- Mobile Health
- Informed Consent
- Anesthesia Information Management Systems
- Claims Analysis
Clinical Associate Professor, Anesthesiology, Perioperative and Pain Medicine
Fellowship: Stanford University Anesthesiology Residency (2011) CA
Residency: Medical University of South Carolina Registrar (2010) SC
Internship: Medical University of South Carolina Registrar (2007) SC
Board Certification: Anesthesia, American Board of Anesthesiology (2011)
Medical Education: Northwestern University Feinberg School of Medicine (2005) IL
Risk of Epidural Hematoma after Neuraxial Techniques in Thrombocytopenic Parturients: A Report from the Multicenter Perioperative Outcomes Group.
2017; 126 (6): 1053-1063
Thrombocytopenia has been considered a relative or even absolute contraindication to neuraxial techniques due to the risk of epidural hematoma. There is limited literature to estimate the risk of epidural hematoma in thrombocytopenic parturients. The authors reviewed a large perioperative database and performed a systematic review to further define the risk of epidural hematoma requiring surgical decompression in this population.The authors performed a retrospective cohort study using the Multicenter Perioperative Outcomes Group database to identify thrombocytopenic parturients who received a neuraxial technique and to estimate the risk of epidural hematoma. Patients were stratified by platelet count, and those requiring surgical decompression were identified. A systematic review was performed, and risk estimates were combined with those from the existing literature.A total of 573 parturients with a platelet count less than 100,000 mm who received a neuraxial technique across 14 institutions were identified in the Multicenter Perioperative Outcomes Group database, and a total of 1,524 parturients were identified after combining the data from the systematic review. No cases of epidural hematoma requiring surgical decompression were observed. The upper bound of the 95% CI for the risk of epidural hematoma for a platelet count of 0 to 49,000 mm is 11%, for 50,000 to 69,000 mm is 3%, and for 70,000 to 100,000 mm is 0.2%.The number of thrombocytopenic parturients in the literature who received neuraxial techniques without complication has been significantly increased. The risk of epidural hematoma associated with neuraxial techniques in parturients at a platelet count less than 70,000 mm remains poorly defined due to limited observations.
View details for DOI 10.1097/ALN.0000000000001630
View details for PubMedID 28383323
The Heart of the Matter: Increasing Quality and Charge Capture from Intraoperative Transesophageal Echocardiography.
A & A case reports
2016; 6 (8): 249-252
Although transesophageal echocardiography is routinely performed at our institution, there is no easy way to document the procedure in the electronic medical record and generate a bill compliant with reimbursement requirements. We present the results of a quality improvement project that used agile development methodology to incorporate intraoperative transesophageal echocardiography into the electronic medical record. We discuss improvements in the quality of clinical documentation, technical workflow challenges overcome, and cost and time to return on investment. Billing was increased from an average of 36% to 84.6% when compared with the same time period in the previous year. The expected recoupment of investment for this project is just 18 weeks.
View details for DOI 10.1213/XAA.0000000000000169
View details for PubMedID 27082233
- "Nothing about us without us"-patient partnership in medical conferences. BMJ (Clinical research ed.) 2016; 354: i3883-?
A Case Illustrating the Costs of Quality Improvement: Nine Months to Move Needles and Syringes on the Anesthesia Cart.
A & A case reports
2015; 5 (5): 88-90
Powerful entities are pushing physicians to become more involved with quality improvement (QI). We report a QI project to standardize and improve the ergonomics of the anesthesia medication and supply cart. Simply obtaining approval to make minor changes to the cart involved 54 phone calls, 164 e-mails, 4 presentations, 2 forms, 9 meetings, and 4 months of time. Confusion over fiscal matters further delayed the project by an additional 3 months. A combination of competing regulations, administrative overprocessing, and the lack of dedicated QI financial resources made simple improvements a challenge. The costs of participating in QI deserve attention.
View details for DOI 10.1213/XAA.0000000000000148
View details for PubMedID 26323036
Bariatric Surgery Operating Room Time-Size Matters
2015; 25 (6): 1078-1085
The goal of this study was to document the relationship between BMI and the components of bariatric surgical operating room (OR) time.The Stanford Translational Research Integrated Database Environment identified all patients who underwent laparoscopic Roux-en-Y gastric bypass procedures at Stanford University Medical Center between May 2008 and November 2013. The 434 patients were divided into 3 groups: group 1 (n = 213) BMI ≥35 to <45 kg/m(2), group 2 (n = 188) BMI ≥45.0 to <60 kg/m(2), and group 3 (n = 33) BMI ≥60 kg/m(2). The primary variable measured was total operating room time, defined as beginning when the patient entered the OR until the moment the patient physically left the OR. Secondary variables were anesthetic induction time, nursing preparation time, operation time, time for emergence from anesthesia, and total length of hospital stay.Increasing BMI was associated with increased total OR time (group 1 = 202 min, group 2 = 215 min, group 3 = 235 min), mainly due to longer operation time (group 1 = 147 min, group 2 = 154 min, group 3 = 163 min). Anesthetic induction (group 1 = 17 min, group 2 = 18 min, group 3 = 23 min) and emergence times (group 1 = 12 min, group 2 = 12 min, group 3 = 22 min) were also significantly longer in the largest patients.Operating room schedules and plans for resource utilization should recognize that the same bariatric procedure will require more time for patients with BMI >60 kg/m(2) than for smaller bariatric patients.
View details for DOI 10.1007/s11695-015-1651-5
View details for Web of Science ID 000354216500022
View details for PubMedID 25802066
Scheduling of procedures and staff in an ambulatory surgery center.
2014; 32 (2): 517-527
For ambulatory surgical centers (ASC) to succeed financially, it is critical for ASC managers to schedule surgical procedures in a manner that optimizes operating room (OR) efficiency. OR efficiency is maximized by using historical data to accurately predict future OR workload, thereby enabling OR time to be properly allocated to surgeons. Other strategies to maintain a well-functioning ASC include recruiting and retaining the right staff and ensuring patients and surgeons are satisfied with their experience. This article reviews different types of procedure scheduling systems. Characteristics of well-functioning ASCs are also discussed.
View details for DOI 10.1016/j.anclin.2014.02.020
View details for PubMedID 24882135
Obesity increases operating room times in patients undergoing primary hip arthroplasty: a retrospective cohort analysis.
Background. Obesity impacts utilization of healthcare resources. The goal of this study was to measure the relationship between increasing body mass index (BMI) in patients undergoing total hip arthroplasty (THA) with different components of operating room (OR) time. Methods. The Stanford Translational Research Integrated Database Environment (STRIDE) was utilized to identify all ASA PS 2 or 3 patients who underwent primary THA at Stanford Medical Center from February 1, 2008 through January 1, 2013. Patients were divided into five groups based on the BMI weight classification. Regression analysis was used to quantify relationships between BMI and the different components of total OR time. Results. 1,332 patients were included in the study. There were no statistically significant differences in age, gender, height, and ASA PS classification between the BMI groups. Normal-weight patients had a total OR time of 138.9 min compared 167.9 min (P < 0.001) for morbidly obese patients. At a BMI > 35 kg/m(2) each incremental BMI unit increase was associated with greater incremental total OR time increases. Conclusion. Morbidly obese patients required significantly more total OR time than normal-weight patients undergoing a THA procedure. This increase in time is relevant when scheduling obese patients for surgery and has an important impact on health resource utilization.
View details for DOI 10.7717/peerj.530
View details for PubMedID 25210656
View details for PubMedCentralID PMC4157296
- Obesity increases operating room times in patients undergoing primary hip arthroplasty: a retrospective cohort analysis. PeerJ 2014; 2
Game theory: Applications for surgeons and the operating room environment
2012; 152 (5): 915-922
Game theory is an economic system of strategic behavior, often referred to as the "theory of social situations." Very little has been written in the medical literature about game theory or its applications, yet the practice of surgery and the operating room environment clearly involves multiple social situations with both cooperative and non-cooperative behaviors.A comprehensive review was performed of the medical literature on game theory and its medical applications. Definitive resources on the subject were also examined and applied to surgery and the operating room whenever possible.Applications of game theory and its proposed dilemmas abound in the practicing surgeon's world, especially in the operating room environment.The surgeon with a basic understanding of game theory principles is better prepared for understanding and navigating the complex Operating Room system and optimizing cooperative behaviors for the benefit all stakeholders.
View details for DOI 10.1016/j.surg.2012.06.019
View details for Web of Science ID 000310943900020
View details for PubMedID 22862903
Anesthesia Information Management Systems: Past, Present, and Future of Anesthesia Records
MOUNT SINAI JOURNAL OF MEDICINE
2012; 79 (1): 154-165
Documenting a patient's anesthetic in the medical record is quite different from summarizing an office visit, writing a surgical procedure note, or recording other clinical encounters. Some of the biggest differences are the frequent sampling of physiologic data, volume of data, and diversity of data collected. The goal of the anesthesia record is to accurately and comprehensively capture a patient's anesthetic experience in a succinct format. Having ready access to physiologic trends is essential to allowing anesthesiologists to make proper diagnoses and treatment decisions. Although the value provided by anesthesia information management systems and their functions may be different than other electronic health records, the real benefits of an anesthesia information management system depend on having it fully integrated with the other health information technologies. An anesthesia information management system is built around the electronic anesthesia record and incorporates anesthesia-relevant data pulled from disparate systems such as laboratory, billing, imaging, communication, pharmacy, and scheduling. The ability of an anesthesia information management system to collect data automatically enables anesthesiologists to reliably create an accurate record at all times, regardless of other concurrent demands. These systems also have the potential to convert large volumes of data into actionable information for outcomes research and quality-improvement initiatives. Developing a system to validate the data is crucial in conducting outcomes research using large datasets. Technology innovations outside of healthcare, such as multitouch interfaces, near-instant software response times, powerful but simple search capabilities, and intuitive designs, have raised the bar for users' expectations of health information technology.
View details for DOI 10.1002/msj.21281
View details for Web of Science ID 000299033500016
View details for PubMedID 22238048
Analysis of 4999 Online Physician Ratings Indicates That Most Patients Give Physicians a Favorable Rating
JOURNAL OF MEDICAL INTERNET RESEARCH
2011; 13 (4)
Many online physician-rating sites provide patients with information about physicians and allow patients to rate physicians. Understanding what information is available is important given that patients may use this information to choose a physician.The goals of this study were to (1) determine the most frequently visited physician-rating websites with user-generated content, (2) evaluate the available information on these websites, and (3) analyze 4999 individual online ratings of physicians.On October 1, 2010, using Google Trends we identified the 10 most frequently visited online physician-rating sites with user-generated content. We then studied each site to evaluate the available information (eg, board certification, years in practice), the types of rating scales (eg, 1-5, 1-4, 1-100), and dimensions of care (eg, recommend to a friend, waiting room time) used to rate physicians. We analyzed data from 4999 selected physician ratings without identifiers to assess how physicians are rated online.The 10 most commonly visited websites with user-generated content were HealthGrades.com, Vitals.com, Yelp.com, YP.com, RevolutionHealth.com, RateMD.com, Angieslist.com, Checkbook.org, Kudzu.com, and ZocDoc.com. A total of 35 different dimensions of care were rated by patients in the websites, with a median of 4.5 (mean 4.9, SD 2.8, range 1-9) questions per site. Depending on the scale used for each physician-rating website, the average rating was 77 out of 100 for sites using a 100-point scale (SD 11, median 76, range 33-100), 3.84 out of 5 (77%) for sites using a 5-point scale (SD 0.98, median 4, range 1-5), and 3.1 out of 4 (78%) for sites using a 4-point scale (SD 0.72, median 3, range 1-4). The percentage of reviews rated ≥75 on a 100-point scale was 61.5% (246/400), ≥4 on a 5-point scale was 57.74% (2078/3599), and ≥3 on a 4-point scale was 74.0% (740/1000). The patient's single overall rating of the physician correlated with the other dimensions of care that were rated by patients for the same physician (Pearson correlation, r = .73, P < .001).Most patients give physicians a favorable rating on online physician-rating sites. A single overall rating to evaluate physicians may be sufficient to assess a patient's opinion of the physician. The optimal content and rating method that is useful to patients when visiting online physician-rating sites deserves further study. Conducting a qualitative analysis to compare the quantitative ratings would help validate the rating instruments used to evaluate physicians.
View details for DOI 10.2196/jmir.1960
View details for PubMedID 22088924
Challenges that limit meaningful use of health information technology
CURRENT OPINION IN ANESTHESIOLOGY
2010; 23 (2): 184-192
Health information technology (HIT) is perceived as an essential component for addressing inefficiencies in healthcare. Without understanding the challenges that limit meaningful use of HIT, there is a high chance that institutions will convert complex paper-based systems to expensive digital chaos.Clinical information systems do not communicate with each other automatically because integration of existing data standards is lacking. Data standards for medical specialties need further development. Database architectures are often designed to support single clinical applications and are not easily modified to meet the enterprise-wide needs desired by all end-users. Despite the improvements in charge capture and better access to health information the realized savings and impact on patient throughput is not enough to cover the cost of the technology, maintenance, and support. HIT is necessary for improved quality of care but it increases the cost of doing business. Poor user interface and system design hinders clinical workflow and can result in wasted time, poor data collection, misleading data analysis, and potentially negative clinical outcomes. Healthcare organizations have little recourse if a vendor fails to deliver as intended once the vendor's system becomes embedded into the organization. Decisions on technology acquisitions and implementations are often made by individuals or groups that lack clinical informatics expertise.Government incentives to increase HIT will likely result in a more computerized clinical environment. Understanding the challenges can help avoid costly mistakes. The future looks promising but caution is warranted, as achievement of full benefits of HIT requires addressing significant challenges.
View details for DOI 10.1097/ACO.0b013e328336ea0e
View details for Web of Science ID 000275817300011
View details for PubMedID 20084001