Introduction
Harvey Cushing, an American neurosurgeon, recognized that the perioperative environment required detailed data collection. Working with colleagues in the 1890s, he is credited with bringing the intraoperative anesthetic record into popular use. This early pen and paper example of information technology in the operating room has been in existence for over 100 years and is the primary method of documenting anesthesia care for many practitioners. However, over the last decade, advances in information technology and a national focus on patient safety and the delivery of cost-effective care have led to the investment in and development of sophisticated systems to manage, monitor and document care. Having advanced beyond the pen and paper, we recognize that managing multiple streams of data is of paramount importance.
Other industries, such as manufacturing, transportation, and public utilities, drove the development of information technology to capture and analyze data in order to provide more profitable services or obtain a competitive advantage over others in the same commercial space. However, in medicine the proliferation of health information technology is a development that is relatively recent and continuing to mature. Medicine is a broad discipline. Among the various elements of care, the perioperative environment is complex, esoteric, and hidden behind doors that say “Do Not Enter without Proper Attire.” As such, this area has received less informatics-related attention than other areas of the medical enterprise, such as billing, laboratory, and computerized physician order entry. Electronic anesthesia information systems were described as early as 1991. However, implementation rates continued to be low even 25 years later. This low rate has been improving, with new technologies and increased development and research in this critical area.
The legislature has had a significant impact on the development of health information technology (HIT). In 2009 the American Recovery and Reinvestment Act included a significant incentive for organizations to improve HIT implementations. These incentives were designed to encourage the development and implementation of health-related information technology and the development of outcomes measures to gauge the quality and cost efficiency of care. , The Health Information Technology for Economic and Clinical Health Act (HITECH) provided $26 billion in incentives to improve and implement HIT. HITECH provides for both incentives and penalties to physicians who use or fail to use HIT that meets certain meaningful use (MU) criteria. Coupled with the drive to become more efficient and improve safety, we are finally realizing the benefits to the quality efficiency of care which HIT offers.
Scope of health information technology
Multiple HIT systems are in common use ( Table 28.1 ). These components may be integrated into an enterprise wide system provided by one vendor. Enterprise systems cover several or all the required HIT functions in one installation, but often do not provide the specific tools needed for the most highly technical or low volume services. In contrast, “best of breed” applications have been developed to fulfill these specific niches and are often installed in conjunction with enterprise systems when the enterprise system does not provide adequate functionality in a particular discipline.
| Electronic Medical Record (EMR) | Represents an electronic version of the traditional paper chart. May include physician, nursing and ancillary notes, lab results, radiology results, physician order. May include integrated components of the other modalities |
| Computerized Physician Order Entry (CPOE) | Application to record physician orders and transmit the orders to the discipline fulfilling the order (eg, pharmacy, radiology, nursing, physical therapy). May include algorithms for error checking, such as drug interactions, allergy information, weight-based calculations. May include additional functionality such as the electronic transmission of prescriptions to outpatient pharmacies |
| Picture Archiving Communication System (PACS) | Provides storage of and access to images from radiology, ultrasound, and related imaging modalities. Often replaces traditional chemical film imaging with digital radiology capture |
| Anesthesiology Information Systems (AIMS) | Application designed to record the progress of intraoperative care, including vital signs, medications administration, airway and patient management, documentation of operative times and practitioner comments and attestations of care |
| Perioperative Information Management System (PIMS) | Series of applications designed to capture and record the documentation of care from multiple disciplines (eg, nursing, anesthesiology, perfusion, respiratory therapy) throughout the perioperative process. Includes preoperative, intraoperative, and postoperative documentation by nursing teams, and AIMS system, OR suite management, supply and equipment tracking, patient status boards and other applications |
| Specialized Applications | Developed for use in one or two primary areas to cover specific functions. Examples include software to track the flow of patients in the emergency department, applications to record the progress of labor with fetal telemetry, applications to provide integration and remote delivery of data from operative or ICU environments |
A key element for the success of any HIT program is acceptability by clinicians for integration into their preexisting workflow. Barriers to adoption have been studied and include factors such as financial, technical, organizational, and psychological challenges. Properly designed systems will minimize the time required to document and the need to reenter any previously existing data. Toward this aim, the user experience or human factor considerations (the interfacing of systems, the design of the user interface, the actual appearance of the data entry screens, and processes) must be carefully examined when selecting or developing any HIT-related product.
Scope of health information technology
Multiple HIT systems are in common use ( Table 28.1 ). These components may be integrated into an enterprise wide system provided by one vendor. Enterprise systems cover several or all the required HIT functions in one installation, but often do not provide the specific tools needed for the most highly technical or low volume services. In contrast, “best of breed” applications have been developed to fulfill these specific niches and are often installed in conjunction with enterprise systems when the enterprise system does not provide adequate functionality in a particular discipline.
| Electronic Medical Record (EMR) | Represents an electronic version of the traditional paper chart. May include physician, nursing and ancillary notes, lab results, radiology results, physician order. May include integrated components of the other modalities |
| Computerized Physician Order Entry (CPOE) | Application to record physician orders and transmit the orders to the discipline fulfilling the order (eg, pharmacy, radiology, nursing, physical therapy). May include algorithms for error checking, such as drug interactions, allergy information, weight-based calculations. May include additional functionality such as the electronic transmission of prescriptions to outpatient pharmacies |
| Picture Archiving Communication System (PACS) | Provides storage of and access to images from radiology, ultrasound, and related imaging modalities. Often replaces traditional chemical film imaging with digital radiology capture |
| Anesthesiology Information Systems (AIMS) | Application designed to record the progress of intraoperative care, including vital signs, medications administration, airway and patient management, documentation of operative times and practitioner comments and attestations of care |
| Perioperative Information Management System (PIMS) | Series of applications designed to capture and record the documentation of care from multiple disciplines (eg, nursing, anesthesiology, perfusion, respiratory therapy) throughout the perioperative process. Includes preoperative, intraoperative, and postoperative documentation by nursing teams, and AIMS system, OR suite management, supply and equipment tracking, patient status boards and other applications |
| Specialized Applications | Developed for use in one or two primary areas to cover specific functions. Examples include software to track the flow of patients in the emergency department, applications to record the progress of labor with fetal telemetry, applications to provide integration and remote delivery of data from operative or ICU environments |
A key element for the success of any HIT program is acceptability by clinicians for integration into their preexisting workflow. Barriers to adoption have been studied and include factors such as financial, technical, organizational, and psychological challenges. Properly designed systems will minimize the time required to document and the need to reenter any previously existing data. Toward this aim, the user experience or human factor considerations (the interfacing of systems, the design of the user interface, the actual appearance of the data entry screens, and processes) must be carefully examined when selecting or developing any HIT-related product.
Clinical decision support
Clinical decision support (CDS) is a key function of clinical information systems, including perioperative information management systems (PIMS). CDS can take many forms, ranging from simple data field checks to more complex calculations performed in the background—all designed to help clinicians make better and more timely decisions. Most commercial electronic systems enable end-users and/or system administrators to customize alerts and notifications, which can all be considered part of CDS.
Most CDS within anesthesiology has focused on enabling providers to achieve better compliance with evidence-based process guidelines. , These include quality measures promulgated by national societies, quality organizations (such as the Surgical Care Improvement Project), and both government and commercial payors. Common implementations of CDS include decision support around prophylactic antibiotic administration (including agent selection, timing, redosing, and appropriate discontinuation), administration of beta blockers in cardiac patients, management of blood glucose levels in diabetic patients, and provision of deep vein thrombosis prophylaxis. Within neurosurgical anesthesia, some CDS systems have focused on appropriate management of antibiotics, intracranial pressure, and ventilation.
Multiple studies have demonstrated that CDS can enable providers to achieve more reliable performance and a handful of studies have even linked CDS to better patient outcomes, including reductions in surgical site infections and postoperative
In order to be effective, clinical decision support systems must engage the end-user at the time when the information will be most helpful. If information is not delivered in a timely fashion, delayed, or otherwise out of date, then the impact of the system is likely to be greatly diminished. This requires the information to be delivered in a manner that engages the end-user. This may involve sending an on-screen alert to an end-user on a dedicated workstation, an alphanumeric text page, SMS message, email, or other visual cues.
Managerial functions
Compliance Tracking
In addition to providing CDS, most perioperative information management systems also provide functionality for tracking billing and regulatory compliance. By applying a series of logical business rules across a database of cases, systems can provide concurrency checking to ensure billing times do not overlap, and providers are not signed into an inappropriate number of cases. These compliance checks can take the form of a billing report that coders can use to adjust how payment is requested, or in some cases can provide real-time reminders to clinicians to enable them to adjust their staffing as needed. These systems also commonly can provide checks to detect when data are missing from electronic charts–such as required billing elements or other critical information such as patient drug allergies. At one hospital, software that automatically evaluated the anesthetic records and alerted clinicians to documentation errors led to a decline in the percentage of anesthetic records that could never be billed from 1.31 to 0.04%. The same authors estimated that their system implementation increased departmental revenue by approximately $400,000 per year.
Quality Management
The ability to scan large numbers of cases to evaluate for trends has been a helpful feature for many quality managers. Additionally, the reporting functionality brought by PIMS has enabled departments to use these systems to actively manage quality, participate in incentive programs, and identify problems. At least one center has leveraged their PIMS to develop the capability to automatically scan for downstream events, and then notify the perioperative provider when adverse events have occurred. This is possible through the analysis of postoperative orders, medications, and laboratory values—data which can all be made available electronically for continuous analysis.
A number of systems have also incorporated adverse event reporting. These systems have demonstrated a remarkable ability to identify problems by facilitating data capture, reporting, and analysis. , Key to the success of adverse event reporting has been integration into the end-users’ workflow along with assurance that data will be subject to peer-review protections. Both are possible, but require attention to the detail of implementation. For example, many suggest that peer-review event data be sequestered in a separate database, to ensure adequate legal protection.
Ongoing Professional Performance Evaluation
Since 2008, the Joint Commission has required Ongoing Professional Practice Evaluation (OPPE) as a part of credentialing and privileging providers. These might include periodic chart review, direct observation, monitoring of diagnostic and treatment techniques, or discussions with other individuals involved in the care of the provider’s patients. Several institutions have developed processes that leverage data from their automated information systems to facilitate compliance with this requirement. For example, the Massachusetts General Hospital developed an OPPE system that provides automated reports to physicians, listing for a series of metrics the total number of compliant cases and noncompliant cases, and a comparison by percentage to the baseline departmental evaluation. Additionally, a summary statement describes whether a physician’s performance was within the group representing 95% of all department physicians and noncompliant cases are listed by medical record number and case date—to enable physicians to review individual cases.
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