The adoption of computers and computer software to convert, store, protect, process, transmit, and securely retrieve information is fundamentally changing the practice of medicine . These health information technologies often require a redesign in the delivery of patient care.
In spite of the growing evidence supporting the advantages of information technology in the operating room [2–4], adoption has been slower than many expected, in particular with anaesthesia information management systems (AIMS). For example, hospital information technology systems outside the operating room such as for ancillary hospital services (e.g. radiology or pharmacy) are deployed commonly , whereas AIMS are deployed in only 14% of US academic hospitals . This gap in AIMS adoption versus other hospital systems might be explained by several factors, including high acquisition price and maintenance costs for AIMS, no clear return on investment for the hospital, need for customization to suit the needs of a particular facility, lack of interoperability with other hospital information systems, immaturity of the software, and lack of proven benefits.
To our knowledge, no data are available on AIMS adoption among European university-affiliated anaesthesia departments. The purpose of this study was to use an Internet survey to assess the prevalence of AIMS in European university-affiliated anaesthesia departments and to identify the motivations for and barriers to adoption. We chose to study academic departments because they are known to be more likely to adopt health informatics ahead of nonacademic institution . We also looked to explore whether AIMS implementation was associated either with hospital size, as measured by the annual number of anaesthetics performed, or with the administrative structure of the anaesthesia department (e.g. department is part of a hospital, of a university, or of a private organization).
Survey development and validation
A review of the literature on AIMS identified possible reasons for adoption and resistance to AIMS implementation. Content validity of the survey was provided by repetitive rounds of refinement of questions (and potential answers) among the authors and through feedback from clinical AIMS administrators at several institutions. Feedback also came from a pilot study with a convenience sample of six anaesthesiologists in Europe.
A logic-branched survey design (http://stanford.checkboxonline.com/Survey.aspxs=cc388a6fl2fe49dlab060fc0ea8a93b5&[email protected]@invitationID) was chosen. This allowed irrelevant questions based on a prior response to be eliminated. For example, if the respondent indicated that an AIMS was not installed, the question ‘Which was the year of install of the AIMS’ would not be presented.
After approval by the Institutional Review Board, an e-mail requesting completion of a web-based survey (Checkbox, Prezza Technologies Inc., Cambridge, Massachusetts, USA) was sent in January 2008 to anaesthesia chairs of university-affiliated European hospitals of the following 22 European countries: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Lithuania, Norway, Poland, Portugal, Romania, Slovenia, Spain, Sweden, Switzerland, The Netherlands, and United Kingdom (Table 1).
We used publicly available data (http://www.iime.org/database/index.htm) and Google (search terms: name of hospital, anaesthesia department) to identify medical schools, university-affiliated hospitals (total n = 294) and the respective chair of the anaesthesia department and their e-mail for 252 facilities (Fig. 1). University-affiliated anaesthesia departments were defined as either those affiliated with a medical school or those departments with a residency programme but not affiliated to a medical school. The list of chairs surveyed is available from the authors.
Our survey was sent to all countries pertaining to European Union, including those which have partly committed to the European Union's economy and regulations (Iceland, Norway, and Switzerland). Unfortunately, due to language restrictions, we were unable to extend our study to Bulgaria, Cyprus, Czech Republic, Latvia, Malta, and Slovakia, and, for this reason, facilities from those countries were not included in our survey.
Three reminder e-mails were sent after 3, 6, and 12 weeks. To increase the response rate, we sent a final e-mail asking a single question to indicate the current status of AIMS adoption. The hospital name was used to avoid possible duplicates, and the responses were de-identified for further analysis.
We evaluated whether academic anaesthesia departments committing to AIMS were more likely than nonadopters to have a larger anaesthetic case volume, to be part of the hospital's organization (as opposed to being an independent entity), and to belong to a hospital that has already implemented a number of other information technology systems. As was done in a similar study of US academic medical centres, we defined ‘adoption’ of AIMS technology as a response indicating that the department had already implemented, was in the process of implementing, or was searching for an AIMS. We defined nonadoption as those indicating no current or future plans to implement AIMS.
Anaesthesia information management system adoption status
Of the original sample of 252 academic anaesthesia departments that were sent an initial e-mail with an invitation to answer the survey, 41 e-mails were returned as undeliverable. Sixty-one responses were received from the 211 remaining anaesthesia departments. Six of these were duplicate responses and were removed, leaving an initial response cohort of 55 unique respondents. Additionally, 31 single responses (meaning the entire survey was not completed, just the AIMS adoption status was provided) were also received. Therefore, information about AIMS status was received from a total of 86 respondents or 29% of the 294 hospitals (Fig. 1). AIMS prevalence by country could not be determined because of insufficient numbers for any single country.
Overall, 44 departments (51%) were considered AIMS ‘adopters’ because they were already using an AIMS (n = 15, 17%), implementing an AIMS (n = 13, 15%), or selecting an AIMS (n = 16, 19%). The 42 remaining departments (49%) were considered ‘nonadopters’ given that they were not planning to implement an AIMS, because of lack of funds (n = 27, 31%), because of other reasons (13, 15%) or because they simply did not want that system (n = 2, 2%; Fig. 2).
Characteristics about hospitals in the survey are summarized in Table 2. For the 55 respondents who completed the entire survey, the administrative relationship between the anaesthesia department and the hospital was similar between adopters and nonadopters. Most (42 of 55) anaesthesia departments belonged to a different corporate entity (hospital and university). Not one responder indicated that the anaesthesia services were provided by a private group.
Fifty per cent of smaller hospitals (those with fewer than 20 000 anaesthetics/year) were adopters, whereas 52% of big hospitals (more than 20 000 anaesthetics/year) were adopters.
Adopters reported having more information technology systems already deployed throughout the hospital (Table 3), with intensive care unit information systems and operating room scheduling systems being already deployed in approximately half of the facilities.
Twenty of 27 (74%) respondents indicated that the hospital provided financial support for the purchase of the AIMS and for 14 (52%) the hospital was the unique financial provider. The government provided funds in 33% of purchases, and in six of them (22% of total), the government was the only source. The anaesthesia department and the university contributed monies to the purchase of AIMS in 22 and 11%, respectively, of responding facilities.
The anaesthesia chair was involved with the financial decision in 70% of cases to purchase the AIMS (Table 4). The anaesthesia department represented by chair and/or anaesthesia committee was involved in 81% of the search and purchase processes.
Twenty of 28 (71%) hospitals did not choose an AIMS from the same vendor as that of the main hospital information technology system. In 10 cases (36%), the acquisition price was the main criterion used to choose an AIMS, whereas in eight (29%) reasons other than price were the primary consideration. Some respondents did not know whether the AIMS was from the same hospital information technology vendor as other installed systems in the hospital, or whether price was a main reason to choose a specific AIMS type.
AIMS implementations at respondents' facilities took place between 1993 and 2007. The types of AIMS included Copra Systems (Sasbachwalden, Germany), Dräger Medical (Lübeck, Germany), Datex and General Electric Healthcare (Buckinghamshire, United Kingdom), IMDsoft (Leiden, The Netherlands), Imeso GmbH (Hüttenberg, Germany), McKesson Information Solutions (Warwick, United Kingdom), Philips Healthcare (Best, The Netherlands), Picis Inc. (Barcelona, Spain), and Yuse (Leuven, Belgium).
Between 1993 and 2007, there was less than one AIMS implementation per year. Nine anaesthesia departments are currently implementing AIMS to become operational in 2009–2010. An additional 10 facilities have already selected but not yet started implementation with likely installs in 2010–2011.
Motivations for installing anaesthesia information management systems
The top ranked motivating factors for installing an AIMS were improved clinical documentation, improved patient care and safety, convenience for anaesthesiologists, and improved operating room efficiency (Table 5).
Perceived benefits after anaesthesia information management system implementation
The nine anaesthesia departments with an installed AIMS served as the subgroup to analyse how well AIMS functionality matched expectations. The top ranked benefits of AIMS implementation were improved clinical documentation, reliability of AIMS, quality improvement programmes, ease of creating reports, end-user acceptance, and convenience for anaesthesiologists (Table 6).
Barriers to anaesthesia information management system implementation
Sixteen of 27 (59%) nonadopter anaesthesia departments considered the absence of funds as the most important barrier to implementing AIMS. The magnitude of funds needed for the initial investment, lack of funds for information technology projects in general, and lack of clear return on investment were the most frequently cited financial reasons for not implementing an AIMS (Table 7). Insufficient resources from the clinical information department, incompatibility with existing hardware, and lack of support from hospital administrators were reported as the most important nonfinancial barriers for implementing AIMS (Table 8).
Finally, we asked two open-ended questions: ‘why do you think AIMS installs lag behind installs of other hospital information technology systems?’ and ‘why do you think some anaesthesia departments decide to adopt AIMS whereas others do not?’ Seventeen respondents considered lack of funds and seven considered ‘lack of an open-minded culture by anaesthesiologists’ as a main barrier to installing an AIMS.
At least 28 or 10% of the 294 European university-affiliated departments have already implemented or are implementing an AIMS. This estimated prevalence of 10% is quite conservative, given that the numerator is based on the number of institutions already owning or implementing an AIMS and the denominator equals our total sample of university-affiliated departments in Europe (294).
The main barrier identified by AIMS nonadopters in university-affiliated medical centres in Europe is lack of funds. However, to overcome these financial hurdles, anaesthesiologists can use the increasingly large literature to support the claim that AIMS help make the clinician's job in the operating room easier, faster, and safer [3,8]. Automated anaesthesia records are more accurate, contain more data, should not be lost, and are readily available [9,10]. With AIMS, quality improvement programmes will be able to analyse incidents more quickly [4,11,12]. Finally, increased compliance with practice guidelines and the implementation of computerized decision support systems should help improve patient care and safety [13–15].
Our study has several limitations, some of which are general to any survey study and some specific to this study. The first is the response rate and the risk of responder bias. Although our survey had a branch logic question format, allowing responders to avoid unnecessary questions, the full survey if all questions were answered had more than 1000 words, a described threshold affecting the response rate . Also, in medical surveys, physicians tend to have the lowest response rates . One way to assess whether nonresponders were systematically different from responders is to compare AIMS implementation prevalence between those who completed the full survey the first time (n = 55) and those who just answered the implementation status question sent with the last e-mail reminder. Although the AIMS adoption prevalence was similar in these two groups, we cannot exclude some responder bias such as perhaps AIMS adopters being more willing to respond to the survey than nonadopters.
As western European countries often differ socioeconomically from eastern European countries, inclusion of data from the latter may reduce the overall AIMS implementation rate as shown by our study.
Our survey did not reach all university-affiliated hospitals. First, we do not know whether all schools of medicine have a web page. Second, various countries and universities can have differing organizational configurations. One or more facilities may be associated with one university and our survey could have reached one of these facilities but not all. Also, because website content can be outdated, in some cases, our search could have erroneously identified a chair actually retired from the respective position. Likewise, in some cases we were unable to find the chair's e-mail address or the identity of the anaesthesia chair.
Another limitation is that we cannot extrapolate AIMS prevalence to the entire population of European hospitals, including private facilities not associated with a university. In the United States, for example, nonacademic centres usually have less hospital information technology implementation than academic medical centres .
Finally, to assess the penetration of information technology systems throughout the hospital, we assumed that the person completing the survey either would be familiar with all information technology systems used in the hospital or would ask someone able to provide the answer. However, we cannot confirm this, and the results on the information technology system penetration must be interpreted accordingly. It appears from our study that the more information technology systems a European university-affiliated medical centre already has deployed outside the operating room, the more likely the hospital is to have an AIMS. Interestingly, prevalence of information technology systems in the intensive care unit is higher than AIMS.
Our results indicate that the anaesthesia chair or a department representative was involved in most of the financial decision-making processes to purchase the AIMS. However, in 20% of hospitals, anaesthesia departments were not involved in the AIMS search and purchase decision process. In general, the hospital was the principal funding agent for AIMS and the participation of the university was low. In several university-affiliated medical centres, governmental health authorities were providing funds to purchase AIMS. This might be evidence of a movement towards increased availability of information technology systems in healthcare in European university-affiliated medical centres.
Most hospitals had different vendors for the hospital information technology system from those for the AIMS. Clinical benefits were reported as the top ranked motivation for AIMS installation, over administrative or economic issues. In addition, after implementation of AIMS, adopters reported benefiting from improved clinical documentation, reliability of AIMS, quality improvement programmes, ease of creating reports, convenience for anaesthesiologists, and end-user acceptance. Among barriers, the top ranked were economic, mainly initial investment, lack of funds, and lack of support from the information technology department or from the hospital. One of the reasons hospitals may not fund adoption of AIMS is that the economic and administrative benefits of operating room management systems for case scheduling and staffing are perceived as sufficient . However, we found an implementation rate for operating room management systems of 64% for AIMS adopters and 30% for academic medical centres without AIMS.
Our findings suggest that the adoption of AIMS is currently behind other information technology systems installed in European university-affiliated hospitals. Nonetheless, an increasing number of anaesthesia departments are in the process of selecting AIMS.
In a similar study among US academic hospitals, Egger Halbeis et al.  found that an AIMS was installed in at least 14% of anaesthesia departments, and that at least 30% of other departments were in the process of implementing or selecting a system. Analogously, they also found information technology penetration in other parts of the hospital to be higher in facilities with an AIMS. Similar to our results, they did not find any relationship between AIMS adoption and hospital size or ownership structure of the anaesthesia group.
In conclusion, AIMS had been implemented or were in the process of being implemented in at least 28 (10%) European university-affiliated hospitals. Including those departments searching for an AIMS (16), at least 44 or 15% of the 294 academic departments had decided to commit to an AIMS. The main barrier identified by AIMS nonadopters is lack of funds. Hospitals with a higher number of information technology systems already installed are more likely to be AIMS adopters.
The present work was supported by departmental sources only.
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