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Anesthesia Informatics Grows Up

Hofer, Ira S. MD*; Levin, Matthew A. MD; Simpao, Allan F. MD, MBI; McCormick, Patrick J. MD, MEng§; Rothman, Brian S. MD

doi: 10.1213/ANE.0000000000003431
Editorials: Editorial

From the *Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California

Department of Anesthesiology Perioperative and Pain Medicine, Icahn School Medicine at Mount Sinai, New York, New York

Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

§Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York

Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee.

Accepted for publication April 4, 2018.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Ira S. Hofer, MD, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at the University of California, Los Angeles, 757 Westwood Plaza, Room 3325, Westwood, CA 90095. Address e-mail to

Ten years ago, the book Anesthesia Informatics was published.1 While some of the content has not aged well (particularly the pre-iPhone “Handheld Devices” chapter), the chapters discussing the importance of bringing information technology (IT) into the practice of anesthesiology are still relevant. Anesthesia informatics adds value to the practice of anesthesia by improving our workflow, allowing research studies of perioperative physiology on a large scale, providing a more complete picture of the quality of anesthesia care, and helping us better understand the outcomes of our patients. This edition of Anesthesia & Analgesia features 2 articles2,3 that provide an objective look at how far anesthesia informatics has come and how the required skills have evolved. Both articles feature Richard Epstein and Franklin Dexter, who are perhaps the most prolific anesthesia informatics researchers since the inception of the field. Drs Epstein and Dexter have set a rigorous standard for informatics research that emphasizes which interventions provide the promised benefits and which ones do not.

In the first article, “Database Quality and Access Issues Relevant to Research Using Anesthesia Information Management System Data,”2 the authors synthesize what they have learned while publishing an astonishing 47 articles over a 10-year period. The authors provide a detailed and comprehensive review of the data that they were able to obtain and the technical barriers that they needed to overcome. This review is invaluable for those trying to do similar work. The article clearly communicates 2 key features that were crucial to their success: first, an unrelenting focus on data quality, and second, their ability to readily access data from other hospital systems, such as pharmacy management and perioperative scheduling, and link it to the data from their Anesthesia Information Management System (AIMS). For example, the authors give an excellent description of how they were able to use the combined data from their AIMS and operating room management systems to link cases that were incorrectly unlinked due to workflow issues at the point of care. This linkage allowed them to get important information such as the primary surgeon for the case and key scheduling information.

This arrangement of department-run specialty information systems, where access is controlled on a local level and readily granted, is increasingly rare today. Over the past several years, the trend has been for institutions to migrate from “best of breed” information systems to “one size fits all” solutions, that is, enterprise-wide–integrated electronic health record (EHR) systems from vendors such as Epic and Cerner. The vendors offer the promise of “one patient, one record” and claim improved care processes and data access as a result. In truth, oftentimes what occurs is a consolidation and restriction of access. As a result, technical skills alone are often no longer sufficient to successfully obtain needed data. A collaborative relationship with main hospital IT, support of the Chief Medical Informatics Officer, and the ability to navigate complex political environments are increasingly required to access perioperative data that used to be at our fingertips.

In the second article, “The Anesthesiologist-Informatician: A Survey of Physicians Board Certified in Both Anesthesiology and Clinical Informatics,”3 Drs Epstein and Dexter join with Dr Poterack to explore the attitudes of anesthesiologists who have obtained board certification in Clinical Informatics. The American Board of Preventive Medicine offers Clinical Informatics as a subspecialty board certification to any physician who already has certification from another American Board of Medical Specialties member board. The authors found 36 anesthesiologists among the 1105 physicians who were board certified in Clinical Informatics in 2016. According to the American Board of Preventive Medicine and the American Board of Anesthesiology (personal communication) as of February 2018, there are now approximately 50 anesthesiologists who are board certified in Clinical Informatics, a 38% increase. Nonetheless, these 50 are only around 0.1% of the over 53,000 board certified anesthesiologists in the United States.

Why is board certification in Clinical Informatics important? Board certification provides external validation that the diplomate possesses the domain-specific knowledge and expertise needed for IT operations and research. This “stamp of approval” can be invaluable in convincing hospital and IT leadership that it is “safe” to allow the diplomate access to centralized EHR data and encourage leadership to invite the diplomate to participate in executive-level decision making. Furthermore, the survey confirmed that informatics certification consists of a broader skillset than programming a computer—in fact, nearly half of the respondents replied that they never write computer code. Having obtained subspecialty certification, we can attest to the fact that certification involves not only an understanding of the hardware and software that comprise hospital systems but also an understanding of team management strategies and development methodologies. The board examination places equal if not more emphasis on these “peopleware” skills as it does on pure programming and systems knowledge. Indeed, these skills are crucial for being successful in today’s modern health care environment.

In that vein, it is not surprising that the authors found that over 75% of survey respondents had a role outside of their home departments. These institutional roles are part of what makes Clinical Informatics so crucial to anesthesiology. Many believe that the future of our specialty requires significant engagement at the leadership levels of our hospitals. This belief is demonstrated by the American Society of Anesthesiologists’ (ASA’s) recent collaboration with the American College of Healthcare Executives as well as the ASA Executive Physician Leadership Program in conjunction with the Kellogg School of Management. Given the increasing importance of data in driving our everyday decisions, the field of clinical informatics provides a ready way for anesthesiologists to expand into these leadership roles.

Despite the reasons outlined above, readers may wonder if obtaining board certification in Clinical Informatics is worth the effort, particularly if they currently do not actively pursue any informatics-related activities. Until 2022, physicians can obtain certification by spending at least 10 hours per week practicing medical informatics for 3 years (the practice pathway) or by completing a 24-month Accreditation Council for Graduate Medical Education (ACGME) accredited fellowship in Clinical Informatics.4 After 2022, the practice pathway will end, and the only path to certification will be via the fellowship pathway. Based on the survey results and our experience at 5 different institutions, we suggest that it is certainly worthwhile to obtain board certification for those who are already engaged in activities that qualify them for the practice pathway or those who will do so for at least 3 years before 2022. For those who are still in training and would need to complete an ACGME fellowship in Clinical Informatics, the answer is a bit more complex. As of this writing, only 1 Clinical Informatics fellowship exists within an anesthesiology department (Vanderbilt University).5 Although anesthesiologists can complete the fellowship in any department, this may not be desirable because of anesthesiologists’ unique workflow. Obtaining informatics training from nonanesthesiologists may be suboptimal, and the trainee may not learn how to deal effectively with intraoperative data that tend to have significant issues with artifact (veracity), volume, and resolution (velocity).2 For example, as evidenced by the ASA’s “when seconds count” campaign, anesthesiologists frequently respond to events in the order of seconds or even fractions of a second (ie, bronchospasm, hypoxia). Training with other specialties that are not used to this reality may blind the trainee to limitations of data that are only recorded at the resolution of 1 minute, as is the case in some current EHRs. Regardless of what department it is performed in, the fellowship typically requires 80% nonclinical time, which might lead to an undesirable deterioration in clinical skills. Furthermore, the authors noted that fewer than one-third of respondents experienced any change in their role as a result of passing the board examination. Thus, the opportunity cost of completing an ACGME fellowship may currently be high when considering that the return on investment is unclear. A more conservative approach is to combine an informatics fellowship with another postanesthesia fellowship or a masters-level graduate degree to increase the potential benefits of the time investment.

There are some limitations to the 2 articles. In their review article, Drs Epstein and Dexter spoke only about their own single-institution experiences. While we can all attest to the similarities between what they reported and our own work, crucial differences exist. This article will likely serve most readers best as a reference that describes what one might expect when performing similar work rather than a step-by-step guide for the reader to follow. This is especially true as academic institutions replace standalone AIMS with EHR-based anesthesia modules that provide their own unique opportunities and challenges. The authors also did not include many technical details that might enable others to conduct these studies successfully at scale, such as balancing the desire for high resolution data (ie, 5-second vital signs) with the storage and performance issues such collection creates. We do, however, understand that an in-depth technical discussion would be beyond the scope of their review.

The anesthesiologist survey is somewhat limited due to the time that has elapsed since the survey was conducted. In the rapidly changing field of Clinical Informatics, 18 months is a significant amount of time and some of the survey results may be out of date. As noted above, about 50 physicians are now boarded in both Clinical Informatics and Anesthesiology, suggesting that the number of respondents would be greater today. Based on our experience, we suspect that the overall results of the survey would be unchanged, but this obviously cannot be confirmed. In addition, the authors provided limited information regarding the resources that are now available to those studying for the certification examination. For those who might want additional study materials beyond the recommended book, we suggest exploring one of the master’s degree programs (such as the one offered by Oregon Health & Sciences University), the American Medical Informatics Association online or in-person coursework, or some of the myriad online courses that cover portions of the examination content.

Anesthesia informatics is no longer a hobby, but a serious subspecialty within anesthesiology with its own career path. Success requires an understanding of how to rigorously evaluate new technologies and integrate them within the larger health care enterprise. We all agree that anesthesia informatics will continue to be extremely rewarding for the foreseeable future, and these articles by Drs Epstein, Dexter, and Poterack give a sense of what is required to thrive in this exciting, constantly evolving field.

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Name: Ira S. Hofer, MD.

Contribution: This author helped prepare the manuscript.

Name: Matthew A. Levin, MD.

Contribution: This author helped prepare the manuscript.

Name: Allan F. Simpao, MD, MBI.

Contribution: This author helped prepare the manuscript.

Name: Patrick J. McCormick, MD, MEng.

Contribution: This author helped prepare the manuscript.

Name: Brian S. Rothman, MD.

Contribution: This author helped prepare the manuscript.

This manuscript was handled by: Maxime Cannesson, MD, PhD.

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1. Stonemetz J, Ruskin KAnesthesia Informatics. 2008.London: Springer Verlag;
2. Epstein R, Dexter FDatabase quality and access issues relevant to research using Anesthesia Information Management System data. Anesth Analg. 2018;127:105–114.
3. Poterack K, Epstein R, Dexter FThe anesthesiologist-informatician: a survey of physicians board certified in both anesthesiology and clinical informatics. Anesth Analg. 2018;127:115–117.
4. American Board of Preventive Medicine. Clinical Informatics Pathways. Available at: Accessed February 25, 2018.
5. ACGME. ACGME Accreditation Data System. Available at: Accessed February 25, 2018.
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