Anesthesia Information Management Systems (AIMS)

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Anesthesia Information Management Systems (AIMS) can be independent applications or modules in an integrated electronic health record (EHR). Anesthesia information management systems (AIMS) are mechanisms to improve patient safety; however, these systems are underutilized. Galvez et al report that in 2011, only 24% of US anesthesiologists were utilizing AIMS. In 2014, nearly 75% of US Academic Medical Centers were using AIMS [1]. It is estimated that by 2020, nearly 84% of US Medical Centers will be utilizing AIMS. It is postulated that meaningful use will likely led to a higher adoption percentage.

Anesthesia is a field that relies on frequent measurements and collection of data regarding various physiologic parameters. For years, the major mode of documentation for anesthesiologist was via paper. Many providers continue to utilize paper records as a means to record the delivery of an anesthetic. Paper charting makes it difficult to create an accurate record because it does not provide a continuous sampling of data. Other challenges of paper documentation include recall bias (as charting often occurs after the procedure), inaccurate documentation, and illegible information [2]. Anesthesiologists often chart BP’s every 3-5 minutes and this charting often takes away from patient care delivery.

Anesthesiologists must be able to provide anesthesia in a number of locations, many of which extend beyond the boundaries of the operating room. Anesthesiologists may practice at various hospitals, caring for patients in different operating room complexes. Patients requiring anesthesia may present in a number of settings, including diagnostic radiology suites (MRI, interventional radiology procedures, PET/CT imaging), radiation oncology centers, gastroenterology or endoscopy suites, ambulatory surgery centers, intensive care unit, recovery room, emergency room, or other clinical care areas where procedures may be performed). Furthermore, anesthesiologists may be involved in transporting a patient between multiple venues.

The anesthesia record was first conceived over 100 years ago by Dr. Harvey Cushing and Dr. Codman [3] while in medical school, and consisted of serial measurements of vital signs and a list of medications administered during the course of the anesthetic. Over the past decade, the scope of the information monitored by anesthesiologist has changed. At present, the anesthesia record is a comprehensive document that describes the course of an operation in the form of a timeline, including physiologic measurements (blood pressure, heart rate, respiratory rate, cardiac rhythm, ventilation parameters, medication record, intravenous fluids and transfusions, urine output, estimated blood loss, and additional techniques such as airway management as well as invasive monitoring equipment). Given the need for more comprehensive parameters-monitoring, it is important to have a system that can efficiently record the delivery of anesthesia and monitor patient parameters, while maintaining and improving patient safety outcomes. Utilization of an AIMS in conjunction with an electronic health record (EHR) is a mechanism for meeting the comprehensive needs of anesthesiologist, while ensuring patient safety.

There has been a proliferation of automated processes to capture most of the physiologic parameters, as well as ventilator settings and anesthetic delivery via gas analyzers. The utilization of automated recording applications is supported by patient safety experts, such as the Anesthesia Patient Safety Foundation[4]. However, despite these benefits and endorsements, adoption of AIMS platforms is still not universal across the United States.

In general, there are a number of challenges that pertain to the implementation of an AIMS platform that may thwart organizations from implementing the system. One of the challenges that often may delay adaption of AIMS is cost. However, long-term benefits often offset these costs. For example, costs might be recovered with reduced anesthetic-related drug costs, improved billing and coding as well as increased efficiency. Other challenges include fear that the system will be used against the anesthesiologist during a legal matter as well as concerns about productivity.

The AIMS pose several benefits to the practice of anesthesiology. One benefit is that it allows for data collection without placing additional stress on the provider. Other benefits include improved costs, improved quality of care, improved documentation as well as better data to perform translational research. With the paper record, there is increased opportunity for inaccurate documentation of vital signs, other physiologic parameters, and medications. An additional benefit is that AIMS have the ability to collect more data points during a procedure, which offers an advantage from a medical-legal standpoint.

Key functions that pertain to AIMS and can integrate with meaningful use requirement include: - Integration with hospital EHR for medication reconciliation - Developing allergy list - Drug-drug interaction checking - Syndromic surveillance and reporting

The most useful AIMS will be one that is completely integrated within the hospital’s Electronic Health Record System. Anesthesiologists would benefit from the ability to access the patient record days before a surgery. This would likely improve the patient-physician relationship as the anesthesiologist would have time to thoroughly review the patient’s information and clarify any questions or concerns that he or she may have. In addition, the anesthesiologist would have immediate access to information regarding any prior surgeries and patient specific surgery complications.

- The Anesthesia Quality Institute (www.aqihq.org) is currently a leading entity in reporting of anesthesia-related events at a national level. The organization maintains a registry that can assist anesthesiologists to improve patient safety by understanding developing trends that may otherwise not be seen at a local or even regional level.

Muravchick et al., report on certain functional requirements that are specific to the operating room, which should be taken into consideration when designing and deploying an AIMS [1]: - Workstation function during transient hospital power failure. - Workstation behavior after accidental power-down. Does it automatically return to a log in screen? - Is network access required to initiate/complete a case? - Is it possible to start a case in an emergency, prior to identifying a patient and entering all demographic information in the system? - Is the data stored in a server or a local workstation? - Does hardrive failure on the server cause data corruption? - Does the AIMS consistently record physiologic variables during the course of a case? - Does the AIMS interact with surgical and perioperative scheduling applications? - How does the AIMS function during daylight savings transitions? How does the database account for redundant vital signs during daylight transition during a case?

While the AIMS are slowly being utilized in operating rooms, it has positive future implications including direct assistance to anesthesiologists in the operating room. Positive changes that Kadry et al predict may occur as result of the AIMS are automatic care notifications when extreme metrics are met, automated risk stratification, and more usable printed anesthesia records [5]. In addition, utilization of AIMS will provide pre-procedure decision support. Pre-procedure decision support might include antibiotic suggestions or reminders that patient may have had a difficult airway in the past.


References:

Anesthesia Patient Safety Foundation [6]

Anesthesia Quality Institute [7]

Galvez, Jorge. A Narrative Review of Meaningful Use and Anesthesia Information Management Sysems. International Anesthesia Research Society. 2015 Sept; 121 (3): 693-706. [8]

Kadry B, Feaster W, Macario, A, Ehrenfield, J. Ansthesia Information Management Sysems: Past, Present and Future of Anesthesia Records. Mount Sinai Journal of Medicine. 2012 (79): 154-165. [9]

Muravchick S, Caldwell JE, Epstein RH, Galati M, Levy WJ, OʼReilly M, et al. Anesthesia Information Management System Implementation: A Practical Guide. Anesthesia & Analgesia. 2008 Nov;107(5):1598–608. [10]

Wake Up Safe [11]

Submitted by Jorge Galvez

Submitted by Erin Hickman