Occasionally, a technologic innovation will cause a fundamental change in the field in which it is used. The electronic medical record (EMR) is such a tool and is altering the manner in which health care is provided, consumed, researched, and even conceived. EMR is a broad term and refers to a range of software packages, including relatively simple systems used in a single physician’s office, Web-based tools that allow patients to enter health information, or complex software systems used by global health care organizations. Although these systems vary widely in complexity, they share some common components. According to the Institute of Medicine, functions of an EMR include the following:

EMRs can also include a decision support system (DSS) to assist health care providers in making treatment decisions.

Until recently, health care organizations have been slow to adopt EMRs. Common obstacles included the cost of the software, cost of implementation and training, and lack of integration with other health care software. Recent changes in technology and federal financial incentives have accelerated the adoption of EMRs in small practices and hospital systems alike. The specialty of anesthesiology has been particularly slow to adopt EMRs, due in part to the operating room (OR) environment and the unique documentation requirements of the anesthesia record. Indeed, several of the major EMR vendors are only now releasing perioperative medicine suites, including preoperative evaluation, intraoperative anesthesia, surgical, and nursing care, and postanesthesia care. Heretofore, there were few software packages that could support these needs and integrate with the larger EMRs, which tend to focus on clinic and hospital ward medicine requirements.

To meet these challenges, several EMRs specifically designed for the anesthesia department have been developed and are referred to, collectively, as the Anesthesia Information Management Systems (AIMS). In many cases, larger software vendors acquired, modified, and integrated software packages originally developed by anesthesiologists.

Because the majority of AIMS currently available are used within hospital environments, the remainder of this chapter focuses on hospital EMRs and AIMS. The EMR has grown from recording simple health information to complex integrated systems that can improve the efficiency and quality of health care delivered to patients. Historically, hospital information systems centered around individual departments (e.g., the laboratory industry developed software to automate lab results reporting; the radiology industry developed specialized software to archive and retrieve digital radiologic studies). Hospitals frequently utilized a “best of breed” approach to select the best software systems available for each department. Unfortunately, these systems were not integrated and could not “talk” to each other. Increasingly, hospital administrators and health care providers seek departmental software systems only if they are integrated with other hospital information systems, as this eliminates the inefficiencies and redundancies inherent in having separate systems that do not communicate
with one another. The most recent trend is that a few large hospital information systems vendors have begun to dominate the market. They offer completely integrated hospital information systems that include an outpatient EMR, inpatient EMR, lab system, radiology system, financial and billing system, scheduling, facilities and supply chain management, and pharmacy operations. Only recently have they begun including the perioperative environment. These departments and systems are linked though an enterprise-wide intranet and also allow remote access through the Internet. All access to patient health information through these systems must comply with the security and privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Core functions of a modern EMR include the following:

Anesthesia technicians will be called upon to interact with EMRs or hospital information systems in a variety of ways: equipment/supply ordering, results reporting and retrieval, documentation of quality control testing results, and information entry in AIMS.

Anesthesiology departments have been slow to adopt EMRs into the OR. Only 1% of anesthesiology departments use electronic charting in the United States versus the much higher rates in other disciplines. Anesthesiology providers have been hesitant to incur the costs and perceived complication of integrating EMR into anesthetic practice, as it was not clear if they or their hospitals would benefit from adopting AIMS. Things have changed on both sides of the equation:

To speed adoption by a Department of Anesthesiology, an AIMS must not only record
vital signs and data with efficiency during the intraoperative period but also effectively combine preoperative notes and laboratory and radiologic studies with perioperative documentation. The AIMS must work with, and not impede, the normal workflow in the OR. The system must not cause the anesthesia provider to constantly divert his or her attention from the patient to deal with the computer. The AIMS display must be easy to read, printouts of anesthesia records should be easy to read and maintain some of the look and feel of traditional paper records, and data should be seamlessly incorporated into the patients’ global EMR.

Modern AIMS now include integrated lab, radiology and cardiology results, ordering and prescribing capabilities, and decision support functions that prompt for possible drug interactions or dosing errors, patient allergies, antibiotic reminders, and treatment guidelines. Advancements in technology and processor speed have made it possible for systems to operate in real time, to match the fast pace of events in the OR. Touch screens and “scripts” have significantly improved the usability of these systems and reduced the burden of using them by anesthesia providers. A “script” bundles together activities that require documentation. For example, a basic general anesthesia script includes documentation events for room time, induction, airway management, eye care, patient positioning, and antibiotic administration. These innovations, specifically those that reduce data entry and related distractions, have resulted in improved acceptance by anesthesia providers.

EMRs have improved efficiency and decreased some types of medical errors (though some argue that EMRs have also introduced new kinds of errors). Care in outpatient settings has improved because of easy access to outside records, labs, and studies; this also reduces the cost and risk associated with redundant testing associated with transfer between institutions. In addition, comprehensive results availability has allowed physicians to have a more complete historical medical picture of their patients, thus improving their quality of care.

DSSs assist physicians with prompts and evidence-based protocols (algorithms) for specific diseases, as developed by the Centers for Medicare & Medicaid Services (CMS) and specialty societies. These algorithms improve the quality and cost of care by prompting providers to order timely diagnostic studies (e.g., mammogram, hemoglobin A_1c), provide vaccinations, or intervene upon receipt of abnormal test values. They also assist in the critical task of medication reconciliation.

Within EMRs, CPOE has had the greatest impact on decreasing medical errors. CPOE programs in both outpatient and inpatient settings improve safety by minimizing the errors associated with manual prescription drug and order writing. These errors include illegible orders, incorrect units, inappropriate doses (especially with renal disease), and incomplete orders. In the inpatient setting, these three errors are associated with 55%-80% of medication errors. Implementing a CPOE with a clinical decision support system (CDSS or DSS) can eliminate the majority of these types of medication errors. In one study in patients with renal failure, implementation of a CPOE reduced medication errors by threefold.

Similarly, AIMS have the potential to decrease costs and improve care. The ready availability of notes, consults, and testing results reduces the need for ordering additional testing. In addition, this makes unnecessary case cancellations less likely. Within AIMS, CPOE may prevent the anesthesia provider from making medication errors. AIMS DSSs can assist anesthesia providers by alerting them to medically significant conditions, such as antibiotic redosing interval or tourniquet time. Scripts prompt providers to perform tasks and complete documentation. For example, the inclusion of a reminder to document antibiotic administration at the beginning of a script can help providers remember to give any necessary preoperative antibiotics at the right time (which is also an important CMS quality indicator). These systems also facilitate complete information transfer during anesthesia provider transitions.

Another important impact of AIMS is the ability to provide information for quality improvement and outcomes research. Reviewing electronic records is inherently simpler and more efficient than wading through copious paper documents, deciphering handwriting, and inferring the information inadvertently omitted therein. In
one study, automatic recording of vital signs by the EMR significantly improved the accuracy of the vital signs data versus a paper record.

As noted above, AIMS have the ability to improve efficiency and accuracy of data entry for clinicians in the OR. By allowing importation of other EMR data or data from prior anesthesia records, AIMS can reduce redundant data entry and streamline workflow (recall a case in which a patient has repeated abdominal washouts or wound debridement). By improving and simplifying data input, AIMS increase the accuracy and quality of information recorded. However, it is also true that an error entered once may be propagated by clinicians copying records without editing them for accuracy. Clinicians are more likely to record events that are included in preformed scripts, instead of having to free text, resulting in a more thorough record.

Governmental and private insurers now require a significantly greater amount of documentation before they pay for a medical claim (many insurers even require a complete copy of the anesthesia record). By using AIMS, anesthesiologists increase documentation accuracy of key times and events required to receive reimbursement for anesthesia services. For example, an AIMS may prompt an anesthesiologist to perform an attestation or complete a procedure note. Incomplete charts or illegible charts increase the revenue cycle time and in some cases, lead to inability to bill. One study demonstrated that an anesthesiology department that implemented an AIMS increased revenues by 3.4% because of better documentation of anesthesia services that supported claims submitted to insurers.

Clear and accurate documentation is key for anesthesia providers to receive reimbursements, avoid fines from regulatory agencies, and protect themselves from malpractice claims. AIMS facilitate complete documentation, which is necessary to be compliant with the Joint Commission requirements for items such as preinduction patient assessment and the preprocedural pause or time out. AIMS also facilitate documentation to comply with CMS pay-for-performance rules. In addition to compliance with regulatory agencies, clear and accurate records produced by an AIMS can assist in defending against malpractice claims. Research shows that physicians who use EMR are less likely to have paid malpractice claims. Some malpractice insurance carriers even provide discounts to physicians who utilize AIMS. However, plaintiff’s attorneys also use the OR software to document use of potentially distracting software, such as Web browsers.

The use and technologic advancement of EMRs and AIMS have generated large amounts of detailed clinical data that were previously impossible to retrieve. Because AIMS-based documentation is more inclusive than self-reporting, AIMS document a significantly increased incidence of critical anesthesia events like hypoxemia and severe hypotension than self-reports from providers. This suggests that studies performed based on AIMS data are likely to be inherently more accurate than those performed based on manually entered data, as the latter are subject to measurement bias.

Electronic data generated from AIMS can be aggregated across multiple institutions, allowing investigators to perform previously impossible or prohibitive forms of research. Multi-institution studies compare how patient populations and treatments vary across regions, institutions, or practice settings and create large data sets that can be used to examine outcomes that have a very low incidence.

As technology advances, AIMS will almost certainly acquire new capabilities. For example, automatic notification to a radiologist that a new central line x-ray requires reviewing or an alert to the inpatient Pain Medicine service that a patient with an epidural infusion has arrived in the postanesthesia care unit (PACU). In addition to improved communication, it is likely that AIMS decision support will become more sophisticated. For example, the system might suggest a certain anesthetic technique or notify a provider of an elevated international normalized ratio
(INR) in patients being considered for regional anesthesia. Researchers are already studying the feasibility of adding voice recognition software as a method of data entry. Other advancements will involve greater patient interaction with the EMR. Much like in other industries (e.g., airlines), patients may access self-check-in kiosks to check in, change demographic data, change insurance information, sign consent forms, and even pay co-pays.

Occasionally, a technologic innovation will cause a fundamental change in the field in which it is used. The electronic medical record (EMR) is such a tool and is altering the manner in which health care is provided, consumed, researched, and even conceived. EMR is a broad term and refers to a range of software packages, including relatively simple systems used in a single physician’s office, Web-based tools that allow patients to enter health information, or complex software systems used by global health care organizations. Although these systems vary widely in complexity, they share some common components. According to the Institute of Medicine, functions of an EMR include the following:

EMRs can also include a decision support system (DSS) to assist health care providers in making treatment decisions.

Until recently, health care organizations have been slow to adopt EMRs. Common obstacles included the cost of the software, cost of implementation and training, and lack of integration with other health care software. Recent changes in technology and federal financial incentives have accelerated the adoption of EMRs in small practices and hospital systems alike. The specialty of anesthesiology has been particularly slow to adopt EMRs, due in part to the operating room (OR) environment and the unique documentation requirements of the anesthesia record. Indeed, several of the major EMR vendors are only now releasing perioperative medicine suites, including preoperative evaluation, intraoperative anesthesia, surgical, and nursing care, and postanesthesia care. Heretofore, there were few software packages that could support these needs and integrate with the larger EMRs, which tend to focus on clinic and hospital ward medicine requirements.

To meet these challenges, several EMRs specifically designed for the anesthesia department have been developed and are referred to, collectively, as the Anesthesia Information Management Systems (AIMS). In many cases, larger software vendors acquired, modified, and integrated software packages originally developed by anesthesiologists.

Because the majority of AIMS currently available are used within hospital environments, the remainder of this chapter focuses on hospital EMRs and AIMS. The EMR has grown from recording simple health information to complex integrated systems that can improve the efficiency and quality of health care delivered to patients. Historically, hospital information systems centered around individual departments (e.g., the laboratory industry developed software to automate lab results reporting; the radiology industry developed specialized software to archive and retrieve digital radiologic studies). Hospitals frequently utilized a “best of breed” approach to select the best software systems available for each department. Unfortunately, these systems were not integrated and could not “talk” to each other. Increasingly, hospital administrators and health care providers seek departmental software systems only if they are integrated with other hospital information systems, as this eliminates the inefficiencies and redundancies inherent in having separate systems that do not communicate
with one another. The most recent trend is that a few large hospital information systems vendors have begun to dominate the market. They offer completely integrated hospital information systems that include an outpatient EMR, inpatient EMR, lab system, radiology system, financial and billing system, scheduling, facilities and supply chain management, and pharmacy operations. Only recently have they begun including the perioperative environment. These departments and systems are linked though an enterprise-wide intranet and also allow remote access through the Internet. All access to patient health information through these systems must comply with the security and privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Core functions of a modern EMR include the following:

Anesthesia technicians will be called upon to interact with EMRs or hospital information systems in a variety of ways: equipment/supply ordering, results reporting and retrieval, documentation of quality control testing results, and information entry in AIMS.

Anesthesiology departments have been slow to adopt EMRs into the OR. Only 1% of anesthesiology departments use electronic charting in the United States versus the much higher rates in other disciplines. Anesthesiology providers have been hesitant to incur the costs and perceived complication of integrating EMR into anesthetic practice, as it was not clear if they or their hospitals would benefit from adopting AIMS. Things have changed on both sides of the equation: