Information needs for the OR and PACU electronic medical record
This is a review of "Information Needs for the OR and PACU Electronic Medical Record" from the July 2014 edition of Applied Clinical Informatics. 
Objective: The amount of clinical information that anesthesia providers encounter creates an environment for information overload and medical error. In an effort to create more efficient OR and PACU EMR viewer platforms, we aimed to better understand the intraoperative and post-anesthesia clinical information needs among anesthesia providers.
Materials and Methods: A web-based survey to evaluate 75 clinical data items was created and distributed to all anesthesia providers at our institution. Participants were asked to rate the importance of each data item in helping them make routine clinical decisions in the OR and PACU settings.
Results: There were 107 survey responses with distribution throughout all clinical roles. 84% of the data items fell within the top 2 proportional quarters in the OR setting compared to only 65% in the PACU. Thirty of the 75 items (40%) received an absolutely necessary rating by more than half of the respondents for the OR setting as opposed to only 19 of the 75 items (25%) in the PACU. Only 1 item was rated by more than 20% of respondents as not needed in the OR compared to 20 data items (27%) in the PACU.
Conclusion: Anesthesia providers demonstrate a larger need for EMR data to help guide clinical decision making in the OR as compared to the PACU. When creating EMR platforms for these settings it is important to understand and include data items providers deem the most clinically useful. Minimizing the less relevant data items helps prevent information overload and reduces the risk for medical error.
The perioperative area has been mostly overlooked when related to electronic health record development. These areas have very specific need and this research intends to identify the essential elements for the operating room (OR) and post-anesthesia care unit (PACU).
This quantitative study utilized a 7-point Likert scale questionnaire to assess clinical views on what is required in a perioperative EHR. While the study questionnaire allowed for free responses in addition to the ratings, it was felt by the researchers that no new information was gained from these responses. With the responses, the researchers then used multiple statistical analysis to compare between the two departments and between the various clinical roles that were included in the survey.
137 questionnaires were returned from 4 groups of people (Certified Registered Nurse Anesthetists-CRNAs, Student Certified Registered Nurse Anesthetists-SCRNAs, Anesthesiologists, and Physician in Training-PT). Of these questionnaires it was found that the SCRNAs and CRNAs responses correlated with each other while the anesthesiologists and PT responses correlated with each other. It was also found that the clinicians felt that more data was essential in the OR, while in the PACU, some items needed in the OR were not as essential.
The study showed that, in general, clinicians in the OR setting rated the physiological data as some of the most important, compared to the PACU clinicians who viewed the data regarding airway complications and allergies as the most important. Overall both areas viewed patient demographic data to be essential.
This study is an essential first step in developing a system to incorporate perioperative data into a patient’s EHR. By identifying essential element for the OR and PACU, the EHR can flag these items to be recorded or displayed at the appropriate times depending on the location of the patient and the clinician. These elements can then be included in to clinical decision support systems within the perioperative area, thus hoping to create improved patient safety. Finally by identifying these elements and incorporating them into the perioperative EHR, we are one step closer to creating a fully interoperable hospital or system electronic health record.
- Herasevich, V., Ellsworth, M. A., Hebl, J. R., Brown, M. J., & Pickering, B. W. (2014). Information Needs for the OR and PACU Electronic Medical Record. Applied Clinical Informatics, 5(3), 630–641. http://doi.org/10.4338/ACI-2014-02-RA-0015