deliver greater valued-based perioperative care, the scope, services, goals, and deliverables of the outpatient preoperative clinic must be expanded (Fig. 19.1) (2). This can be validly reflected in and endorsed by the changing name of an organization’s likely existing but now outdated preanesthesia clinic (Fig. 19.2).
This expansion of preoperative management can rely upon either an anesthesiologist or an internist. However, a clinic practice incorporating both an anesthesiologist and an internist takes full advantage of their respective knowledge and clinical experience. It supports a co-management triad with the surgeon. This expanded preoperative clinic may ideally be staffed with a consistent, core group of anesthesiologists, internists, APPs, and registered nurses.
In proposing to expand the scope of an existing, conventional preanesthesia assessment clinic—and even more so to “stand up” a new comprehensive preoperative management clinic—a common and legitimate immediate question is “How will we get paid for doing this?” The answer to this fundamental question will change as healthcare reimbursement simultaneously evolves from volume-based, fee-for-service to value-based, alternate payment models.
BILLING FOR PREOPERATIVE MANAGEMENT SERVICES
Justifying a Preoperative Medical Consultation
Surgical patients routinely undergo a preoperative evaluation by a surgeon and an anesthesiologist. Over the last 20 years, an increasing number of patients are being referred for additional preoperative medical consultation—predominantly by an internist, cardiologist, or family practitioner (6).
Anesthesiologists are assuming a wider role in perioperative care and population health management (2). Medical consultations by anesthesiologists have recently been increasing in frequency (6). With appropriate documentation, additional services outside the scope of routine preanesthesia assessments can be separately billed.
Billing for clinical services beyond routine anesthesia pre-evaluation can take the form of Evaluation and Management (E/M) services preoperatively or Transitional Care Management (TCM) services provided to patients during the 30-day period after hospital discharge (7).
As stated in 2015 by the American Society of Anesthesiologists (ASA), “In some cases, a surgeon might request that the anesthesiologist determine if a patient’s clinical condition is optimized to allow scheduling of a surgical procedure and, if not, request assistance in managing the preoperative care (e.g., assessing and managing underlying clinical conditions, such as coronary artery disease, chronic obstructive pulmonary disease, asthma, diabetes mellitus, etc.)” (7). Other common clinical conditions include hypertension, anemia, and chronic opioid use.
 Figure 19.1 Expanded scope, services, goals, and deliverables of the outpatient preoperative clinic. |
 Figure 19.2 Changing name of an organization’s existing but now outdated preanesthesia clinic. |
A key distinction is that a preoperative medical consultation can only be justified as an additional billable E/M service in a subset of surgical patients, who have been identified based on preoperative risk stratification. This can be done using a formal risk stratification tool (8). It can be done using a combination of the ASA Physical Status (PS) score, the intensity of the planned surgical procedure, or “red flags” on a preoperative screening questionnaire (9). Patients identified as “high risk” can then legitimately receive a preoperative consultation for clinical optimization and additional case management (Fig. 19.3).
There are three Current Procedural Terminology (CPT) criteria required to bill for a consultation, rather than E/M:
Your opinion or advice regarding the evaluation and/or management of a specific problem is requested by another physician or appropriate source.
The request and need for the consultation is documented in the patient’s medical record.
You prepare a written report of your findings, including any services ordered or performed, and provide it to the requesting healthcare provider.
If appropriately worded and vetted, a paper or electronic “Preoperative Patient Screening and Consult Questionnaire”—that is jointly completed by the patient and a healthcare provider—can fulfill the above CPT consultation criteria 1 and 2.
Billing Codes for a Preoperative Medical Consultation and Follow-Up Visits
Billing for initial and follow-up outpatient E/M services is based on a combination of (a) the extent of the patient evaluation (number of elements contained in the history
and physical examination) and (b) the complexity of medical decision making (straightforward, low, moderate, or high). The range of billing codes includes:
and physical examination) and (b) the complexity of medical decision making (straightforward, low, moderate, or high). The range of billing codes includes:
 Figure 19.3 Preoperative consultation process for clinical optimization and additional case management. |
