Does computerization of the operating room lead to better patient care?

D. M. THYS, M.D.

Introduction
Few would dispute that medicine, in general, and anesthesiology more specifically are in a period of great change. Some even suggest that the world as a whole is in a period of transformation towards a society in which knowledge is the primary resource [1]. In that society, INFORMATION is the skeleton around which organizations are designed. How anesthesiology will best meet the challenges of a changing environment is currently being debated [2]. No one disputes, however, that the intra-operative management of the surgical patient will remain the primary or core activity of our specialty. It is, therefore, unsettling that in the Information Age, information concerning our most essential activity continues to be documented in an analog format that relies predominantly on paper and pen. Indeed it is estimated that, today, no more than 50 departments of anesthesia or 1% of all departments in the United States of America have invested in and use Anesthesia Information Management Systems (AIMS). In other parts of the world, a similar percentage is likely. The purposes of this review are to: 1- define what composes an AIMS, 2describe why AIMS will be essential in the future, 3- review some of the criteria that need to be considered when selecting an AIMS and 4- describe our personal experience with an AIMS in more than 60,000 cases.

What is an anesthesia information management system?

In its most basic meaning, an AIMS is a computer system that captures anesthesia-related information in a digital format [3, 4]. One of its essential components is the Automated Anesthesia Record keeper (AAR) that collects
Correspondence to: Department of Anesthesiology, St. Lukes-Roosevelt Hospital Center, Columbia University, IIII Amsterdam ave, New York, N.Y., 10025.

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information on anesthesiologys intraoperative activities. An AAR alone, however, does not qualify as an AIMS as it does not allow one to use anesthesia information for management purposes.

What does an AIMS do?

An AIMS gathers information on virtually every patient with whom a department of anesthesia interacts. The information is primarily intraoperative information, but should, preferably, also include data from the perioperative period. The information is pooled in a database where it is stored and can be arranged in a format that allows analysis. The AIMS database may interface with other databases in the hospital or those of a larger health care delivery system.

What are the components of an AIMS?

Hardware

Information enters the AIMS through input devices. Data acquisition devices can automatically collect data such as hemodynamics, gas analyses, oxygen saturation, and some ventilator settings. Other devices are designed for manual input of data such as drug and fluid administration, interventions, and observations. Common input devices for manual entry include the keyboard, touch screen, mouse or trackball, and bar code scanner. Microphones and voice recognition devices are also under evaluation. Once the data are acquired, devices are needed to store the data and rapidly retrieve it for analysis and reproduction. Because databases often pool data from multiple recording stations, the data need to be transmitted to a central location by networking devices. At the central location, a file server further serves as a storage vehicle within which the data can be organized, stored, and replicated. Storage devices commonly consist of optical disks, large capacity hard drives, and groups or arrays of hard drives. For long-term storage and backup, magnetic tapes are frequently utilized. The data also need to be readily accessible for display, reproduction or analysis. At present, file servers are most commonly accessed via personal computers and the data are reproduced by printing an anesthesia record, spread sheet, or structured report (Fig. 1).
Software

While the hardware components used in AIMS are mostly standard commercial products made suitable for the AIMS tasks by minimal adaptation, software designed for the input and handling of the anesthesia information is very specific to our specialty and the way we work. Processes that the software needs to be able to perform include the recognition of anesthesia-related data, the rejection of artifacts, the sorting of the data in a time-ordered or other logical sequence, formatting of the data for storage, replication and analysis. At present, the printed reports are still truly unique and resemble the format of manual anesthesia records rather than standard computer-generated reports (Fig. 2). In addition, software programs are needed to control the flow of data between the various components of the network. Analysis of the data can be conducted using either proprietary analysis programs or standard database and spreadsheet programs.

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Anesthesia information management system OR Stations Printer Storage

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FILE SERVER

Access Stations
Fig. 1. - Hardware components of an Anesthesia Information Management System.

Why are AIMS essential for the future?

Individual patient
Better care through better records

The essential purpose of maintaining an anesthesia record is to document how an individual patient responds to anesthesia and surgery. The information is permanently stored in the medical record for the patients benefit and to allow other practitioners to care for the patient in a more informed manner. Therefore, the more accurate the recorded information, the greater the likelihood that the care will be tailored to the patients individual needs. One can postulate that the accurate recording of a patients responses to anesthetic interventions will lead to better patient outcome. Several published reports have shown that automated anesthesia records are more accurate than manual records [5, 6, 7]. In addition, the storage of anesthesia records in a digital database allows the rapid and easy retrieval of a patients previous anesthesia records.

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Fig. 2a. - Sample anesthesia record produced by an automated anesthesia record keeper.

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Fig. 2b. - Sample anesthesia record produced by an automated anesthesia record keeper.

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Fig. 2c. - Sample anesthesia record produced by an automated anesthesia record keeper.

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Better ergonomics for the anesthesiologist

In the operating room, anesthesiologists face a complex environment. They need not only to assimilate multiple information inputs, but also to nearly instantaneously integrate, analyze and prioritize these to respond appropriately. Record keeping often represents a significant distraction from more immediate patient care needs. It is estimated that the time occupied by record keeping comprises 10 to 15% of the total anesthesia time [8]. While some authors have found that automated record keeping significantly reduces the record keeping time [9], not every investigation has confirmed this. There is agreement, however, on the observation that vigilance is not negatively affected by automated anesthesia record keeping and that anesthesiologists are better able to organize their intraoperative activities when automated record keeping is utilized [10]. Manual entries into the automated record are performed at times of less intense activity without great loss in overall data accuracy since most of the data collection is automatic and continuous. It has even been argued that with automated anesthesia recordkeeping the anesthesiologist shifts his/her activities to higher, cognitive level, supervisory tasks [11].

Anesthesia practice
Quality assurance function

The analysis of intraoperative incidents is facilitated when automated records are used. Indeed, the automated records tend to contain more data than manually kept records. In addition, the data are sampled more frequently and are more accurate than on manual records. A specific benefit of AAR is their ability to accurately time various intraoperative events (e.g. did desaturation precede bradycardia or bradycardia precede desaturation?). A concern that has been raised in connection with incident analysis is related to the confounding role of artifacts. In a large study of automated records, artifacts were readily recognized by the investigators when they reviewed both the printed records and the digital database [12]. In addition, AIMS allows the rapid scanning of a large database for specific incidents. Therefore, trends in certain incidents can be identified and their occurrence with individual physicians can be profiled.
Outcomes assessment

The availability of digital information on a large number of patients allows one to more readily tie specific patient characteristics or intraoperative events to patient outcomes. Meaningful outcomes analysis often relies on the study of a large number of patients. For some outcomes, a single institution may not have a sufficient patient volume to conduct scientifically valid outcomes analysis. Databases that are in digital format can easily be shared among several institutions and in this manner the power of a particular analysis can be increased. Managed care organizations are also interested in patient outcomes. The availability of anesthesia information in digital format permits its integration with the hospitals other databases (Fig. 3). As such, information about anesthesia care can be incorporated in a patients record of total care and

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the role of anesthesiology in affecting overall patient outcomes can be assessed. In addition, the effects of variations in the practice of anesthesia by individual physicians can be analyzed.

AIMS
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ADT
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OR Management
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HOSPITAL INFORMATION NETWORK

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Billing Inventory

Laboratory

Fig. 3. - Possible components of a Hospital Information Network (AIMS: Anesthesia Information Management System, ADT: Admissions, Discharges, & Transfers).

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Education

Intraoperative events are readily retrieved from a digital database and reproduced in a manner that allows their thorough analysis. Continuous data that are recorded automatically, are often stored with a high temporal resolution (every 15). Once reproduced, they can easily be used for educational purposes. The meticulous analysis of a sequence of events may provide insights that are not immediately obvious from the study of manual records.
Medico-legal protection

While there are no reports on the use of automated records in court proceedings, as a general principle, accurate information will most often work to the advantage of a defendant. The automated record provides unbiased and contemporaneous documentation of intraoperative events. It may help refute claims of negligence and allow one to positively demonstrate that intraoperative responses were appropriate for a given event. While security of the data and the possibility of tampering are major concerns, most manufacturers of AIMS have been able to successfully address this problem.

Management function
Tabulation of services

The exact tabulation of daily anesthesia activities can be a considerable challenge particularly in large anesthesia departments with multiple anesthetizing locations. An AIMS with workstations in all the settings where anesthesia services are provided greatly facilitates the compiling of such data. Not only can reports be generated that summarize the daily anesthesia activity, but the precise duration of each of the activities can also be measured. The information of individual patients can be forwarded automatically to a billing service for the prompt processing of charges.
Costs

In most anesthesia departments, drugs and supplies represent major budgetary expenditures. The availability of an AIMS offers the possibility to analyze the utilization of drugs and supplies in a systematic manner. Their usage can be categorized in multiple formats such as per patient, per case, per surgical category, per anesthesia type, per physician, per operating room, etc. While practice guidelines can be developed to encourage cost-efficient drugutilization, compliance with guidelines is best verified through scanning of an AIMS database. In a recent report, investigators at Duke University estimated that such an approach had resulted in generating recurring pharmaceutical savings of approximately $ 1,000,000 per year [13].
Resource utilization

The exact time at which various perioperative events take place is documented with great precision by an AIMS. The AIMS database, therefore,

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contains large amounts of information that permit the tracking of resource utilization. For every case, the times of admission to the operating room, of induction, of surgical incision, etc. are stored. From this information, it is possible to derive OR utilization data by service, by surgeon, or by anesthesiologist. In addition, it is possible to clearly document the time occupation of individual anesthesiologists and to confirm that Medicare concurrence regulations are followed (Fig. 4).

Hours of Anesthesia / Attending / Month

150 Research Administration Ambulatory Pain Management OB Anesthesia Critical Care

100

50

0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37

Fig. 4. - Hours of anesthesia per attending physician per month. The data were collected over a 24 months period. The solid horizontal line represents the average (89 hours/attending/month). Most physicians with fewer than the average number of hours had significant activities that were not captured by the AIMS.

Compliance with accreditation agencies

Most health regulatory agencies mandate that comprehensive records be maintained for every patient encounter. A secondary requirement is that the records be legible. Many anesthesiologists have had unpleasant encounters with regulatory agencies because these stipulations were not met. The ability to produce a legible anesthesia record on every patient who received anesthesia services is highly appreciated by most surveyors. For training programs in anesthesia, specific numbers of various cases that each resident must perform to fulfill the American Board of Anesthesiologys training requirements have recently been published. Compliance with these requirements is easily achieved and verified when all anesthesia records are stored in a digital database. Individual resident assignments can be tailored to each residents need for specific cases.

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How does one select an AIMS?

The selection of an optimal AIMS, requires that the prospective user formulate a number of important questions. They can be divided in user specific and system specific questions.

User specific
What is the anticipated scope of the AIMS?

When a department of anesthesiology considers the purchase of an AIMS, it first needs to clearly define the scope of the activities that it intends to capture with the system. Is it anticipated that the automated anesthesia record keeper will document preoperative and postoperative interactions, in addition to intraoperative care? If the response to this question is positive, the extent of the perioperative activity that one wishes to capture needs to be delineated. Further questions related to the scope of the system need to focus on the role of the AIMS in the PACU, ICU, labor & delivery unit, pain management clinic, and possible off-site anesthetizing locations (ambulatory surgery units, MRI suite, catheterization laboratories, etc.) Any anticipated change or expansion of the anesthesia activity is also best taken into account from the onset.
What monitoring and anesthesia equipment will the AAR interact with?

While most modern monitoring and anesthesia equipment have electronic data output capabilities, this may not be the case with older equipment models. Is the department interested and willing to upgrade to new equipment? An associated question relates to the current availability of computer equipment in a department or institution. Access to an AIMS may be desirable from desktop computers of selected individuals within a department. As the AIMS network structure is being considered, the availability of facilities for the installation of computer equipment and the provisions that have been made for the electronic transmission of data need to be evaluated. An important question focuses specifically on the existence of network wiring in the anesthetizing locations. The department also needs to consider, early on, the particular software requirements it may have and what other software programs it may wish to interact with (Windows NT? Microsoft SQL Server?).
What other systems will the AIMS interface with?

Electronic data systems that are commonly found in hospitals include the ADT (Admissions, Discharges, and Transfers) system, an OR management system, laboratory data retrieval systems (routine and emergency laboratory data), an inventory system for drugs and supplies, and a patients billing and accounting system. While in an optimal digital world all of these systems would be linked through a hospital information network (Fig. 3), in reality this is almost never the case. When designing an AIMS, it is essential to carefully evaluate what systems it can be safely interfaced with, without compromising

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its functionality. In addition, it is necessary to predefine the interface language(s) that will be utilized. The choice is usually between a standardized interface language such as HL7 (Health Level 7) or a custom-built interface language (point-to-point). The need to develop a custom-built language may have significant cost implications.
What support will the institutions MIS (Management Information Systems) department provide?

Most institutions have an MIS department that has overall control over information systems within the health care facility. An anesthesia department needs to determine early on where an AIMS fits into the overall computer plans for the institution. MIS interest in an AIMS may range from a will for total control to deliberate detachment. If the MIS department becomes involved, it is essential to clarify that there are peculiar aspects to data collection in the operating room environment. While elaborate security procedures may be the norm for access to computers in other parts of the institution, the need for immediate access in rapid OR turn-over or emergency situations demands a more flexible approach.

System specific
Is the system proprietary or non-proprietary?

A proprietary system interacts only with anesthesia or monitoring equipment from a single manufacturer. The advantage of such systems is that they are usually sold by large and well-known vendors of monitoring or anesthesia equipment. These vendors have extensive experience in the operating room environment and can provide additional equipment as an enticement to the purchase of their AIMS. The disadvantages of proprietary systems are that existing monitoring or anesthesia equipment may not be compatible with the vendor s equipment. In addition, to maintain compatibility, future equipment purchases will be predetermined by the selection of a proprietary AIMS. Non-proprietary systems interface with equipment from many manufacturers. Therefore, if a departments existing equipment has electronic data output capabilities, the installation of an AIMS may not require any upgrade of anesthesia or monitoring equipment. The major disadvantage of non-proprietary systems is that they are usually sold by smaller corporations, whose long-term survival may not be guaranteed.
Who is the vendor?

The purchase of an AIMS is very different than the purchase of other anesthesia equipment. Indeed, this is probably one of the largest capital investments a department will undertake. It is, therefore, essential to be comfortable with a vendor s business philosophy as one is embarking on a long-term relationship with that manufacturer. AIMS software and hardware evolve over time and one needs to understand the pathways for such upgrades. Because of the magnitude of the investment and the long-term nature of the

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relationship, the vendor s position in the marketplace and financial stability are major considerations. In the selection of a vendor, one would wish to know how many of its systems are currently in use, for how long they have been in use and how satisfied the current customers are with the system and the vendor s support. A visit to a department of anesthesiology that has accumulated significant experience with the AIMS is highly recommended.
What are the systems technical features?

While all the possible technical features of an AIMS are too numerous to be listed, a few important considerations will be mentioned. They concern the system itself and the user s interaction with the system. One would wish to know whether the system uses commercial or proprietary hardware, how it interacts with standard commercial hardware and software, and how it interfaces with other systems. It is also important to know where data are processed and stored, whether the system is network compatible and/or network dependent, and what happens with network failure. A related question pertains to the tracking of patients from the preoperative to the postoperative phase, and the manner in which the system handles a return to the operating room. The user needs to know how automatic and manual data are entered into the system, how adaptable it is to individual user s or patients needs, and what security features and data access restrictions are built-in. Since data analysis is a major aspect of an AIMS capabilities, questions need to be asked concerning the analysis capabilities. They include whether data can be analyzed in-house, and whether it can be performed with commercial software or requires proprietary software.
What is the cost of the system?

While each manufacturing firm has its own pricing structure, some general principles apply to all. In the development of a price, it is important to clearly understand what features are included or not. Hidden costs lie in the installation, maintenance, educational support, and the systems upgrades. The vendor s position on each of these aspects needs be defined prior to purchase. A department also needs to consider whether additional personnel will be required for the systems operation, maintenance or for data analysis. The most common approach to the selection and pricing of a system begins with the development of an RFP (request for proposal). It provides future users with the opportunity to analyze, sometimes in great detail, what they expect from an AIMS and how each vendor responds to such expectations. The more detailed the RFP, the smaller the likelihood of unhappy surprises once the system is running.

Personal experience with an AIMS

In 1991, the Department of Anesthesiology of St. Lukes-Roosevelt Hospital Center decided to proceed with the implementation of a fully automated anesthesia information management system. As of today, the system

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has been fully operational for 4 years and more than 60,000 anesthesia records are stored in its database.

System sescription
The system that was selected by this department is the COMPURECORDTM system manufactured by ARI, Pittsburgh, PA. The main reasons for selecting this particular system were: 1- its user-friendliness, 2- a well-established track record, and 3- competitive pricing. The system consists of 35 PC-based anesthesia workstations with touch screens and keyboards for data entry. While each anesthesia workstation can function independently, they are networked to a file server for data storage and printing. The file server can be accessed by 14 peripheral stations for overview functions, record completion in the PACU, QA data entry and retrieval, and statistical analysis. The file server is also connected to laserjet printers for output of the anesthesia record, a high-speed modem for access by the manufacturer for system upgrades and troubleshooting. Data are stored on large capacity hard disks (2 x 4.3 Gbytes) in the file server and on magnetic tape in a remote location for long-term protection.

Current applications
Anesthesia record keeping

All surgical cases that are performed in the hospitals main operating rooms (93% of cases) are completely captured by the AIMS. The other cases are those performed in off-site locations such as a stand-alone ambulatory suite, radiology suite, etc. For those cases, essential demographic information is also stored in the AIMS, but the details of the anesthetic are not included. On labor and delivery, all surgical cases (C-sections, etc.) are recorded, but only limited information is stored on normal labor epidurals and vaginal deliveries.
Quality assurance

On a monthly basis, the statistics for all of the departments clinical activities are retrieved from the AIMS. They are sorted by types of procedures and types of anesthetics. In addition to the mandatory QA reports, the anesthesia records are also scanned for specific deviations from predefined limits of acceptability. When incidents are detected, the raw data for that specific record are retrieved. Since continuous data are recorded at 15 seconds interval, more detailed analysis of the incidents is performed. The data in 15 seconds interval is used to better understand each incident and to discuss, in educational sessions, the specific sequence of events that led to its unfolding.
Resource management

Because time information is stored with great accuracy, the data can be utilized to analyze OR utilization. In one instance, we tracked OR turn-around time for all the surgeons of a single department by individual physician. The

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data demonstrated that the average turn-around time was less than 15 minutes and that the surgeons were frequently able to use 2 different operating rooms in sequence, leading to negative turn-around times. The total amount of anesthesia time is also tracked per anesthesiologist on a monthly basis. The information allows to better understand the dynamics of a large multi-faceted department of anesthesia and to plan the hiring of additional anesthesiologists on the basis of documented activity.

Conclusions
A gradual move towards automated databases is just as inevitable in anesthesia as it has been in other areas of health care and industry. The trend towards effective utilization of limited resources will continue and the need for accurate data will accelerate. At the present time, digital systems provide the only practical method to store and analyze large amounts of data and they are, therefore, essential components of a modern anesthesia environment. The perfect AIMS does not yet exist. Current commercial systems are, however, well-developed and provide their users with an early entry into a digital world that is inescapable. Anesthesiologists who embrace this new technology place themselves at a significant competitive advantage. The initial price is high, but the potential rewards are enormous.

REFERENCES
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[10] Weinger M.B., Herndon O.W., Gaba D.M. - The effect of electronic record keeping and transesophageal echocardiography on task distribution, workload, and vigilance during cardiac anesthesia. Anesthesiology, 1997, 87, 144-155. [11] Gaba D.M., Howard S.K., Small S.D. - Situation awareness in anesthesiology. Human Factors, 1995, 37, 20-31. [12] Sanborn K., Castro J., Kuroda M. et al. - The detection of intraoperative incidents by electronic scanning of computerized anesthesia records: A comparison with voluntary reporting. Anesthesiology, 1996, 85, 977. [13] Lubarsky D.A., Sanderson I.A., Gilbert W.C. et al. - Using an anesthesia information management system as a cost containment tool. Description and validation. Anesthesiology, 1997, 86, 1161.

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