Neil Kirschen, MD, is the chief of pain management in the department of anesthesiology at South Nassau Communities Hospital in Oceanside, N.Y., and the medical director for the Pain Management Center of Long Island in New York. He is board-certified in anesthesiology, pain medicine, acupuncture and massage therapy. He has practiced anesthesia for more than 28 years.
Here Dr. Kirschen weighs in on goals for anesthesiologists to meet in the new year and ways we can expect the specialty to evolve in 2013.
Question: What is a clinical goal for anesthesiologists to meet this year?
Dr. Neil Kirschen: One goal in anesthesia is to reduce surgical infection rates. Infections increase the length of stay in the hospital setting. We should also strive for better control of intraoperative patient blood sugar and temperature. Those tend to be the hardest to achieve. We now have better monitors for intraoperative monitoring and getting blood glucose levels. We have much better ways to warm patients up. The goal of all of this is to decrease surgical infection rates. More studies are coming out showing the more normal we can keep a patient — normal temperature, normal blood sugar — the better we should be able to achieve fewer infections. Also by keeping blood pressure more normal, we will have fewer intraoperative cardiac events.
Q: How do you expect the business of anesthesia to change this year?
NK: The business side of anesthesia is becoming more corporate. Bigger groups are taking over the smaller groups. This allows one voice to be spoken to payment and insurance companies and government payors. It is both good and bad. It's good because there is more unity amongst the groups, acting as one, but you've lost the mom and pop type providers. You no longer have individual anesthesiologists but 300 or 400 anesthesiologists taking care of patients across multiple hospitals. [My anesthesia group] was taken over by a corporation. We still run the day-to-day operation, but the billing and negotiations with insurers are handled by the corporation. This makes billing easier for us, actually.
Q: Where can anesthesiologists work to decrease operating costs?
NK: You have to run a tight, lean machine. Unfortunately, because of the needs of patients and 24-hour-staffing, more anesthesiologists are being used per group now. Cutting back and doing more with less doesn't seem to be the trend. We are going to have to bring on more people because there are more and more coverage areas, including hospitals, outpatient settings, endoscopy centers and pain clinics. We are spread out across multiple types of anesthesia locations. In attempt to save money we can look to buying equipment in bulk and getting some group discounts.
Q: What anesthesia advances have been made?
NK: Patients are sicker and are having more acute problems. To properly treat them you have to stay up on the latest technology. You have to have appropriate monitoring systems in place. Before our monitoring procedures were more haphazard but now they are very standard. The American Society of Anesthesiologists has done a great job standardizing what monitoring needs to be done during an operation. The ASA, in conjunction with the Joint Commission, has had a role in making sure patients are receiving beta blockers and antibiotics at the appropriate time. Part of the time-out before surgery that we use to identify the patient and site of surgery we are now also incorporating antibiotic usage and cardiac medication checks so everyone in the room is aware of what the patient is receiving and what needs to be given before surgery.
Q: What will be the biggest upcoming challenges?
NK: The biggest challenge is the use of electronic medical records. EMRs can be very helpful but they require a large learning curve. It can take a while to implement and customize what is needed for each location. The goal is to seamlessly integrate health records into a clinical practice, and it's the biggest challenge to do. [My practice] is in the learning curve of implementation. It has taken longer to get orders through, but the advantage later on is that picking up orders will be much more seamless.
Meaningful use is another challenge. A lot of the information required is not meant for specialties such as anesthesia. A lot of questions are hard to integrate into our specialty, such as demonstrating vital signs in real time with the depth of anesthesia. There are a lot of gray areas in anesthesia, and meaningful use requirements make it so you have to capture those gray areas. We are still leery of recording all events during an anesthetic session.
Q: How can technology be incorporated into anesthesia?
NK: We have monitors that track cerebral function. We are incorporating them into the administration of anesthesia and using them more and more, commonly under neurosurgical types of cases and large orthopedic and abdominal cases. With cerebral monitoring, the depth of anesthesia is monitored. The machines work with the EMR. The anesthesia record will have the information from the monitor in addition to what agents are being used concerning depth of anesthesia.
We can also use mobile technology with hospital schedules. We can send information faster. I used to have to call on Sunday evenings to find out what cases I would be doing the next day. Now I can find that out on my cell phone.
More Articles on Anesthesia:
ASA Looks for Anesthesia Exemption to Meaningful Use Stage 3
Noridian Adjusts Anesthesia Coverage Policy
Iowa Anesthesiologist License Reinstated After Yearlong Suspension
Here Dr. Kirschen weighs in on goals for anesthesiologists to meet in the new year and ways we can expect the specialty to evolve in 2013. Question: What is a clinical goal for anesthesiologists to meet this year?
Dr. Neil Kirschen: One goal in anesthesia is to reduce surgical infection rates. Infections increase the length of stay in the hospital setting. We should also strive for better control of intraoperative patient blood sugar and temperature. Those tend to be the hardest to achieve. We now have better monitors for intraoperative monitoring and getting blood glucose levels. We have much better ways to warm patients up. The goal of all of this is to decrease surgical infection rates. More studies are coming out showing the more normal we can keep a patient — normal temperature, normal blood sugar — the better we should be able to achieve fewer infections. Also by keeping blood pressure more normal, we will have fewer intraoperative cardiac events.
Q: How do you expect the business of anesthesia to change this year?
NK: The business side of anesthesia is becoming more corporate. Bigger groups are taking over the smaller groups. This allows one voice to be spoken to payment and insurance companies and government payors. It is both good and bad. It's good because there is more unity amongst the groups, acting as one, but you've lost the mom and pop type providers. You no longer have individual anesthesiologists but 300 or 400 anesthesiologists taking care of patients across multiple hospitals. [My anesthesia group] was taken over by a corporation. We still run the day-to-day operation, but the billing and negotiations with insurers are handled by the corporation. This makes billing easier for us, actually.
Q: Where can anesthesiologists work to decrease operating costs?
NK: You have to run a tight, lean machine. Unfortunately, because of the needs of patients and 24-hour-staffing, more anesthesiologists are being used per group now. Cutting back and doing more with less doesn't seem to be the trend. We are going to have to bring on more people because there are more and more coverage areas, including hospitals, outpatient settings, endoscopy centers and pain clinics. We are spread out across multiple types of anesthesia locations. In attempt to save money we can look to buying equipment in bulk and getting some group discounts.
Q: What anesthesia advances have been made?
NK: Patients are sicker and are having more acute problems. To properly treat them you have to stay up on the latest technology. You have to have appropriate monitoring systems in place. Before our monitoring procedures were more haphazard but now they are very standard. The American Society of Anesthesiologists has done a great job standardizing what monitoring needs to be done during an operation. The ASA, in conjunction with the Joint Commission, has had a role in making sure patients are receiving beta blockers and antibiotics at the appropriate time. Part of the time-out before surgery that we use to identify the patient and site of surgery we are now also incorporating antibiotic usage and cardiac medication checks so everyone in the room is aware of what the patient is receiving and what needs to be given before surgery.
Q: What will be the biggest upcoming challenges?
NK: The biggest challenge is the use of electronic medical records. EMRs can be very helpful but they require a large learning curve. It can take a while to implement and customize what is needed for each location. The goal is to seamlessly integrate health records into a clinical practice, and it's the biggest challenge to do. [My practice] is in the learning curve of implementation. It has taken longer to get orders through, but the advantage later on is that picking up orders will be much more seamless.
Meaningful use is another challenge. A lot of the information required is not meant for specialties such as anesthesia. A lot of questions are hard to integrate into our specialty, such as demonstrating vital signs in real time with the depth of anesthesia. There are a lot of gray areas in anesthesia, and meaningful use requirements make it so you have to capture those gray areas. We are still leery of recording all events during an anesthetic session.
Q: How can technology be incorporated into anesthesia?
NK: We have monitors that track cerebral function. We are incorporating them into the administration of anesthesia and using them more and more, commonly under neurosurgical types of cases and large orthopedic and abdominal cases. With cerebral monitoring, the depth of anesthesia is monitored. The machines work with the EMR. The anesthesia record will have the information from the monitor in addition to what agents are being used concerning depth of anesthesia.
We can also use mobile technology with hospital schedules. We can send information faster. I used to have to call on Sunday evenings to find out what cases I would be doing the next day. Now I can find that out on my cell phone.
More Articles on Anesthesia:
ASA Looks for Anesthesia Exemption to Meaningful Use Stage 3
Noridian Adjusts Anesthesia Coverage Policy
Iowa Anesthesiologist License Reinstated After Yearlong Suspension