Anesthesiologists work in a dynamic environment in which information critical to patient care must be transmitted quickly and accurately. Patients undergoing procedures are often critically ill with rapidly changing vital signs. Treatment plans must be changed rapidly to meet the demands of the surgical procedure and the patient’s condition. Health information technology (IT) is critical to patient safety in the perioperative environment. Nearly every new piece of equipment in the operating room (OR) contains one or more microcomputers, making a basic understanding of medical informatics essential for every anesthesiologist. Thus, anesthesiology is an information-intense specialty, and computers play an important role in the OR as well as in other areas of the hospital.
The practice of anesthesia requires the use of computers for data management, quality assurance, automated record keeping, and signal processing. An electronic workflow facilitates direct patient care and can also be used for purposes such as quality assurance and submission of health insurance claims.
One study of 98 Florida hospitals suggests that simply adopting IT may improve patient care. These hospitals’ use of clinical, administrative, and strategic applications was associated with a decreased risk-adjusted mortality in percutaneous transluminal coronary angioplasty, gastrointestinal (GI) hemorrhage, and acute myocardial infarction. The authors concluded that adopting the use of health IT improved patient outcome. In this study, use of IT systems was also negatively correlated with unnecessary incidental appendectomy. Interestingly, the adoption of strategic IT applications was associated with decreased risk-adjusted morbidity from laparoscopic cholecystectomy and craniotomy.
Studies such as this one underscore the benefits of adopting IT initiatives as part of anesthetic practice. This chapter discusses the role of medical informatics in anesthesia practice and medical education, and includes a brief discussion of information security.
The latest generation of anesthesia workstations and physiologic monitoring systems offers a wide range of capabilities, from advanced monitoring to ventilator functions comparable to those of an intensive care unit (ICU) ventilator. Current designs may help to improve patient safety by incorporating features such as checklists (e.g., the United States Food and Drug Administration [FDA] anesthesia machine checkout) and double-check systems that prevent unintended changes to ventilator or gas flow settings. Anesthesia workstations can exchange information with electronic health record (EHR) systems, thereby creating an accurate, contemporaneous anesthesia record while also making pertinent history and laboratory results available to the anesthesiologist. Incorporation of these features, most of which rely on systems automation and computers, have been recommended to reduce errors in the OR. Anesthesia workstations also can improve patient safety by requiring compliance with established checkout procedures. The software that drives modern anesthesia workstations allows enforcement of policies and helps prevent use errors. This is an important feature because anesthesiologists are not particularly good at identifying machine faults. For example, the Datex-Ohmeda Aisys and Avance workstations (GE Healthcare, Waukesha, WI) require the user to complete the recommended checkout before the workstation can be used for patient care. (This feature can be bypassed for emergency surgery, and an abbreviated checkout can be done after the first anesthetic of the day.) Interlocks prevent use errors, making it difficult or impossible to deliver a hypoxic mixture or dangerously high peak airway pressures. Advanced workstations require the user to confirm settings, forcing a double-check of the selections. New workstations can also be used to deliver novel anesthetics such as xenon.
The newest generation of anesthesia workstations requires that users receive a significant amount of training before using them for patient care. It is no longer possible to simply turn a knob to increase the gas flow or flip a switch to turn on a ventilator. The new machines use a complicated user interface with a layered series of menus. Usability has become an important design feature, and newer designs offer improved ergonomics. In one study comparing a first-generation workstation with four second-generation workstations, 10 specific qualities were evaluated on a 10-point scale; two design and monitoring criteria, four ventilator criteria, and four maintenance criteria were studied. So-called second-generation workstations were found to have an improved user interface and superior readability. They also were easier to set up both at the start of the day and between cases. In particular, the ventilator controls were more intuitive and easier to use.
In modern, integrated anesthesia workstations, the gas machine, ventilator, and physiologic monitor share the same physical space and are designed to work together. These systems offer a variety of new features, including multiple ventilator modes, more precise administration of potent volatile anesthetics, the ability to exchange data, and automated checklists. A sophisticated user interface allows multiple features to be accessed at the touch of a button. Online help systems can allow the clinician to find a particular feature, and newer systems are far more intuitive and easy to use. With these features and careful attention, modern anesthesia workstations can be used to improve patient care.
Anesthesia Information Management Systems
Anesthesiologists have been among the first to develop technology for keeping EHRs. In one recent study, 44% of all academic anesthesiology practices had adopted anesthesia information management systems (AIMS). This ability to collect, store, and organize large amounts of data makes AIMS ideal for quality assurance and clinical research. Anesthesiologists have been working with medical device manufacturers and standards organizations to create new devices that can communicate with each other and with EHRs.
AIMS can improve patient care because they produce customized, legible anesthesia records while storing high-resolution physiologic data in a database that can be easily searched. This simplifies finding a specific record and facilitates new data analysis techniques, such as data mining, which allows large quantities of data to be searched for subtle associations. This information can be used for quality assurance, to search for and track specific events and their outcomes, and to analyze specific personnel. Nair and colleagues reported that including real-time alerts for prophylactic antibiotic administration increased the rate of timely administration by more than 9%, and they concluded that a decision support system that includes real-time guidance and alerts can improve compliance with guidelines.
Perhaps the most significant difficulty in upgrading anesthesia medical records systems occurs when it is time to completely replace one computerized system with another. Although most systems store information in relational databases, such as the Microsoft SQL Server, it may be very difficult to move large numbers of patient records into a new system. When faced with the complexity of matching up a hundred or more fields from one system with another, at least one hospital decided to simply abandon the previous structured records of more than 100,000 patients. This illustrates how important it is to choose a system that can grow and adapt to a changing practice. It is also important to carefully explore problems related to data migration before choosing a new system.
Despite the obvious advantages of EHRs, their complexity and perceived costs have prevented many providers, particularly those in small hospitals or rural practices, from adopting this technology. AIMS can provide a return on investment by ensuring compliance with Physician Quality and Reporting System guidelines and Center for Medicare and Medicaid Services (CMS) documentation requirements. AIMS have also been shown to increase scheduling efficiency, decrease drug costs, and provide better charge capture and diagnosis and procedure coding.
The amount of knowledge needed to provide high-quality medical care is rapidly increasing, yet physicians have less time than ever to keep abreast of the literature. Computers can help physicians find critical information quickly and have therefore become commonplace in anesthesia education.
Most books, medical journals, and other educational materials can be accessed electronically, and many physicians now prefer electronic references to printed ones. Journals can be extensively cross-referenced and are no longer restricted to the linear flow of text on a page. Search engines and links from websites make it easier to find information, allowing the average clinician to perform complex literature searches with little or no prior computer experience. Interactive educational materials can quiz the student prior to moving on to new material, and they can use three-dimensional models or video clips to explain a difficult concept. One study suggests that physicians frequently ask clinical questions but may pursue the answers to only slightly more than half. The most common reason cited for abandoning a question was the doubt that an accessible answer existed. In one study, anesthesiologists were given a clinical question and were asked to use PubMed, UpToDate, Ovid, or Google to find the answer. Interestingly, those residents who used Google and UpToDate were more likely than those who used PubMed to find the answer to the question, and searches with Google were faster than those with UpToDate or Ovid.
Because they are portable, smartphones and tablet computers offer access to journal articles, guidelines, and the patient record without the need to leave the patient. One study of these devices in the emergency medicine department showed that physicians who used them were more likely to correct a patient’s diagnosis or treatment. Many clinicians use their handheld computers as their primary source of information, and access to the devices appears to improve clinical decision making, although some physicians are slower to accept mobile computing devices than others. Moreover, transmission of microorganisms by these devices is a concern. Video mobile telephones, which are widely available in Europe and are becoming available in the United States, have been proposed as a possible tool to help bystanders perform CPR. Although early studies on this role have been equivocal, specialized training may enable dispatchers to help bystanders at an accident.
During a life-threatening event, being able to quickly recall a series of actions necessary to manage a rapidly unfolding clinical scenario may improve patient outcome. Critical incident analysis has identified specific nontechnical skills that are vital to the successful resolution of a critical incident in the OR. Traditional anesthesia training does not involve the teaching of crisis resource-management skills. Topics such as situational awareness, resource allocation, team management, and medical decision making must be actively taught and cannot be learned by reading or simply by being present in the OR. Yee and colleagues studied the effectiveness of simulator-based crisis resource-management training and found that a single exposure to a simulated critical event improved nontechnical crisis-management skills in anesthesia residents. As a result, many institutions have begun to adopt medical simulation as an integral component of their educational programs.
Because of their ability to create a standardized clinical scenario, patient simulators allow trainees to practice and to make mistakes without placing an actual patient at risk (see Chapter 25 ). The simulation can be stopped, restarted, or reset as needed to facilitate teaching; important points are not lost in the rush to stabilize a sick patient. Because critical events can unfold quickly during surgery, anesthesiologists were among the first physicians to adopt the routine use of full-scale simulation. Simulators have been used to teach medical students and new residents the basic principles of airway management and physiology as well as the fundamentals of anesthetic management of patients. Large commercial simulators make extensive use of computers and a manikin to generate appropriate sounds, movements, and signals for monitors. Small PC-based simulators such as Anesthesia Simulator Consultant (Anesoft, Issaquah, WA) and Gas Man ( www.gasmanweb.com ) can be run on a desktop computer and are used to teach basic concepts.
Anesthesiologists work in a dynamic environment in which information critical to patient care must be transmitted quickly and accurately. Failures in communication were shown to be the second most prevalent cause of medical errors. Rapid transfer of relevant patient information prior to surgery can also improve OR efficiency by reducing the incidence of delays on the day of surgery, and reliable IT tools are critical to patient safety in the perioperative environment.
Modern Communication Devices
Anesthesiologists can choose from a variety of tools to gain access to the information they need. Handheld computers, tablets, and smart phones are ubiquitous, and services such as UpToDate provide evidence-based, peer-reviewed information and guidelines. Online communities and social networking sites can be used to form a “virtual coffee room,” where physicians can network with their friends and colleagues.
Cellular telephones, wireless computers, and other communication tools can improve patient care by providing rapid access to vital information from any location. Effective communication has been shown to be a critical component of safety in high-risk environments. Several reviews have postulated that improving communication among health care professionals may improve patient safety. Cellular telephones provide rapid, two-way voice communication and can also be used to exchange pictures and short text messages. Several cellular service providers offer a walkie-talkie mode that allows one user to contact a member of his or her group at the push of a button. The results of at least one study suggest that the use of mobile telephones decreases the incidence of errors.
Computer Interfaces and Networks
Most monitors are now capable of transmitting numbers and waveforms, such as an electrocardiogram (ECG) or blood pressure tracing, to another monitor or to a computer at a remote location, making this critical information immediately available to the clinician. An ideal communication system therefore should include paging, voice communication, and data networking. A portable device capable of displaying this critical information allows a physician to be immediately available in the event of a sudden change in the patient’s condition. Wi-Fi networks can handle multiple data streams at once, are relatively inexpensive to set up and maintain, and are highly versatile.
The development of widely used data transmission standards has made it possible to connect medical equipment together and to transmit medical information through existing networks to desktop computers, servers, or monitoring stations. The end result is that a core communication infrastructure is likely to be compatible with new devices, and it can be installed using readily available equipment. Wi-Fi networks can also be used to carry voice conversations. Voice over Internet Protocol (VoIP) is widely accepted by the general public as an alternative to traditional telephone service, and specialized systems can be installed in the health care environment. These advantages, combined with the low cost and wide availability of Wi-Fi equipment, make this technology well suited for many health care applications. In one study, the staff of a pediatric surgical suite—including anesthesiologists, nurses, and surgeons—were provided with VoIP hands-free communication devices. This technology significantly improved each staff member’s ability to communicate, but problems were experienced with voice recognition in a noisy environment, and the system was not reliable in all areas of the OR.
Hospitals in the United States and Europe had implemented policies that prohibit the use of wireless communication devices in patient care areas. Unfortunately, most of these policies were developed in response to anecdotal reports of interference and ignore the potential benefits that cellular telephones can bring to patient care. Modern cellular telephones transmit on specific frequencies dedicated to their use and are designed to minimize spurious, out-of-band transmissions. Several large studies have shown that the risk of using wireless devices at a distance at least 3 feet from a medical device is very low.
E-mail is an effective tool that permits rapid distribution of information and allows images and other attachments to be exchanged easily. The use of e-mail can enhance the patient-physician relationship by making the physician more accessible, but it raises concerns about both privacy and security. Important messages can be saved for future reference, and e-mail’s asynchronous nature allows busy health care professionals to exchange information without having to find one another on the telephone. Physicians and patients routinely use e-mail to communicate with each other. In 2006, 17% of physicians routinely used e-mail to communicate with their patients, and over two thirds of physicians used e-mail to communicate with other physicians. As physicians become increasingly comfortable with IT, it is likely that the number of physicians who use e-mail to communicate will increase. One study by Brooks and Menachemi found that only 1.6% of physicians who used e-mail adhered to published guidelines, which include printing e-mail correspondence and placing it into the patient’s chart. Only one third of physicians who used e-mail informed patients about privacy issues.
Many of the problems that arise during e-mail communication are caused by the fact that it is difficult to positively identify the true author of the message. Unencrypted e-mail may be intercepted during transmission or if the mail server at either end of the transaction is compromised. E-mail messages can also be intercepted if either the patient’s or physician’s computer is lost or stolen, or if an e-mail account is compromised. Many physicians assume that an e-mail correspondent is telling the truth about his or her identity and diagnosis, but it is relatively easy to impersonate another individual by registering an e-mail address similar to that of the intended victim. Eysenbach and Diepgen sent e-mail to the owners of medical websites posing as a fictitious patient with a dermatologic lesion. Although 93% of physicians who responded recommended that the patient see a physician, over half mentioned a specific diagnosis in their response.
As a result of these potential problems, the American Medical Informatics Association has developed guidelines for the use of e-mail by physicians and patients. These guidelines recommend obtaining informed consent prior to using e-mail to communicate, prohibiting the forwarding of e-mail without consent, explaining and using security mechanisms such as encryption, avoiding references to third parties, and informing patients as to who will have access to e-mail communications and whether e-mail will become a part of their medical record. The recommendations also included simple tasks such as double-checking all “To:” fields before sending messages and printing paper copies of messages and replies to place in the patient’s chart. Taking these relatively straightforward precautions will enhance the use of e-mail while minimizing security risks. Using secured e-mail programs compliant with the Health Insurance Portability and Accountability Act (HIPAA), such as the Accellion (Palo Alto, CA) plugin for Microsoft Outlook, is also a good option and is now required by law in the United States.
Telephone consultations are now widely used in health care delivery and pose a different set of problems. Telephone calls are widely used by both physicians and patients in the health care setting; unfortunately, this practice can lead to a breach of patient confidentiality. Health care workers rarely if ever ask a caller to prove his or her identity before releasing information. Curious friends, attorneys, or other interested parties may potentially lie about their identities (known as social engineering ) to gain access to confidential information. Even staff who claim that they can recognize a patient’s voice can be fooled. Because of the limited bandwidth of the telephone network, it may be possible for another person to impersonate the patient. To alleviate this problem, Sokol and colleagues have recommended the use of an authentication system that requires the caller to provide a password, making it easy for a patient or authorized representative to be identified.
Social networking sites have fundamentally changed the way many people keep in touch with friends and colleagues. Social media sites such as Facebook and LinkedIn allow their subscribers share news and pictures with friends and acquaintances. Each service offers a different “feel” and encourages the formation of specific types of communities. In general, LinkedIn is used primarily to maintain professional contacts and is used by recruiters to find candidates for positions in a variety of industries, including medicine. As of this writing, Facebook was the largest service, drawing users with both professional and social interests. Most subscribers use these services as a kind of continuously updated “Family and Friends” newsletter. Others use it to keep in touch with professional colleagues.
Although commercial social networking sites should not be used to discuss specific patients, medical groups have begun to develop their own dedicated sites that allow patients and physicians to interact with each other using instant messaging or community web pages. Social networking sites have become an important method of communication among medical students and residents. In one study, half of medical trainees who responded to a survey participated in at least one social networking site, and only one third made their personally identifiable information private. Use of these sites decreased somewhat as trainees approached graduation.
Patient care issues and any confidential information should not be discussed because of the obvious lack of privacy. Many social networking sites do not provide a way to close an account, meaning a user cannot remove his or her profile once it has been created, although it is, of course, possible to remove nearly all of the information associated with that profile. Information that has been posted may therefore be available online long after its owner had wanted it to be removed. Moreover, the business model of Facebook consists of selling information about its users to advertisers and other organizations. As a result, information that a user might have assumed to be private may be widely available to others. It is important to repeatedly check the privacy policies of social networking sites and the privacy settings of each individual account to make sure that confidential information is not being shared.