PGA 2011 – Merge Healthcare, Teecie Cozad

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Dr. Howard Rollins, EHRtv AIMS specialist and medical consultant, interviews Teecie Cozad of Merge Healthcare.

Category: AIMS, Uncategorized
Date: February 8, 2012
Views:5,141 views

Dr. Howard Rollins: This is Dr. Howard Rollins with EHRtv. I have the pleasure today of speaking with Teecie Cozad who is a Perioperative Clinical Consultant for Merge Healthcare. Teecie, thank you very much for being with us today.

Teecie Cozad: My pleasure!

Dr. Howard Rollins: I have a few questions for you. Now, my understanding is that AIMS is really kind of at its early stages of adoption even though it’s been around for a while. Do you think that’s true and if so, why?

Teecie Cozad: I do think that’s true. I think the primary reasons are that, there are several. One, when an AIMS is purchased. It’s purchased by the hospital but most of the AIMS practitioners, the anesthesiologists, and CRNAs, and residents, the anesthesiologists are part of a private group so they are typically contracted with the hospital.

Dr. Howard Rollins: Right.

Teecie Cozad: So you have a set of users who are not hospital employees but the hospital is purchasing the system. That’s probably one of the primary ones. The second reason is that anesthesiologists have been hesitant–

Dr. Howard Rollins: Right.

Teecie Cozad: – to move forward with an electronic record for reasons of fear of medical liability, they’re afraid that it will put things in a record that aren’t necessarily reflective of the case, and they don’t want it to slow them down or to take their attention away from the patient.

Dr. Howard Rollins: Give me a few examples of why having an AIMS improves safety in the operating room.

Teecie Cozad: In our system, we have several methods that it does that. Number one, we have a method of capturing the patient’s medical history from them via the web and pass that information on to the Anesthesia Preoperative Record as well as to the Nursing Record.

Dr. Howard Rollins: How was that information put into the system to begin with? Was that from the patient?

Teecie Cozad: From the patient, via–

Dr. Howard Rollins: Where– where do they do that?

Teecie Cozad: From home or even a surgeon’s office as soon as they–

Dr. Howard Rollins: There is a patient portal.

Teecie Cozad: There is a patient portal. The nice thing about our particular patient portal is it also helps to triage patients preoperatively and smooth out throughput. But back to the safety issue.

Dr. Howard Rollins: Right.

Teecie Cozad: Joint Commission found that the number one reason that anesthetic accidents did occur was lack of communication about the patient. So that’s number one.

Dr. Howard Rollins: Right.

Teecie Cozad: Being able to communicate that information.

Dr. Howard Rollins: From the various people that are involved in the care.

Teecie Cozad: That’s exactly right. Second thing is we have a nice robust rules engine underlying hour application which means we can set up some prompts for the clinician based on what they wish to be prompted on. One of the major ways of preventing a surgical site infection for example is for the patient to receive an antibiotic within 60 minutes of incision. We have a method of prompting them to do that if the system hasn’t seen an antibiotic. So we’ll recognize what types of drugs have been given.

Dr. Howard Rollins: Right.

Teecie Cozad: And prompt them, but only for the cases that it’s important on. If it’s a cataract patient, we won’t prompt them so it’s smart, same thing for baby lock.

Dr. Howard Rollins: And this can all be set up by the user

Teecie Cozad: It’s set up during implementation.

Dr. Howard Rollins: Right.

Teecie Cozad: Those rules engines and then can be tweaked along the way as things change or, you know. We allow documentation of safe IV catheter insertion for central lines, beta-blocker delivery.

Dr. Howard Rollins: So you’re hitting on SKIP protocols and it’s clear to me, at least, I believe this will help with compliance with SKIP protocol.

Teecie Cozad: Absolutely! If a patient’s temperature drops below the agreed upon level that the institution wants to look at, we can remind them to put in a note about how they’re keeping the patient warm as well.

Dr. Howard Rollins: For me, certain items are often overlooked as being just run of the mill, you do it so you don’t think about it a lot. But I’m always concerned about patient– correct patient identification. I think that’s a very big issue because that’s one of the most avoidable and disastrous complications that I can think of.

Teecie Cozad: Absolutely.

Dr. Howard Rollins: Tell me how your system deals with correct patient identification.

Teecie Cozad: We’ve incorporated barcoding capabilities throughout the system in many ways, not only for drug delivery and scanning in advance of delivery for safety reasons, but also from the patient identification point of view. We can make sure that we are working on and selecting the correct patient by barcoding their wristband in advance of starting the case. And that is one method to be able to assure positive patient identification.

Dr. Howard Rollins: So will that wristband be put on when the patient enters the hospital?

Teecie Cozad: The hospital.

Dr. Howard Rollins: By the Admitting Department.

Teecie Cozad: By the Admitting Department; and we recognize the hospitals barcodes for account number and that sort of thing. We also have a method of making sure that the anesthesiologist documents his or her participation in the timeout. So that’s also very configurable based on the institution’s methodologies for documenting that, but that’s the other major one.

Dr. Howard Rollins: And does the system recognize different users during the same case? Say during lunch breaks or I certainly, as an anesthesiologist, would not want to have something attributed to me that I didn’t do.

Teecie Cozad: Sure. We also use barcodes scanning as our primary method, although we do other methods as well including magnetic stripe cards, etcetera. But we use a barcode for swiping into the system, saying you are here and what your role is.

Dr. Howard Rollins: Right.

Teecie Cozad: So when you are relieved for lunch, the relieving physician or clinician comes in and also–

Dr. Howard Rollins: Swipes.

Teecie Cozad: – swipes it and takes over care and immediately, within the notes of the system, it’s–

Dr. Howard Rollins: They are now responsible.

Teecie Cozad: It’s documented as medical responsibility shifted to the new person.

Dr. Howard Rollins: How about concurrency issues? How is that dealt with?

Teecie Cozad: We deal with them in real time. During that scan in, the system looks for other cases that would conflict with the concurrency levels that are set by the institution. In New York State, for example, it’s a 3:1 ratio, physician to CRNA or AA. In other states, it may be 4:1. So what the system does is it looks at the time of sign in at all concurrent cases, whether they’re opened, closed–

Dr. Howard Rollins: Right.

Teecie Cozad: – on sign in and on editing, because sometimes, you say, “Oh, this case started five minutes before I was able to look at it and sign in,” or what have you.

Dr. Howard Rollins: So it will let you know and then you can override if you need to.

Teecie Cozad: You can override if you need to but it also will show you where the open cases are, where the issues are so that you can use your other methods of communication.

Dr. Howard Rollins: Right.

Teecie Cozad: To communicate with somebody and say, “Could you please close the record in the PACU?”

Dr. Howard Rollins: Right.

Teecie Cozad: Or attach your sign out time.

Dr. Howard Rollins: So they are not concurrent.

Teecie Cozad: Right.

Dr. Howard Rollins: So now, if you had to sit here with me and tell me the few things– few things that make Merge AIMS unique and better, if you will than anybody else’s AIMS, what would you say the really big ones?

Teecie Cozad: The very largest are the intuitive user interface. It’s very easy to use and it’s all one touch documentation to a large extent which means if I’m providing anesthesia, I don’t turn my attention away from the patient.

Dr. Howard Rollins: Right.

Teecie Cozad: I also chart when it’s time for me to chart from a patient care point of view. The system is designed to– by tort, you can’t document at the same time you’re delivering care.

Dr. Howard Rollins: Right.

Teecie Cozad: So our system is designed when you have time to do that documentation to go back and document at the time things happened.

Dr. Howard Rollins: Well, along those lines, has your reimplementation’s been fairly smooth?

Teecie Cozad: Very smooth. We have a very–

Dr. Howard Rollins: How long did it take?

Teecie Cozad: They are five months. There are 8 events that occur and you know, they usually go of without a hitch.

Dr. Howard Rollins: And the users have been– are all use– the ones that you’ve gone live with, they’re still live?

Teecie Cozad: Yes. We have our very first customer. Our initial beta site customer is still live with our system. So, and that’s 12 years ago.

Dr. Howard Rollins: How do you support implementation?

Teecie Cozad: We have implementation teams which include project managers, applications specialist, hardware specialists, and engineers for interfacing.

Dr. Howard Rollins: Right.

Teecie Cozad: Who go on-site for meetings, setting up, and configuring the system and that configuration is a big plus.

Dr. Howard Rollins: Yeah. I’m really happy that you mentioned the word ‘interfacing’ because it’s so important and I know that it’s not to be taken for granted. It’s–

Teecie Cozad: No. It definitely is not.

Dr. Howard Rollins: Interfacing is a real challenge, isn’t it?

Teecie Cozad: It is a real challenge. There are many interfaces that many companies do fairly easily along with hospitals.

Dr. Howard Rollins: Right.

Teecie Cozad: Including the standard ADT, scheduling, surgical scheduling, lab interfaces, outbound records to document control, that sort of thing. Those are easy. The difficult ones are clinical integration.

Dr. Howard Rollins: Right.

Teecie Cozad: And I must say we have a very nice track record for being able to exchange clinical data like the patient’s history, things like that, with multiple EMR systems.

Dr. Howard Rollins: So the hospital is not a Merge hospital. Does it mean that they can still have a Merge AIMS?

Teecie Cozad: Yes, very definitely. In fact, the Merge AIMS is meant to co-exist and live with other hospital legacy systems. The interesting part from an anesthesiology point of view is that as part of a huge EMR, anesthesiologists don’t always get an AIMS system that works the way they work.

Dr. Howard Rollins: Right.

Teecie Cozad: As a product that started simply focused on anesthesia and its documentation and drug management and the things that are peculiar to the practice of anesthesia will put our system up there with any in terms of working with the way the anesthesiology provider works. And we have had from the beginning needed to work with other systems.

Teecie Cozad: So…

Dr. Howard Rollins: As somebody that knows as much as you do about AIMS, do you recommend that the hospital includes the anesthesiologist in the decision making process?

Teecie Cozad: Absolutely!

Dr. Howard Rollins: Do you see that that’s happening?

Teecie Cozad: Not always. Often that decision is made in the highest levels of the hospital with the CIO–

Dr. Howard Rollins: Right.

Teecie Cozad: – as one of the primary decision makers. And they should be leading that discussion and making sure that the interfaces are legitimate and that sort of thing. But the anesthesiologist chief or the person who’s really charged with making things operational within the department really need to be included in that decision and I encourage every anesthesia department head to ask questions in advance, do as much research as they can into what’s available on the market.

Dr. Howard Rollins: Right.

Teecie Cozad: Our best customer is an educated customer.

Dr. Howard Rollins: One thing that really intrigues me is this barcode application. Are there any– where else will that come in handy during my case?

Teecie Cozad: Sure. Besides the patient ID and identification of the clinician who is working in the case, we also have a drug management system which is expansive or not expansive depending on how you want it implemented.

Dr. Howard Rollins: So what’s the most I can do?

Teecie Cozad: So the most you can do is we can provide a mechanism for pharmacy and anesthesia providers to get together and share information and we can provide scanning in advance of drug delivery which is a safety mechanism that hospitals are implementing in other parts of the hospital throughout the hospital. There hasn’t been really a successful way for that to happen in anesthesia.

Dr. Howard Rollins: Right.

Teecie Cozad: Because they really are one of the few places left in the practice of medicine where you create the order, dispense the drug to yourself–

Dr. Howard Rollins: Right.

Teecie Cozad: – prepare it in a syringe and deliver it to a patient with no other set of controls on that process.

Dr. Howard Rollins: No nurses, no orders written.

Teecie Cozad: Right, right. No orders really, so we have a great medication management system which optimizes that for the practice of anesthesia and allows pharmacy to keep track of things like narcotics.

Dr. Howard Rollins: Right.

Teecie Cozad: And what have you, so we–

Dr. Howard Rollins: Charge capture.

Teecie Cozad: We do, not only charge capture, but complete narcotic reconciliation within our system if the hospital wishes to implement that. We also have a drug cart that goes along with our system, which in many instances drug carts add steps to the practice and delivery of drugs and anesthesia. Ours is one with the AIMS and there’s no duplicate documentation required. It’s a very nice method of controlling and delivering drugs.

Dr. Howard Rollins: Revenue capture for the professional fee, that’s important to a lot of, to all anesthesiologists.

Teecie Cozad: Yes, it is.

Dr. Howard Rollins: We want to make sure. We know that we are losing revenue because certain things are not being charged for in the professional fee.

Teecie Cozad: Right.

Dr. Howard Rollins: Maybe lower than it should be because the coding is incorrect, etcetera.

Teecie Cozad: Right.

Dr. Howard Rollins: How will this help me?

Teecie Cozad: So we’re the only system that I know of that actually incorporates a full complete set of CPT codes and ICD-9, moving to ICD-10 codes into the system.

Dr. Howard Rollins: Are you ready for ICD-10?

Teecie Cozad: Absolutely!

Dr. Howard Rollins: Okay.

Teecie Cozad: And that’s because we use a third-party who provides us with up-to-date codes every quarter of the entire library of codes. We have user interfaces which allow very quick identification of the CPT code that’s appropriate for the surgery, the surgical diagnosis. We automatically provide coding for SKIP compliance, for example. The Category II codes as well as those things like the additional CPT codes that anesthesiologists earned by putting in a lines–

Dr. Howard Rollins: Modifiers.

Teecie Cozad: Modifier, some of the modifiers are automatic that the system recognizes those.

Dr. Howard Rollins: Like the age of the patient.

Teecie Cozad: Yes.

Dr. Howard Rollins: Or the ASA status.

Teecie Cozad: And we have a great method for capturing discontinuous time for the times in pre-upholding where the blocks are delivered that will be the primary anesthetic during the case. So we really take care of all of that automatically and send those bills directly at the close of case over to the billing group and pre-populate the billing record with those along with having available copy of the anesthesia records. So on all accounts from a provider point of view, professional fee capture has been shown to improve anywhere from 5% to 10% with the implementation of our system and days to bill drop down, at the hospital of the University of Pennsylvania, for example, down from 10 days to 1 day. That’s on the professional fee side.

Dr. Howard Rollins: Right.

Teecie Cozad: We also do some really nice revenue capture and cost-savings capabilities for the hospital. Again, this goes back to the fact that it is the anesthesia provider who’s the user of the system, often private practice group.

Dr. Howard Rollins: Right.

Teecie Cozad: And the hospital who’s purchasing it. Unlike many EMRs, we actually have a real return on investment for hospitals. When you think about it, anesthesiologists are in a very nice position from a revenue– potential revenue position with the hospital.

Dr. Howard Rollins: How so?

Teecie Cozad: They see in a hospital who does any decent surgical volume, anywhere from 40% to 60% of in-patients.

Dr. Howard Rollins: Right.

Teecie Cozad: They are actually assessing their health, naming current illnesses, and saying how those illnesses might affect their anesthesia plans, taking those into consideration. It happens. Patients coming in for a knee replacement; everything about the knee replacement in that history regarding that is great in the chart.

Dr. Howard Rollins: Right.

Teecie Cozad: But someone has failed to mention that the patient has a history of atrial fib.

Dr. Howard Rollins: Right.

Teecie Cozad: So that’s why anesthesiologists are great at and as a result, they can positively impact the granularity with which patients’ co-morbid illnesses are documented, and we provide a fabulous way to help them do that in the– even in the arcane terms that are used by medical records and CMS billing, etcetera. So we have shown a 46% increase in the hospital’s Case Mix Index just through our pre-op information capture and the ability to code that data.

Dr. Howard Rollins: That was an unbelievable answer, by the way.

Teecie Cozad: I’m sorry about that.

Dr. Howard Rollins: You really know this product well. Merge is very lucky to have you.

Teecie Cozad: Thank you.

Dr. Howard Rollins: Now I think we should take a look at the system.

Teecie Cozad: Okay. First off, right off the bat, if I am a CRNA, for example, in a care team practice in a hospital and I’m in the OR preparing the OR for the entrance of the patients, I may not have been the one who did the pre-op so having the ability to review a patient’s pre-op in advance of surgery with the touch of one button is great. This shows several things. It’s the entire pre-op of the patient, much of this information was gleaned from the patient portal where they have provided their health history, and we’re now sharing that with multiple providers.

I have the anesthesiologist has done a physical exam. That’s really the only thing they needed to add to this. Had this patient had a difficult airway during a previous case when the system was in use? It would highlight that and provide the difficult airway note right there for the provider so that they can see what was used for that airway in the past surgical procedure. But not only that, if we go to the input screen here, the first thing we typically start with is the ability to access previous records, again, with one touch. I can look back over the patient surgeries and see which records I want to see with a one touch link.

Dr. Howard Rollins: And that is something that can delay a case an hour if all of a sudden I find out outside the operating room, “I need to see the previous record”. By the time I get it, would somebody to go to the re–

Teecie Cozad: To medical records.

Dr. Howard Rollins: Medical records and yet–

Teecie Cozad: And find the old charts.

Dr. Howard Rollins: That’s right. This is–

Teecie Cozad: Right.

Dr. Howard Rollins: This is really advantage.

Teecie Cozad: And that it’s a great advantage of electronic systems. And the second thing is I am showing the first interface with the system which is a real time scheduling interface and as cases are added on or subtracted, canceled for the day, they will be added or adjusted to the system right off the bat. So that’s all great. As I start working, I could scan the patient’s wristband and have it go just to this particular patient’s record and eliminate all the others and that’s a method of positive patient ID as we discussed earlier. And then–

Dr. Howard Rollins: Let me interrupt for a minute. What would happen if you scan the patient’s wristband right there and it wasn’t the patient that was supposed to be in that room at that time?

Teecie Cozad: It doesn’t matter. It’s going to pull up the patient record who is in front of you and assign them to that room automatically.

Dr. Howard Rollins: Okay.

Teecie Cozad: The computer is set up to be designated as a certain location.

Dr. Howard Rollins: Okay.

Teecie Cozad: So it will– it doesn’t matter.

Dr. Howard Rollins: Okay, thank you.

Teecie Cozad: So this is a touchscreen which is meant to give lots of room for touching. Everything that needs to be documented can wait until it’s– you’re ready to document because the first thing of importance is taking care of the patient. We come in and set up these buttons according to your workflow and part of the robustness of the system is it knows what type of surgery or what type of anesthetic procedure you’re going to undertake. So if it’s a general anesthetic assign to certain types of cases, this is the general anesthetic view. These buttons are one touch links to everything that you need to document. We don’t want you spending any time on the computer. We really want you to be able to focus on your patient.

Dr. Howard Rollins: If the procedure changes during the procedure, and you started with a very simple procedure and the template indicated that you were doing an appendectomy but that turned into a hysterectomy–

Teecie Cozad: Sure.

Dr. Howard Rollins: – and a major bile case, will it accommodate that?

Teecie Cozad: Yes, it will. And you can change the layout with a click of the finger to any other type of layout that you have built into the system.

Dr. Howard Rollins: During the case?

Teecie Cozad: During the case, on the fly. For example, if you want to see what’s been going on with the patient on a more frequent vital signs capture basis, I can touch this 3:1 grid ratio and switch from every 15 minutes to every 3 minutes. Now I’m showing a lot of additional physiologic data that’s been captured by the system.

Dr. Howard Rollins: Because those– that is being captured whether you display it or not?

Teecie Cozad: That’s correct, that’s correct. And it’s a variable amount of time that you wish to do that. I have various capabilities. When labs come in from the lab interface, I can light up this button that say, “Hey, you’ve got labs in. You might want to view those.” And we can automatically chart these so that very quickly, you’ve just taken something that people spend minutes on the phone trying to find out, “Are my labs ready? I’m waiting for…”, for whatever. So ease of use, we’re starting at the top, working our way down, and by the time you get to the bottom here, you’ve documented an entire case of the general anesthetic.

Again, the system is smart. If the patient had come in for something short like a little tonsillectomy, the whole setup changes so that I can just very quickly document procedure start time, just that quick. One case note, yes, that’s how it’s ongoing. And then I’m essentially, except for documenting my drugs, done with my documentation for that little short case. And for those drugs, I have various lists that I can access that really make it fast. We don’t want you to have to scroll, (laughs), and be able to very quickly say what you’ve given. We color code by drug class with both our barcodes and our screen so that you can indicate what you’ve documented. So we don’t want you to have to do much more than that in terms of documentation.

Dr. Howard Rollins: We talked a little before about SKIP protocol. Show me how that would work here.

Teecie Cozad: So let me go back to my intra-op here where the patient is going to require an antibiotic. I have just documented that I am ready for induction, only the system hasn’t seen an antibiotic yet. So our method of alerting you to that fact is to give you the note that you need to document for that antibiotic delivery.

Dr. Howard Rollins: Okay.

Teecie Cozad: And I haven’t actually documented any drug delivery. I can mark things that are required to be filled out if I wish and I can document that antibiotic. It’s going to show me what drugs I have documented so far.

Dr. Howard Rollins: Right.

Teecie Cozad: And when I want to add a medication, I can either add a bolus or an infusion. In this case, we’ll add an– now, one of the capabilities of the system is to remind you that this patient has shown an allergic reaction to this. This patient has– the reaction was shortness of breath. You decide whether that’s what you want to give or not. We also have the ability to accommodate intolerances.

Dr. Howard Rollins: Right. Like by hitting “Okay”, I, as the anesthesiologist, I have acknowledged that I’ve seen that and I know it.

Teecie Cozad: That you’ve seen that and you know it. And you can give the drug based on what you guys want to do.

Dr. Howard Rollins: Right.

Teecie Cozad: Or not. But in case you do, we’ll go ahead and put this in. It is now not only going to appear in my note but it’s going to give the exact time here for delivery as in up here on the record. And I’ve just– it’s going to let me do some things here, but. So I’ve documented in both in a note for medical records so that they can do the hospital side of SKIP compliance.

Dr. Howard Rollins: Right.

Teecie Cozad: And in the drug grid as well. All of our notes are meant to be really documentation by exception.

Dr. Howard Rollins: Right.

Teecie Cozad: As long as everything is correct there, and 90% plus of the time it is, that’s all you have to do. If you need to add a note, great! It’s very simple. If I want to back time that because it happened actually a few minutes ago, I can do that. I can also select a time stamp so that I don’t have to go back and see what time something was done. It will automatically match my times so that you don’t even have to go back and edit those times.

Dr. Howard Rollins: So let’s move on to the Recovery Room now. The case is over.

Teecie Cozad: Yes.

Dr. Howard Rollins: And we’re about to transfer the patient.

Teecie Cozad: Right.

Dr. Howard Rollins: First of all, will people outside the operating room such as PACU know that the case is over? Is there a way to indicate that?

Teecie Cozad: Yes. We do have an electronic white board which can be shown in the Recovery Room as well as in the OR locations near the, where you typically will see a white erasable board.

Dr. Howard Rollins: Right.

Teecie Cozad: And so we actually, as you document the case, induction finished, surgery started, surgery ending, etcetera, it changes the patient’s status automatically on the board. So in the PACU, they can see which patients are at emergence and soon to be coming in, and so that’s a big heads up.

Dr. Howard Rollins: Okay. So the case is over. Take us through to the PACU. What happens? Does the chart continue?

Teecie Cozad: The chart continues. We will suspend it here in the OR and then in the PACU, we will re-open.

Dr. Howard Rollins: I see.

Teecie Cozad: And again, using buttons very quickly, document handoff to the nurse so that you can say what’s going on with the patient. We have a great perioperative summary report which allows– it’s a nice handoff report and can be viewed on screen at the patient’s beside via a little tablet, touch tablet, etcetera, and this shows you the highlights, exactly what time the antibiotic was administered so they know when to give the last dose for the patient. So those reporting mechanisms really are enhanced by an electronic system.

Dr. Howard Rollins: It seems to me like you’ve thought of everything.

Teecie Cozad: Well, we’ve tried hard to think of everything, but, you know, we have great users who give us feedback. Our last version, we were able to get at 85% of our user feedback and until you use a system everyday, it’s hard to see how it can be improved. But we have done– we’ve always listened to our customers and that’s been our greatest method of input for what we need to develop.

Dr. Howard Rollins: It sounds like a smart business plan. Well, thank you very much.

Teecie Cozad: Thank you so much, my pleasure.

Dr. Howard Rollins: I appreciate it. This is Dr. Howard Rollins. I’m here at the New York State Society of Anesthesiologist PGA Meeting for 2011 and I have just been speaking with Teecie Cozad of Merge Healthcare.

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