The anesthesia record documents the physiologic status of a patient during the delivery of an anesthetic for a diagnostic/therapeutic procedure. Core requirements for an anesthesia record include permanence, legibility, and authentication of provider authoring the record.60,61 The Anesthesia Patient Safety Foundation endorses the use of technology that enables the automatic recording of physiologic measurements during anesthetic delivery.4 AIMS can be configured to automatically capture data from physiologic monitors and have been shown to improve the quality of data captured in the anesthesia record.37,49,56,61,62,81 Enabling the provider to focus on patient care, rather than completing the anesthetic record by hand during the anesthetic course, is one benefit of such systems. Other AIMS benefits include automated record keeping, improving completion of preoperative anesthesia evaluation, increased anesthesia record accessibility, and reporting discrete data to local and national reporting agencies.12,21,25,31,39,45,61,62 Physiologic data captured with AIMS can be applied for secondary use, such as describing the hemodynamic profile of hypnotic drugs used for induction of general anesthesia.82 In a similar study, Hartmann et al.83 describe the hemodynamic response after administration of spinal anesthesia with data derived from automated hemodynamic recordings.
However, AIMS documentation also can be prone to errors, such as incomplete data entry and data artifacts.37,49 Therefore, it is critical that the user interface be configured in a way that facilitates data entry at the point of care without compromising other functions. Some have argued that vigilance may be compromised when using an electronic anesthesia record. Davis et al.56 studied this phenomenon by assessing anesthesiologists’ recall of important events during a case when using AIMS-versus-paper anesthesia records. The study was conducted in 2 institutions and found no difference between the ability of 2 groups to recall important data.
AIMS products are fairly specialized in their function. Nevertheless, there are vendors that integrate AIMS with the hospital-wide EHRs and others that provide products with partial certifications that have specific functions for anesthesiologists. Although meeting MU requirements may be a primary concern for some, important features and considerations provided by AIMS beyond the scope of the certification process must be considered. It is worth noting that many features that are desirable in AIMS may not fit into the MU criteria. For example, a system that provides reliable documentation and improves workflow may be a great asset for improving OR efficiency and safety, but these features would not contribute to the MU attestation.
Features that include preoperative evaluation integration with the anesthesia record, documentation, and clinical decision support applications during the course of an anesthetic, OR resource management, postoperative and recovery phase, and transfer of care (Table 4) are useful and likely crucial, value-added benefits. For example, an AIMS that integrates with the hospital medication administration record (MAR) database can provide a record of medications administered in the OR that is visible to the entire hospital. During surgery, medication administration reminders have been shown to improve adherence to timely administration of prophylactic antibiotics, β-blockers, and adherence to postoperative nausea and vomiting prevention guidelines in various settings.9,22,24,36,43,53,55,84–86 Furthermore, integration of the AIMS medication record with the hospital MAR can improve transfer of care and timing of postoperative medications such as antibiotics. Postoperative antibiotic dosing can be coordinated by clear identification of the last charted dose of antibiotics in the AIMS record and also can be incorporated into the hospital MAR. Additional features of interest include importing data regarding allergies, active medications, problem lists, and laboratory information into the preoperative evaluation record to assist in data collection.
Intraoperative documentation, whether paper based or electronic, carries the risk of data entry errors. AIMS depend on the user interface to facilitate accurate and thorough data entry while caring for a patient. AIMS offer several advantages over paper records, such as improving completeness of anesthesia record and automatic data capture from the anesthesia machine and physiologic monitors.62,64 Processes that rely on manual data entry are always subject to errors, such as omission or incorrectly documented values, regardless of the use of paper-based or AIMS-based records.20,62,87 Several authors have shown that providing electronic reminders during the course of a procedure improves the rate of completion of key elements essential to achieve compliance benchmarks.10,11,23,44,63,69–71 Improving compliance with documentation, such as the guidelines from the Surgical Care Improvement Project, through electronic reminders embedded in AIMS has demonstrated measurable decreases in complications such as surgical site infections.44 Point-of-care alerts for gaps in hemodynamic monitoring intervals also have been shown to decrease the frequency of prolonged gaps in blood pressure documentation during the course of anesthesia care.50 Dexter et al.17 performed a prospective simulation study to determine whether OR managers (anesthesiology, nursing, and support staff) performed better or worse with a system that displayed recommended actions for daily OR management. Individuals made better quality decisions when given access to the command display system that provided recommended course of action and appropriately ignored recommendations that would compromise patient safety.17
There is ongoing development to refine clinical decision support applications to improve the delivery of anesthesia care in various institutions. Blum et al.65 described a system that displays best practice guidelines for ventilation management in patients at risk for acute lung injury. The clinical decision support system provided recommendations to decrease tidal volume to 6 mL/kg and demonstrated a clinically significant reduction in mean tidal volume between the study arms. Nair et al.43,53,63,66 describe the Smart Anesthesia Manager system, which integrates data from AIMS to provide clinical decision support applications, such as point-of-care reminders for antibiotic, and β-blocker administration. The Smart Anesthesia Manager system also has been configured to provide real-time alerts during management of hypotension and hypertension, which demonstrated reduction of the number of episodes of hypotension by displaying an alert when low blood pressure measurements coincided with MAC >1.25 of volatile drugs.66 Clinical decision support applications also can be applied to the preoperative planning process, such as by determining the probability of transfusion associated with specific procedure groups.67,68
Patient flow through the perioperative environment involves complex processes requiring coordination among multidisciplinary care teams and transitions between the preoperative holding area, the OR, and the postoperative care area. Stakeholders include surgeons, anesthesiologists, and nursing and support personnel who require access to varied information to perform tasks. Tracking patient status and progress through the perioperative area can be achieved with electronic status boards.16,17,20,27,32,88,89 The electronic status boards can be configured to receive real-time event updates to reflect preoperative readiness and intraoperative events as well as postoperative status.32,69 These boards can be further configured to capture data from each OR and from locations throughout a hospital that involve the delivery of anesthesia, sedation services, or nursing care. These updates can provide actionable information to individuals beyond the point of care.16,20,27,32,89
Anesthesia staff assignments for educational programs also can benefit from systems with electronic procedure tracking. Wanderer et al.79 describe the implementation of a system that compares a resident’s case log to the list of required case numbers from the Accreditation Council for Graduate Medical Education (ACGME). The system allows teams that assign anesthesia cases to consider a resident’s experience and case requirements, whereas residents and residency programs can also keep track of educational activity. Simpao et al.42 describe a system that automates the data entry process for anesthesia resident case logs in the ACGME case log system. The automated system relies on text-parsing procedure descriptions and achieved 97% accuracy for the corresponding ACGME category. Furthermore, they demonstrated that more than half of residents underreport or overreport their case documentation by ≥5%.
Electronic status boards can be a vehicle to disseminate accurate, real-time information about patient and OR status, which can facilitate coordination of resources in the OR.88,89 OR management teams can analyze OR performance and resource utilization, which can assist in planning and daily management.70,90 Ideally, the software used to manage the OR schedule and daily operations integrates with the data from the AIMS records, the hospital’s EHR, and other information management systems that incorporate nursing documentation and the OR schedule.60,71,82 Previous work has attempted to develop algorithms to assist in OR management tasks, such as transferring cases from one room to another to minimize delays and personnel utilization.17,33,59,89,90
Designing daily OR block schedules for individual surgeons and services can be optimized to enhance productivity and minimize underused OR time and patient waiting times.41,59,70,72,91 Applying OR management software to improve decision making related to personnel, and resource assignment to optimize flow and productivity, has shown promise in retrospective and simulation studies.17,33 Dexter et al.17 demonstrated that in a simulated OR schedule, nurses and anesthesiologists made better decisions when given access to a command display with recommendations. When the recommendations compromised patient safety, the teams appropriately ignored them. Doebbeling et al.59 describe the role of leadership in investing and enabling the application of analytical and support applications to optimize both patient and staffing schedules to improve OR efficiency. Broka et al.91 conducted a retrospective evaluation of case duration and applied the information prospectively to adjust the surgical block schedule, leading to a reduction in number of procedures exceeding the allotted block time as well as the surgical waiting list during the study period. Elective block time may be affected by external factors, such as hospital capacity. Dexter and Lubarsky92 analyzed length-of-stay data for surgical and nonsurgical patients and found that the average length of stay for surgical patients is shorter and should be considered when deciding to cancel elective procedures on the grounds of hospital capacity.
Developing efficient models for OR block time relies on data analytics and intimate knowledge of the unique institutional dynamics in the perioperative environment.59 Surgical procedures may be scheduled for a specific amount of time based on a surgeon’s estimates, averages of actual case duration for a particular surgeon, or a combination of techniques. Yet patient factors, such as coexisting disease and unique characteristics, may present unforeseen challenges that contribute to longer or shorter than anticipated procedure times and contribute to gaps in the OR schedule. Surgical block times and resource allocation can be optimized with OR utilization data from daily operations.59,70,72,91 In addition to optimizing block schedules and resources, schedule optimization also can improve patient waiting times and the number of patients in the holding area by minimizing delays and providing clear expectations for fasting time and waiting-room time.41 Patients also can be risk stratified to optimize ambulatory procedures and those requiring overnight admission.73 Agnoletti et al.70 describe their experience incorporating data analysis techniques, which allowed the restructuring of the OR schedule to minimize unscheduled procedures and overtime staff without affecting total surgical case volume.
Electronic status boards can be designed to display the surgery time in several formats. A particular problem revolves around displaying information for procedures that are taking longer than anticipated, such as displaying the time remaining for a procedure that was scheduled to end at 4:00 PM at 4:30 PM. Sorge93 described an unsuccessful attempt to predict actual surgical time with an OR management system that relied solely on historical case duration. Electronic status boards may be configured to display the expected procedure end time, which does not convey actionable information to individuals outside the OR, as a procedure may be finished ahead of schedule or last longer than planned.74 Tiwari et al.74 describe a system that displays the expected remaining time for a surgical procedure rather than the expected time of completion.74 The system relies on status updates, such as indicating when the surgeons begin to close the incision. This study describes one of the challenges of electronic status boards: variations in presentation of information related to case duration.
Tracking patients through the perioperative process continues to benefit from ongoing development in OR management systems.69 Status boards have been applied for uses beyond the immediate needs of running an OR. Sullivan32 describe the development of a preoperative tracking system that allows the perioperative team to monitor patients’ readiness for the OR days before their scheduled procedure. Dexter et al.16 and Smallman and Dexter41 describe systems implemented to optimize individual preoperative fasting time instructions based on predictors of procedure duration for the preceding surgical procedures in a specific OR. Similarly, the transition from the OR to the recovery area can be a source of delays, particularly if nursing staff is not sufficient to manage the expected patient volume. Status boards can alert the recovery room of an imminent arrival. Dexter18 and Driscoll et al.20 describe methodologies to systematically evaluate the cause of delays related to transporting patients to the recovery area. Ehrenfeld et al.80 describe the initial implementation of an alert system to assist the postanesthesia care unit (PACU) in assigning beds to patients from ORs that would result in reduction of OR delays from unavailable PACU beds. Although the system was functional, it had no effect on reducing OR delays due to unavailable PACU beds.
Several groups have attempted, with varied success, to develop predictive systems to improve the accuracy of the OR schedule.34,41,74,93 Although status boards alone have not been shown to improve OR efficiency, the ability to track real-time use of the ORs and patient flow is valuable for disseminating information in the OR complex, assisting daily schedule management including staffing assignments, as well as for strategic planning at the institutional level.70,72,94 An additional benefit of OR-management systems used for schedule monitoring and evaluation of operational data is that they can provide critical insight for strategic OR-management decisions.27,33,59,70,72,91 Ultimately, the strength of any information management system depends on all of the processes that govern data entry in the institution.
Anesthesiologists serve as patient safety advocates by participating in national data repositories used to establish benchmarks for outcomes such as the frequency of adverse events.28,75–78,95–107 These efforts have relied traditionally on voluntary reporting, a method that can often fail to reliably capture adverse events.51,96–98 Benson et al.98 compared the incidence of adverse events between manual reporting and automatic detection and demonstrated a greater rate of detection with automated systems. Techniques that either automate event reporting or incorporate reporting into the clinical workflow have been shown to increase the rate of reported events.46,51,96–98,108 Incident reporting systems are critical in detecting rare complications and can set the foundation for hypothesis generation and quality improvement initiatives.77
In the United States, MU stage 3 will focus on automating the process for delivering adverse event reports for the purpose of conducting population-level studies. Indeed, several agencies are collecting anesthesia-related, population-level data from hospitals throughout the country, including the Anesthesia Quality Institute, the Multicenter Perioperative Outcomes Group, Wake Up Safe, and the Pediatric Regional Anesthesia Network.57,58,75–77
Meanwhile, automated AIMS incident reporting systems have been implemented in other countries, including the Australian Incident Monitoring database, the German quality project, and the United Kingdom National Reporting and Learning systems.12,13,25,39,45,99–104 These systems allow for automatic AIMS data capture, which is then compiled at the national level to evaluate adverse event rates (e.g., medication errors), perform root cause analysis, and study the incidence of morbidity and mortality studies.78,105–107
The federal incentive program for implementation and MU of the EHR technology provides opportunities for EPs and EHs to receive federal incentive payments if they are able to demonstrate compliance with MU eligibility criteria. Anesthesiologists are currently allowed automatic exemption from participation in the program but may choose to enroll in MU eligibility and collect federal incentive payments. The criteria for provider and hospital eligibility are different under Medicare and Medicaid rules, although an individual or institution may receive incentive compensation from only one of the programs.
Anesthesiologists may be eligible to participate in the MU program and to receive incentives under certain scenarios as specified by the Medicare and Medicaid guidelines. Before enrolling in the MU program, anesthesiologists should consult with institutional MU experts as well as their local regional health information organization to verify eligibility and ability to meet reporting requirements. It may be difficult to comply with all of the reporting measures if anesthesiologists only have access to the data in a standalone AIMS platform, or for anesthesiologists practicing in several hospitals, particularly if the hospitals do not share EHR systems. Much of the data required for MU attestation can be obtained from certified EHR software.
CMS is continually defining MU criteria, which is currently divided into 3 stages. The criteria for the first 2 stages have been fully defined, although modifications to the criteria within these stages do occur as needed. The third stage is still under development. In general, EPs and EHs begin attestation in MU stage 1 and demonstrate compliance during a 2-year reporting period before advancing to stage 2 and 2 years after stage 2 before advancing to stage 3. Initially, providers will receive incentive compensation for participating in MU attestation. Providers who are eligible but do not participate in MU will be subject to reimbursement reductions of 1% of their annual Medicaid reimbursement. The reduction will increase each year by 1%, potentially to a maximum of 5%, unless a hardship exemption is granted.
CMS and the ONC continue to provide guidance for achieving MU attestation through regional extension centers for EHR systems that meet partial or full HITECH certification criteria. HITECH certification ensures the technology will deliver required functionality for MU, yet the requirements are incomplete with respect to important features needed to improve patient safety and practice efficiency during anesthetic care. The benefit of widespread EHR adoption and use, including AIMS, is to improve the quality of individual care through automated documentation of physiologic monitoring, optimizing quality and performance with clinical decision support applications for the patient and OR as a whole, and, ultimately, by contributing to population health tracking to guide quality improvement efforts.
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