The future of anesthesia record keeping may resemble this example. An Anesthesia Information Management System (AIMS) from Docusys, a company co-founded by anesthesiologist Dr. Robert Evans, who has agreed to answer a few questions regarding AIMS systems in general and the Docusys system in particular...

Dr. Evans, I have been waiting for electronic record keeping to become mainstream for many years.

I have been engaged in trying to get electronic record keepers adopted my entire career. When the personal computer first came on the scene I thought every OR would be computerized by 1985. Every year it seems like ‘this is going to be the year’; but the adoption curve has moved sideways for quite some time. Now I believe there is a confluence of factors which is probably going to be a tipping point. Oversight compliance, on-going publicity about medical errors, financial constraints on hospitals who must find ways to cut costs and work more efficiently, and threats from government like the Office of Management and Budget or the RAC (Revenue Audit Contractor) initiative are but just a few of the pressures being put on practitioners to improve medical documentation. A growing number of new anesthesia program graduates have been exposed to automated record keepers and are looking to see if prospective employing hospitals are forward thinking or mired in an old paper system. This generation has grown up with the computer as a comfortable and useful tool and so the degree of computer phobia is much less. The new Anesthesia Patient Registry is going to be requesting more information on anesthesia outcomes. The Federal government is pushing the adoption of electronic health records and many are finding the entire hospital is computerized except for anesthesia. These and other factors I believe are going to combine to make AIMS squarely in the mainstream in the near term.

I  believe the ideal AIMS would have a short, intuitive learning curve, interact seamlessly with anesthesia monitors and devices and the facilities electronic patient data, automatically capture patient charges for medications and supplies and automatically re-ordering them, capture and transmit professional billing/coding information and a copy of the anesthetic record to my billing service.

The only part of this we do not do today is the re-ordering part although we do transmit a list of supplies used to material management systems which do automate the ordering. What you see on the screen is what you get when it comes to the printout at the end of the case (assuming you even want a paper printout). The record looks like a traditional paper record; making it easy to find needed information and adding to the comfort level for a new user. In fact since most of the information is coming in automatically, about the only thing the clinician has to input are the procedural comments and those are easy click selections of drop-down menu lists. There is an area of the record that holds comments and anyone can type a note in that section if they don’t know how to use the menus; so it’s possible for a new user or locums to get up to a functional level in a case or two. We have drivers (the actual programs that ‘talk’ to monitors) for approximately 400 different monitors, gas machines, ventilators and intravenous pumps from over 30 companies world wide. Furthermore we have a display dashboard that shows the clinician exactly what information is coming from the physiologic monitors along with diagnostics for the network, hardware and software.

This is important because in anesthesia we don’t have the luxury of having a technician at our beck-and-call 24 hours a day to get our equipment to work. When you turn a room around for a left hip instead of a right one, occasionally a cable gets pulled off. Better to know about this before the case gets started, so you don’t look up twenty minutes into the case and find that no vital signs are showing up because the monitor got disconnected.  Some systems are absolutely reliant on the network to get the vitals into the record. If the network goes down, not only do you lose the record but you might lose the vital sign information. Networks are becoming more reliable but we have chosen to make the application local with an in-room PC that captures the data directly from the monitors and backs up to servers every few minutes. This way if something outside the OR shuts down the network, you can still finish the case and the information will be transmitted to IT when the network is re-established.

We can draw patient information from most hospital systems but we have found that there are inconsistencies. In particular free form text is just about worthless. We use standardized tag descriptors for medications, allergies and medical co-morbid conditions. This allows us to bounce the drug about to be given against specific medical conditions in a pharmacy drug database and report on any issues. We license a patient-facing HealthQuiz developed at the Cleveland Clinic which provides a consistent filter to screen surgery patients. The results are matched against expected lab tests and consults but are also transmitted to the surgeon and the anesthesia pre-op.

If a hospital uses our digital drug monitor, DocuJect, when a drug is given it is documented and charged at the same time. We also provide several other ways to ease the process of either scanning or manually documenting drugs given and when that documentation takes place the pharmacy charges are created.

We have a billing/coding module built into the system with the intent that the surgeon, the hospital, and anesthesia all transmit the case details consistently (so the insurers deny the claims less often). It works by either a book-style CPT/ICD-9 look-up or by alphabetic word matching algorithm. This information is made available to billing services electronically as discrete data elements in a database or as a physical copy of the record that can be faxed or emailed to a billing service.The system allows easy input and editing of data, preop, intraop and post op. There is a quality improvement component that interacts with the department’s quality program.

There are extensive editing, annotating and artifact handling features along with an audit trail, QA reporting and post-op outcome documentation. All data in the system is placed into a reporting database to allow automatic reporting on all sorts of clinical issues. These can be vital signs, comments, complications, drugs given, times and responses to messages (like the patient’s temperature has fallen to a threshold level). An example of the types of reports would be the antibiotic to incision time delta (and was there a clinical reason not to give the antibiotic?), the difference between the posted start time and the actual time, and various other benchmarks such as room turnover or delays. Any particular clinical event such as laryngospasm can be flagged for on-going peer review.

While were talking ideal, it would be great to have a quick consult function, where a program would offer suggestions for anesthetic and medical management of the patient and provide a drug/lab/anesthesia reference tool.

We have created a hotlink section which allows a built-in browser to access appropriate web pages such as MHAUS (Malignant Hyperthermia) or the ASA airway algorithm as well as other references. Although we have some clinical decision support for things like beta blocker therapy and DVT prophylaxis, we don’t directly recommend treatment. New lab results on the patient are announced by a flashing button on the screen. Clicking on the flashing button shows you the most recent lab results so you don’t have to make five calls to the lab to get the results.

Dr. Evans, will you share the current “real world” of AIMS and describe how close I am to experiencing my ideal AIMS product?

I have been describing our product in its current form, not in a hypothetical ‘might be able to do someday’ form. Different vendors have different features that are unique to their offering. The ‘ideal’ AIMS is really a question about ease of clinical use and how well the system automatically interoperates with other systems in the hospital. Several of the systems on the market are really nursing or some other software that has been crow-barred into anesthesia. The interaction with the computer is awkward in the anesthesia workflow. The ‘ideal’ AIMS should ultimately allow collation of gathered information that can be used to improve patient safety and outcomes. The real question therefore is where do we go from here? We have supported the Anesthesia Patient Safety Foundation’s Data Dictionary Task Force which is now IOTA (International Organization for Terminology in Anesthesia). This effort reduces cases to descriptive tags so that cases done in Oregon can be compared to cases done in England, a military installation, a VHA or a university hospital. This is a long term project but one that I hope and expect will enable us to refine our patient care with real data so that we can all practice the best ‘evidence based’ medicine.

Do AIMS products typically require proprietary hardware or can they be deployed on any properly equipped computer? In addition to standard anesthesia monitors, additional equipment or devices may need to interact with the AIMS intra-operatively, I’m thinking of syringe pumps, bar code scanning, etc. Is this interact-ability a standard feature on AIMS products?

We use off-the-shelf hardware as long as it meets or exceeds our specifications. Other vendors create their own input devices, touch screens or other components. We do have a proprietary drug monitoring device that actually watches an intravenous port so we know what drug is about to be injected. Vendors have challenges with proprietary hardware so, except for the port monitor and our electronic anesthesia cart, we have steered clear of hardware. I am particularly troubled by some that have mixed the record keeper computer with the physiologic monitor or the anesthesia machine. I think that is a very bad idea. One company for example, used the same computer for the physiologic monitor as the record keeper and when the record keeper hung up clinicians also lost monitoring. We have the ability to listen but not instruct syringe pumps and we can actually handle different manufacturer’s pumps at the same time. We make extensive use of bar code scanning for disposable supplies, drugs, fluids, staff and patient identification, as well as blood unit documentation. Most vendors do not yet have barcode scanning capability and still rely a lot on keyboard input.

Now, specifically looking at Docusys, what do you consider the real strength of Docusys, that sets you apart from the other AIMS products on the market?

The most profound strength of DocuSys is that it was developed by anesthesia practitioners in the real world of production pressures and oversight compliance. The real focus has been on ease-of-use and fitting into the workflow of the anesthesia cockpit in a way that doesn’t interfere with clinical care. Also we recognize the importance of getting good information about the patients coming into the OR including medical history, home medications, allergies and appropriate screening labs and consults. Many delays, cancellations and conflicts in the OR center around erratic or inconsistent pre-op workups. We have a standardized Health Quiz that has been vetted on over 500,000 patients and a Pre-Op Planner that matches patients’ medical conditions and the anticipated surgery to a configurable matrix of lab tests and consults. The result gives the pre-op nurses a ‘to do’ list of expected pre-op screenings so that there are fewer surprises the morning of surgery. All this information flows into the pre-anesthesia evaluation and later into the hospital’s EMR without double entry.

There are links throughout this article to the Docusys website, what other references or links could you share with those interested in obtaining more in depth information about Anesthesia Information Systems?

For more information I would recommend the Society for Technology in Anesthesia and I note that there are quite a number of panels, Refresher Course Lectures, and other presentations at this year’s ASA. (Significantly up from previous years.) The most academic and disciplined reference on the subject is a recently available book by Jerry Stonemetz and Keith Ruskin, Eds., Anesthesia Informatics published by Springer London Limited 2008.

I recognize there would be variations in the costs of various systems, depending on complexity of the application, could you provide a range of what a facility should be prepared to set aside when planning on purchasing an AIMS system, from the basic no frills system, to one of my “ideal” systems ?

Like everything else in life you get what you pay for. There are ‘free ware’ programs out there that will make a record for you. The issue is how much effort you have to go to make it work. I have friends who have created their own record keeper and use it every day. In fact one doctor in Texas scanned his hospital’s anesthesia record and loaded on a tablet computer. He then ‘writes on’ the tablet for the vital signs, etc. and at the end of the case prints out the record which looks like a neatly typed copy of the hospital’s standard anesthesia record. If you want vital signs to automatically populate the record you need drivers, interfaces, physical connections and agreements with the hospital to hook up your gadget to their equipment. There are systems that are essentially teasers or deal sweeteners that you can get essentially for free as long as you buy a particular anesthesia machine or monitors. There are offerings of simple laptop-based record keepers in which you can type in the patient’s name, the surgery, the surgeon, etc. and later input all the vital signs and comments so that you end up with a nice looking record at the end of the case but few of these systems automatically interface with the hospital’s systems, or have much technical support if you get into trouble.

The real issue is ‘ease-of-use’. Every interface to labs, pharmacy, ADT (Admissions, Discharge and Transfer), the hospital’s EMR, materials management system and surgery scheduling costs money to implement and maintain, yet these are the essential elements that make a computer information management system for anesthesia easy to use. Our system is not cheap but when we install, we meet the timeline and the system works day one. We have 24/7 support and our users like the system. We have found ROI (Return on Investment) arguments that hospital administrators and private practice anesthesia groups understand. No standard cost is possible to suggest in that every hospital situation is different and we actually send a technician to the location to assess the machines, monitors, network, etc. as well as the desired functionality. Some hospitals just want a record keeper, some want medication management, some want pre-admission screening to avoid delays and cancellations the morning of surgery. We have electronic anesthesia carts that work intimately with the AIMS and an electronic equivalent of the dry erase board that most hospitals use to post their schedule. This display can be HIPAA cloaked so that it can be used in the family waiting area to show the progress of surgery.

Most places decide they want to entertain the implementation of an AIMS and so put out an RFI (Request for Information). The various vendors submit their offerings and the hospital asks the 3 – 5 most interesting to make presentations or demos of their systems. The hospital staff meets and decides what features they like best then issue a RFP (Request for Proposal). The response usually includes some sort of budgetary number for system cost. After critically reviewing the proposals usually 2 or 3 are invited back to show how their system will meet the desired functionality. The field is often narrowed to two and site visits to working facilities arranged. It is a good idea to be rigorous with worksheets detailing how the desired features actually work at those institutions because it can become bewildering to those actually going on site visits. It’s easy to confuse one company’s functionality with another. Finally a decision is made as to the ‘vendor of choice’ and the hospital administration begins the contract negotiations wherein a final cost figure is determined. Contracts are signed and the project is scheduled.

Please share your vision for the next generation of AIMS.

This is the most fun part. Here-to-fore we have been focusing on getting enough functionality to make these systems useful enough to get them installed. Now as basic infrastructure begins to be put in place we can begin to think about how we can use these new systems and approaches. It is no longer about how we can automatically make a record. It is now about how we present information cogently to the clinician. The human ergonomics and display methodology gives us the opportunity to message a caregiver in an efficient and timely manner. We can already assimilate that a patient has enough medical problems that he might be a candidate for beta blocker therapy or poses an increased risk for DVT. Suppose that sometime in the not-too-distant future the pattern of a complex case can be compared to a thousand similar cases at other facilities and when the vital signs stray beyond a standard deviation, suggested etiologies are displayed. Suppose it’s the middle of the night and you have to do an emergency case on a child with dumbfounder’s syndrome. A pediatric anesthesiologist on call at one of our nation’s academic centers might be able to ‘view’ your case and consult with you about it over the internet. Instead of yet another beeping alarm your system might communicate with you verbally through a Bluetooth earpiece that the trend of the heart rate and PA pressure is worrisome; a trend that might be too subtle for most of us to appreciate.

Data is not information. Data can be overwhelming and difficult to comprehend. Edward Tufte in a book entitled The Visual Display of Quantitative Information describes how the presentation of data can impact its understanding whether it be the Challenger accident or the spread of Cholera [Visual Explanations, pp. 27-37] from a well in England. We are data rich and comprehension poor. Information systems, particularly anesthesia information systems, need to become the fighter pilot’s heads-up display rather than the medical records clerk i dotting and t crossing ‘big brother over-your-shoulder’ monitor. AIMS is not just a tool to be used but an evidenced based solution to many of the challenges we face trying to make our OR’s run smoothly and efficiently while ensuring our patients’ safety and good outcomes.

Thank you for sharing your insights and I look forward to hearing your presentation and meeting you at the Oregon Association of Nurse Anesthetists meeting, October23-25,2009 in Portland, Oregon.