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The title of this article comes from the presentation given by Jeffrey S. Plagenhoef, M.D., at the 2007 ASA Conference on Practice Management. Dr. Plagenhoef’s lecture was one of three on the Anesthesia Information Management Systems (AIMS) panel and one of 23 highly informative presentations given during the last weekend in January in Phoenix. All of the abstracts are available at www2.ASAhq.org/publications.

A summary and excerpts from Anesthesia Information Systems…Where Awareness is Good! follow. Dr. Plagenhoef began by making the case for investing in an AIMS now. Among the reasons:

here are at least two good safety arguments for why we need the so-called “black box” or flight recorder in anesthesiology: 1) we need better tools to learn what happened and why it happened after devastating events and near misses; and, 2) we need a global anesthesia database of physiologic and outcomes data that can be used for hypothesis testing about key safety issues and to compare institutions.

Pay-for-performance seems here to stay. Don’t think that those of us who have already invested very significant time and money using and developing AIMS are not trying to engage local payers to consider financial incentives for responding to the need to change.

Every other industry uses electronic means of communication and documentation. Even when getting your car’s oil changed or dropping off a rental car, points of service electronic tools are used to improve both services and the bottom line. The average person comes to the conclusion that we can reasonably expect improvements in perioperative care through the implementation of electronic tools.

So what is an AIMS? Simply put, AIMS are computer systems that capture anesthesia-related information in a digital format. AIMS ideally gather data on all patients pre-operatively, intraoperatively and postoperatively. The data are pooled into a database, and then they are organized, stored and arranged in a format allowing subsequent analysis. Ideally, one database can “talk” with other hospital databases and larger system databases. This is the concept of interoperability, something for which the federal Department of Health and Human Services and the information technology (IT) industry are developing standards.

It is very important for clinicians to understand why standardization of data input is demanded in this arena. Prose, manually typed and satisfying personal preferences in expression or description don’t work…that includes the time honored “Physician Progress Notes.” There must be consistent text for computers to recognize the data elements as unique and then to be able to pool, organize, retrieve and analyze them. Medical informatics requires yes/no answers, or answers selected from predefined standard formatted lists of choices.

Electronic medical records can be divided into three generations. The first generation consists of the simplest record keepers that are basically just electronic repositories for physiologic data. The second generation systems include more end user benefits, like the ability to data mine for systematic analysis of practices. The third generation offers much more than large quantities of data. For example, they offer real-time information that improves patient care like prompts for particular drug use, or avoidance, based upon co-morbid conditions or the surgical procedure. Instead of just recording a blood pressure of 75/40mmHg, the smart third-generation system might suggest “Patient has left main coronary artery disease, maintenance of a higher diastolic blood pressure may be advisable…consider taking actions to raise the blood pressure.”

So, why is there so much resistance to this expected and needed change? Major change is difficult for most people, and some people just do not seem to understand the need for and advantages of this change. Some have significant paranoia or distrust and think generating large data pools will only result in forces used against physicians by health policy makers and payers. System cost is another factor slowing the implementation of AIMS. Many want to know if there is a real return on investment, as opposed to the return on investment (ROI) promised by the salesmen. For many anesthesiologists, the perceived increase in medicolegal risk is a huge stumbling block. Major change often is accompanied by major resistance until individuals are adversely affected for not changing.

Some question if there is an ROI at all, and others argue that calculating an ROI with a high degree of certainty is difficult at best. The production of an ROI with an AIMS likely is affected by the product being used, the group using it, and the environment of use. Nonetheless, a financially sound argument can be made for AIMS. Hospitals and health systems have already made the overall commitment to electronic medical records and computerized physician order entry. An AIMS is simply a subset of that basic commitment. Would it make sense to leave out an area of the hospital that touches 40 percent to 60 percent of the patient volume in providing some of the most intense, high-cost and high-risk acute care in the institution?

The stakes are high in the perioperative world, whether talking about the quality of care delivered or the level of efficiency with which it is provided. Huge costs can be associated with adverse outcomes, with or without litigation. No doubt, if we can improve the systems entwined in provision of perioperative care, we should see a large impact on both quality of care and the bottom line.

The concern over negative medicolegal implications of AIMS persists in spite of many opinions and facts published to the contrary. The basic question is whether computer-based anesthesia records increase or decrease malpractice exposure. Little to no case law exists to help answer this question. Some real world departmental experience has been reported. The ASA Closed Claims Project database shows there were 6,458 claims, with 27 claims where an AIMS was used. There are only four claims where the AIMS was deemed to have played a role in the litigation: 1) the SpO2 was <60 percent for 1.5 hours and the record showed it accurately; 2) unrecognized esophageal intubation where absence of ETCO2 was accurately recorded for 30 minutes; 3) an anesthesiologist’s testimony was discredited when the automated record indicated that no pre-oxygenation was delivered contradicting the claim by the doctor that it had; 4) an AIMS accurately demonstrated that the unsuccessful resuscitation of a patient with postpartum hemorrhage was due to inadequate care. In a large survey of departments using AIMS technology (55 departments surveyed / 18 used electronic medical records (EMRs) for >5yrs / 24 surveys returned), 41 malpractice cases were filed. Three of those rated the AIMS essential to defense, 18 rated the AIMS valuable, and no respondent rated the AIMS as a hindrance to the defense. Some medicolegal advantages of AIMS include legibility, larger volume of data, greater granularity of data, potentially greater accuracy of data, contemporaneous data, readiness for discovery and data validity created by an audit trail. What we do know for sure is that the anesthesia record is the most important medicolegal document, that a poor record increases liability exposure, and that a good record that objectively documents the facts helps in defense. Good care combined with real-time factual documentation of a situation are likely easier to defend, and bad care is always hard to hide – regardless of paper records or computers.

So, how should you initiate product evaluation? First define your departmental goals. Are you looking for just an EMR, or do you want to include patient safety functionality, tools to enhance efficiency, business and O.R. management tools, coding and billing tools? Define where you want to use the AIMS — operating rooms only, or pre-, intra-, and post-op, along with OB and ICU. Another big question to ask in focusing your investigation is whether or not you want to acquire technology that can make drug delivery safer and drug tracking easier. Detailed requests for proposals result in fewer surprises and greater happiness with decisions. Current high-profile systems include: Cerner, DocuSys, Draeger/Saturn, Eko, GE, IMDsoft, Phillips/CompuRecord and PICIS.

Some general questions worth asking:
Who is paying for the system? Who will administer the system? Will your IT department provide the needed support? Who is in your IT department, and do they conceptually support your transition to an AIMS, and do they have the staffing to adequately support your department? What server structure exists in IT? What software products surround your work space…Windows NT, Microsoft SQL, etc.? What other systems will AIMS be expected to talk with (O.R. management, ADT, laboratory, inventory management pharmacy, supplies, billing, etc.)?

How much do data security and privacy as mandated by the Health Insurance Portability and Accountability Act (HIPAA) functionality hinder efficiency?

What are the vendors’ business philosophies and their five- and 10-year business plans? What is their track record on implementation, frequency and cost of software upgrades and service packs? What do current customers have to say about implementation and post-implementation support? What is the vendor’s size and financial health? How many systems were sold in the last year and how many are in the install queue?

Has the company increased the number of implementation teams? Has it ever had a deinstall, or has it been replaced? Is the software commercially available or proprietary? What other systems have they successfully interfaced with? Integrated with? Does hardware and software work with standard commercial hardware and software? Are this vendor’s hardware/devices interfaces written in house or outsourced to experts? Where are the data processed and stored (distributed versus centralized systems)?

Is the system network compatible? How many hours per month (or per year) has the vendor’s system been down at installed sites? Have they ever lost data when the system goes down? How available and skilled is their technical support service? What is the average time from contract signing to implementation? How are emergent trips back to the O.R. handled? What data entry tools are used (touch screen, mouse, keyboard, voice)?

Is data entry using standardized format? How frequently are data saved? Are all changes recorded and reported (“artifact handling”)?

Is there a concurrency documentation system that calculates ratios on the fly? Is there a system for documenting compliance with payer rules? What are the report-generating capabilities and are they easily configurable? What happens upon network failure? What does the vendor see as the weakest link in its products, and what are its plans for improvement?

Pricing questions:
Is the system cost per O.R., or is there a general facility licensing? Is software priced or licensed per anesthetizing location or institutionwide? Are there hidden costs in install, maintenance, disposables or future necessary education/training/clinical support? Be aware that hardware frequently gets cut with price negotiations. Inadequate hardware numbers and power can have a huge negative impact on convenience, efficiency, workflow and therefore user satisfaction.

Conclusion
Awareness is essential to your success! Your goal is “electronic Nirvana,” a state where all systems talk and function error free, and getting there as soon as possible. Because no one system is perfect yet and much ongoing product development is needed, hitch your wagon to the fastest moving train with the best track record, vision and passion for excellence and perfection.

Awareness of the importance of anesthesia leadership is a must for successful implementation and use. Get involved in the process and lead with passion, confidence and conviction. Converting to electronic documentation is very difficult without physician champions. DO NOT defer to the “expert” judgment of your CIO, CMIO or O.R. manager. Nobody else understands the unique clinical demands in anesthesia and the complicated and time-pressured workflow demands that must be facilitated and not hindered.

Awareness of those you work with is crucial. Managing change effectively is more difficult than practicing medicine. Provide plenty of “group therapy” sessions to mold attitudes. Make “problem children” in your department “super-users” in hopes of obtaining their buy-in and neutralizing their usual negativity.

AIMS are essential to bring consistent improvement in anesthesia records. AIMS can improve communication facilitating safer care. AIMS can expedite quality assurance and outcomes analysis. They can also enhance business analysis and reporting as well as compliance documentation and maintenance, and they can reduce medicolegal exposure.

Anesthesiology blazed the patient safety trail for the house of medicine to follow. Now we must utilize our unique skills for the collective good of medicine in general, and our patients in particular. We have the opportunity to leverage the advantages of information technology in taking quality, patient safety and efficiency to the next level.

Mark Your Calendars Now 2008 Conference on Practice Management Tampa, Florida January 25-27, 2008

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Karin Bierstein, J.D., M.P.H., advises ASA officers, committees and members on health policy and practice management strategies.