Anesthesiology EMR and South Carolina REC

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It is challenging to find appropriate electronic medical record (EMR) software for your anesthesiology practice because there are many choices available and many factors to consider. However, this guide can help you understand what to look for in ideal EMR software for your practice in South Carolina, which will make the process easier.

First, to find the right EMR for your anesthesiology practice, you should look for software that is designed specifically for anesthesiologists or a similar specialty. Anesthesiology EMR software is designed for the unique characteristics of administering anesthesia in a variety of settings and situations. Anesthesiology is a very precise specialty where minute differences in factors such as body weight, drug interactivity, cardiac output, age, metabolism, ventilation, and timing, can influence what type and how anesthesia is administered. Ideal anesthesiology EMR software must be able to capture all this type of data.

Secondly, anesthesiologists rely heavily on medical devices to help monitor and detect abnormalities in blood pressure, heart rate, oxygen levels, etc. so your EMR software choice should also be able to integrate with blood pressure monitors, ECG, Spirometers, and other devices.

Thirdly, anesthesiologists must interact with a team of nurses and other physicians (in addition to the patient), so anesthesiology EMR systems need to be able to seamlessly export and import data from other specialty-specific EMR software. Additionally, since a critical part of your specialty involves drug interactions, you should make sure that your anesthesiology EMR has a robust alert system capable of notifying you of any potential adverse drug reactions or allergies prior to any anesthesia delivery.

At the start of software evaluation process, you should evaluate potential anesthesiology EMR based on the following criteria:

  • Practice Size: Anesthesiology EMR software is made for a certain number of users, so be sure that the software you select is appropriate for the number of anesthesiologists in your practice.
  • Systems Architecture: You can purchase two types of anesthesiology EMR software, one that is installed directly on your computer servers on-site at your practice (“client-server”) or one that is located in the “cloud” that you access via the Internet (“cloud-based” or software-as-a-service “SaaS”). Some anesthesiologists choose the client-server based EMR software since they feel more comfortable with HIPAA compliance when they are able to control underlying data on their systems, even though this system needs to be periodically maintained and upgraded. Other anesthesiologists choose cloud-based EMR software because this system can be accessed almost anywhere via the Internet. However, this accessibility makes you dependent on your Internet connection, so you need to make sure the quality and consistency of your Internet service is high. It is important to choose software with the systems architecture that best matches the needs of your practice.
  • Certification: When selecting your anesthesiology EMR, you should make sure that it is tested and certified by an ONC-Authorized Testing and Certification Body (“ONC-ATCB”). The ONC (Office of the National Coordinator for Health Information Technology) is the responsible agency for establishing EMR certification standards and certifying vendor EMR products. ONC-ATCB certification assures that your EMR has met required Meaningful Use (“MU”) objectives and measures. This is a prerequisite to obtaining MU Medicaid (up to $63,750) and Medicare (up to $44,000) incentives for adopting an EMR, and avoiding penalties for not adopting one. You can read the following articles to learn more about these topics:

To begin searching for the right anesthesiology EMR software for your practice, click HERE

Unique Features of Anesthesiology EMR systems

After narrowing down your EMR choices based on practice size, systems architecture, and certification, you can evaluate certain features that are unique to anesthesiology practices.

Such features include:
  • ICD/CPT codes specific to anesthesiology
  • Integration with critical care monitoring equipment that capture physiologic data
  • Integration with ECG, EKG and other devices
  • Capability of interacting with surgeons’ notes, perfusion records and nurses’ notes
  • Time calculator
  • Anesthesia machine (Fraser Harlake, Ohmeda, Bickford, etc.) data compatibility

Pre-designed Templates of Anesthesiology EMR Systems

Anesthesiology EMR vendors know that not all specialties are the same. While there are a lot of similarities shared by all EMR software, you need to be able to customize whatever EMR you choose to fit your specific practice needs.

To facilitate this, anesthesiology EMR vendors offer a variety of pre-designed templates such as ones tailored for:
  • Pediatric anesthesia
  • Anesthesia for obstetrics
  • Pre-operative medicine
  • Cardiac anesthesia
  • Side effects
  • Possible health complications

While selecting an anesthesiology EMR may challenging, having familiarity with the basic criteria of all EMR software, as well as some features customized for your specialty, can help you make the best choice for your practice.

What can South Carolina do for its Anesthesiologists?

Center for Information Technology Implementation Assistance in South Carolina (CITIA-SC) aids physicians, such as anesthesiologists, with the adoption of health information technology (HIT), particularly through the implementation of electronic health record (EHR) systems designed to improve quality of healthcare. This Regional Extension Center was created under the Health Information Technology for Economic and Clinical Health (HITECH) Act’s Health Information Technology Extension Program.

Purchasing certified EHR software is the first step toward achieving meaningful use of health information technology and electronic medical records (EMR). The sheer number of vendors and the complexity of choices available make choosing a suitable EHR software a daunting and time-consuming task. CITIA in South Carolina can play a crucial role in guiding anesthesiologists through the selection and implementation process of the EHR software the physicians have purchased. This Regional Extension Center is also dedicated to the broader long-term goal of supporting Health Information Exchanges development.

Preferred EHR Vendors in South Carolina

Some Regional Extension Centers offer a prequalified or selected list of EHR vendors (also known as preferred EHR vendors). These preferred EHR vendors are selected from EMR (electronic medical record) companies. They have demonstrated a commitment to South Carolina’s health information technology mission through a significant qualification and selection process. The chosen electronic health records vendors offer greater functionality enabling practices to achieve more meaningful use of EMR. Additionally, these EHR vendors offer discounted prices and standardized terms and conditions. This facilitates a smoother adoption of EHR software for the Regional Extension Center participants. Regional Extension Center members may also receive group purchasing discounts from these EHR vendors.

CITIA in South Carolina recommends preferred EHR vendors to its members only.