June 2002
Volume 66 |
Number 6
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| Anesthesia Information
Management Systems |
John S. Gage, M.D.
The Future
An office-based anesthesiologist, you arrive at the surgeon's
operating suite for the first case of the day. The time is several
years in the future. You unpack your equipment and plug your automated
anesthesia record keeper into the ethernet connection located
at the head of the table. You are instantly connected to the central
data warehouse for automated anesthesia records at the ASA data
repository. By entering a unique identifier, you are linked to
the system.
As you enter preoperative data about your patient into the system,
your record keeper stores this information locally and simultaneously
communicates the data, stripped of all identifying information,
to the central data repository at ASA. Your data is automatically
compared with all other cases in the warehouse. As you enter more
data, the central repository instantaneously picks cases that
are similar to yours – same concurrent pathology, same operative
procedure, same anesthetic setting, etc. By the time you are finished
with your preoperative evaluation, the data repository has finished
its search and communicates information back to your record keeper
about how patients like yours have been anesthetized by other
practitioners and what the potential caveats are in similar cases.
You read this information and finalize your anesthetic plan. Throughout
the data interchange with ASA, software installed by the Centers
for Medicare & Medicaid Services has ensured that none of your
data is identifiable and that the privacy guarantees of the Health
Insurance Portability and Accountability Act regulations have
been satisfied.
Once the anesthetic begins, physiologic data from your patient
are stored locally and once again stripped of identifying data,
then communicated to the ASA database. Your data is becoming another
case in the database and, simultaneously, the number of cases
similar to yours is being narrowed by the database according to
the anesthetic choices you have made. Slowly, representative records
of cases nearly identical to yours are selected and displayed
in tandem with your record. This provides you with more insight
into the progress of your anesthetic in the context of very similar
cases and suggests specific questions you can address to an automated
literature search engine or instant message software also available
on your automated record keeper. You see that your physiologic
data "looks better" than most comparable cases, and
you congratulate yourself on a smooth anesthetic.
As the case ends, your patient will need a prescription for pain
medication postoperatively, which you send via encrypted e-mail
to a nearby pharmacy that your record keeper has selected on the
basis of the patient's insurance coverage. Finally, your bill
is submitted electronically to the patient's insurer.
The Present
No element of the hypothetical experiment above currently exists.
Yet each element is possible today. Not only are these features
possible, they are in fact easily and inexpensively implemented
using the most reliable software in use today, software based
on Internet technology – the same software that banks and
other businesses are increasingly relying on for their entire
business process. Users of the Internet can experience something
similar to a central data warehouse of anesthesia cases by searching
with a typical Internet search engine, using progressively more
specific search terms and by observing the number of returned
Web pages decrease. As stated, the technology is in place today.
It is cheap and reliable. Other initiatives related to anesthesia
such as the Accreditation Council for Graduate Medical Education's
program for resident management of resident statistics are beginning
to use Internet technology. To reiterate, the trend has not reached
record keeping, however.
The principle reason usually given for this situation concerns
the hypothetical activities of plaintiffs' attorneys who might,
for example, use prescription records or a central data repository
of anesthesia cases to attack physicians. Ironically, the practice
of law, in contrast to the practice of medicine, is at the forefront
of efforts to computerize its activities. Today many law firms
insist on e-mail submissions of important documents, and every
law firm has available to it the most sophisticated search engines
containing every legal case on record. By fighting a rearguard
action against plaintiffs' attorneys, our specialty has made impossible
any useful attack on improving outcomes with actual data about
actual cases using computer technology. Thus we inadvertently
find ourselves supporting the central contention of the tort bar
that only attorneys can protect patients from medical mishaps
while we watch its members empower themselves with technology
that we deny ourselves.
In this context, it is heartening that the Anesthesia Patient
Safety Foundation (APSF) has recently endorsed the use of automated
anesthesia information management systems (AIMS): "The Anesthesia
Patient Safety Foundation endorses and advocates the use of automated
record keeping in the perioperative period and the subsequent
retrieval and analysis of that data to improve patient safety"
< www.gasnet.org/societies/apsf
> .
In addition, APSF has formed a working committee to design a
"data dictionary" to facilitate sharing data gathered
by AIMS nationwide in a pursuit of outcome data that will permit
the specialty to improve our practice through "a common set
of data elements required in electronic anesthesia records [which
will allow] the collection and comparison of large volumes of
clinical data from multiple institutions for outcomes research
and benchmarking." The APSF's data dictionary project is
clearly the first step toward the goal of real-time, intelligent
database access described above. The project merits the closest
possible attention by all members of the specialty. As it is currently
designed, however, it will not create the sort of national data
warehouse that can most benefit the specialty.
Hence we are still left in a landscape lacking the promise of
Internet technology-based, intelligent record keepers that are
possible today. It is true that the principal AIMS vendors have
extensive Web sites marketing their products, but these Web sites
are static marketing set pieces lacking interactive examples.
Current Systems
The CompuRecord information management system was developed by
an anesthesiologist. It is currently produced and marketed by
Philips Medical Systems. The Compurecord Web site < www3.medical.philips.com/en-us/
product_home/product/compurecord_detail.asp > provides several
screen images taken from the system. CompuRecord has achieved
strong user acceptance from those who have used it. In at least
one institution, the same computers used to interact with the
CompuRecord system also are linked to the Internet, enabling anesthesiologists
to access medical information and e-mail in the operating room.
The Saturn Information System from Draeger Medical, Inc., < www.nad.com/LEVEL10_Saturn_Prod.htm
>, emphasizes end-user customization: "The List Manager provides
a graphical interface for creation and maintenance of pick lists
including access and accountability rights. The Environment Manager
allows for the customization of default drugs, fluids, events,
etc." These features acknowledge that AIMS must be flexible
enough to change in response to an evolving clinical environment
and that each setting is subtly different. Numerous graphics of
representative screens are available.
The Picis Web site < www.picis.com/html/products/module_chart2Banesthesia.html
> contains a screen shot and an extensive description of the system.
Picis has recently merged with Medical Systems Management to form
PicisMSM to expand their product offering, including operating
room scheduling and inventory management.
A relative newcomer to the AIMS scene is eko systems .
Of all the current AIMS, eko has the most sophisticated networking
features. Software to enable the record keeper to interact with
monitors and infusion devices is stored centrally and automatically
downloaded when the record keeper identifies a particular device.
In addition, eko promises creation and installation of new interfaces
to other hospital systems in a matter of weeks, an extraordinarily
fast turnaround time.
Deio, from Datex-Ohmeda, can be seen at . The Web
site contains many screenshots of the main system and the various
tools for customizing the system. Deio describes extensive integration
capability between its record keeper, monitoring equipment and
other hospital computer systems.
Scalable Vector Graphics
As a final note about Internet technology, it has, in the past,
had one Achilles heel: it is a text-based system that does not
support interactive graphics easily. This may be news to the reader
who doubtless views the Internet as a cornucopia of graphics;
but in reality, until quite recently, there has only been one
source of what are called vector graphics (an efficient and interactive
technology for graphic interfaces) on the Internet: Macromedia®
Flash®. This proprietary system has been used largely in advertising.
An example can be found at the PicisMSM site: < http://www.picismsm.com/index3.html
> .
The World Wide Web Consortium®, recognizing the need for
accessible and standard vector graphics on the Internet, has sponsored
the creation of a standard called Scalable Vector Graphics (SVG)
< www.w3.org/Graphics/
SVG/Overview.htm8 >. Using SVG, a truly interactive anesthesia
record keeper with the most sophisticated graphic capability can
be installed on a local machine using Internet software and made
capable of communicating facilely to other devices and databases
over standard networks. The author has created a Web site using
SVG and Internet software to provide a proof of concept for these
techniques for the reader. In order to view the site, the reader
must first download the SVG browser plug-in from < www.adobe.com/svg/viewer/install/main
.html > and install it. Internet Explorer® 5.5 or higher
is recommended. The proof of concept is at < www.roitsystems.com/aims/
>.
Automated record-keeping is long overdue for our specialty. APSF
has laudably taken a leadership role is achieving widespread installation.
Modern Internet technology, reliable and available today, may
be a crucial addition to AIMS of the future.
Editor's Note: The mention of certain brand-name products
is not intended to be construed as an endorsement by ASA and is
essentially the personal preference of the author.
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John S. Gage,
M.D., is Associate Professor of Anesthesiology, State University
of New York at Stony Brook, Stony Brook, New York. |
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