Difference between revisions of "Anesthesia Information Management Systems (AIMS)"

Revision as of 03:47, 18 October 2021

An Anesthesia Information Management System (AIMS) is a software product that generates the medical record for an anesthesia encounter, including the pre-operative, intra-operative, and post-operative documentation. AIMS may be independent applications or modules in an integrated electronic health record (EHR). It may be used at hospitals, or stand-alone outpatient facilities.

What constitutes anesthesia?

Anesthesia and sedation services may be provided in many locations in a hospital or health clinic. Procedures may include a variety of surgical procedures as well as minimally invasive procedures, endoscopic procedures, radiologic procedures, cardiac procedures, etc. Thus, although most people think of anesthesia only happening in the Operating Room, it can happen in locations throughout the hospital, including endoscopy, cardiac cath lab, radiology suites (interventional radiology (IR), MRI, CT, etc), radiation oncology, ICU, and the Emergency Department. Ambulatory Surgery Centers (ASCs) may be free-standing or affiliated with the hospital. Furthermore, the Department of Anesthesia is responsible for setting the standards, including documentation standards, for all sedation provided in the hospital.^[1] This anesthesia care may also include anesthesiologists transporting a patient between multiple venues, i.e., procedural area to PACU or ICU.

The Anesthesia Record

The anesthesia record was first conceived over 100 years ago by Dr. Harvey Cushing and Dr. Ernest Codman^[2] and consisted of serial measurements of vital signs and a list of medications administered during the course of the anesthetic. In the 1970s, anesthesiologists often dictated a report, much like the operative report, to go along with such serial measurements. The scope and contents of information have changed as monitoring tools have changed, including routine use of end-tidal capnography (EtCO2) and pulse oximetry (SpO2) in the 1990s and depth of anesthesia monitoring and objective neuromuscular (paralysis) monitoring in the 2010s.

The present anesthesia intraoperative record is a comprehensive document that describes the course of an operation in the form of a timeline. This timeline includes basic physiologic measurements (blood pressure, heart rate, respiratory rate, cardiac rhythm, pulse oximetry), respiratory/ventilation parameters (ventilation mode, tidal volume, anesthetic gas as both inspired and expired concentrations, end-tidal carbon dioxide (EtCO2), PEEP), medications given, fluids in and out (crystalloids, colloids, and transfusions, urine output, estimated blood loss), and procedures such as airway management or invasive monitoring.

In addition to the intraoperative documentation, both preoperative and postoperative documentation is created during the care of the patient. The preoperative assessment is similar to an H&P, focusing on information critical to planning the anesthetic including anticipating potential complications. Optimization of chronic and acute medical conditions is a key portion of this evaluation, and access to prior records is critical. The postoperative assessment is an evaluation of the patient after the anesthetic encounter is completed, and the patient has recovered.

Evolution of Documentation

For years, the major mode of documentation for anesthesiologist was via paper. Even today (2021), 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.^[3] Anesthesiologists often chart vital signs every 3-5 minutes and the need to balance this charting with patient care delivery can lead to incomplete record keeping. The American Society of Anesthesiologists (ASA) has a statement on documentation of anesthesia care which delineates the necessary requirements.^[4]

The first Anesthesia Record Keepers were developed in the late 1970s/early 1980s in several different labs. One of the earliest publications was in 1987, from the team at Ohmeda (now GE).^[5] However, there were some issues with these, and they did not gain widespread usage.

Given the need for more comprehensive intraoperative anesthetic monitoring, it has become 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 EHR is a mechanism for achieving these goals.

Patient Safety

In addition to the core function of documentation, AIMS provide mechanisms to both directly and indirectly improve patient safety, and its use has been recommended by the Anesthesia Patient Safety Foundation (APSF).^[6] It can also cause delays and impair patient safety. As with other EHR systems and modules, there is a learning curve, which may contribute to these delays and impairments.

Direct improvements are provided by minimizing the distractions of documentation, once a physician becomes competent with the system. This is particularly useful during active and critical periods of care, including induction/intubation, emergence, and both expected and unexpected periods of rapid physiologic changes. It may also directly improve patient care by alerting the team to potential problems such as a difficult airway, adverse reactions to medications, and risk stratification.

Indirect improvements come about as data is analyzed, and opportunities for quality improvement are identified. Electronic data may be reviewed for all cases, not just those where an obvious issue is identified, which allows for aggregate information analysis. Data analysis for both hospital-based and outpatient-based facilities should be done.^[7] There are multiple registries that use the EHR and administrative data to analyze patient demographics, comorbidities, outcomes, and other quality metrics, including Anesthesia Quality Institute (AQI)^[8], the Multicenter Perioperative Outcomes Group (MPOG)^[9], and Wake Up Safe^[10] sponsored by the Society for Pediatric Anesthesia.

Additional improvements in patient care may be driven by incremental changes in the workflow of the AIMS based on Quality Assurance and Improvement (QA&I) assessments, such as reminders for redosing antibiotics, alerts for allergies, or identification of prior anesthetic issues such as a difficult airway.^[11]

Adoption & Implementation

In 2011, only 24% of US anesthesiologists were utilizing AIMS.^[12] However, by 2014, nearly 75% of US Academic Medical Centers were using AIMS.^[13] Despite widespread adoption of hospital EHRs, an integrated AIMS is still lacking in a significant number of facilities. In addition, although in 2017, HealthIT.gov^[14] reported that 96% of all US hospitals possessed a certified EHR to meet the HITECH Act’s Meaningful Use criteria,^[15] use of an AIMS is not required, and they do not track that data.

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. These challenges fall into the broad categories of technology, productivity, and finances. Technology issues generally revolve around importing the data from the anesthesia ventilator and physiologic monitor into the EHR. Typically there are a variety of third-party vendors who provide this functionality. Some of the middle-ware does not import certain data points, particularly some of the newer monitoring techniques such as adequacy of anesthesia measurements. Productivity issues are frequently cited as a problem, but more recent experience has shown that the productivity of the anesthesia provider is not significantly changed once the learning curve period is completed. That said, it can be up to a year for that learning curve to stabilize.^{[16] [17]} Financial issues for implementation and for ongoing maintenance are not trivial, but are generally offset by improved billing/coding, as well as the availability of better data for common metrics, such as first-case on-time starts and turnovers, which in turn generally leads to workflow improvements.^[18]

While case-law is appearing that is specific to the use of an EHR, the concern that an AIMS will increase the potential risk for an anesthesiologist does not appear to be significant.^{[19] [20] [21]}

Key Functions & Requirements

Key software functions of an AIMS include:

• Automated vital sign and other monitoring data capture
• Ability to display/send an anesthesia record or summary document to the main EHR
• Ability to integrate/send medication information to main EHR for subsequent medication reconciliation
• Ability to edit/update allergy list and send changes to main EHR
• Drug-drug interaction checking
• Analytics and reporting

Key technical requirements of an AIMS include:^[22]

• Workstation functions:
  • during power failure (with or without UPS)
  • after accidental power-down
  • during network access failure
• Data storage:
  • thin vs thick client
  • backups
  • risk of data corruption with a failed hard drive
• Data capture:
  • consistent recording during a case
  • manual vs automatic device selection and linking
  • importing data after a disconnect
  • direct vs third-party middleware
• Special circumstances:
  • Emergency case without a scheduled procedure or complete demographics info
  • Daylight Savings Time (and either duplicate time stamps or a gap in time stamps)

The most useful AIMS will be one that is completely integrated within the hospital’s Electronic Health Record System. However, even a stand-alone product that includes preoperative assessment information with the ability for remote access is a benefit, as anesthesiologists are able to access the patient record ahead of surgery. This leads to a better patient-physician interaction, as the anesthesiologist is able to better focus questions on already identified history, including issues from past procedures and anesthetics. It also improves patient satisfaction.

We continue to see increasing adoption of AIMS at hospitals as well as free-standing ambulatory surgery centers. While the financial investment remains significant, the benefits continue to become more apparent.

Notes

Submitted by Jorge Galvez (Winter 2013)

Submitted by Erin Hickman (Fall 2015)

Submitted by Christine Doyle (Fall 2021)

References

1. ↑ CMS §482.52, Conditions of Participation: Anesthesia Services, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/SCLetter11_10.pdf
2. ↑ Sundararaman LV, Desai SP. The Anesthesia Records of Harvey Cushing and Ernest Codman. Anes & Analg, 126(1):322-329, January 2018. DOI: 10.1213/ANE.0000000000002576
3. ↑ Kadry B, Feaster W, Macario, A, Ehrenfield, J. Anesthesia Information Management Systems: Past, Present and Future of Anesthesia Records. Mount Sinai Journal of Medicine. 2012 (79): 154-165.
4. ↑ https://www.asahq.org/standards-and-guidelines/statement-on-documentation-of-anesthesia-care
5. ↑ Dirksen R, Lerou JGC, van Daele M, Nijhuis GMM, Crul JF. The clinical use of the Ohmeda Automated Anesthesia Record Keeper integrated in the Modulus II Anesthesia System: A preliminary report. J Clin Monit Comput 4(3):135-139, 9/1987. DOI: 10.1007/BF02915899
6. ↑ Stoelting RK. https://www.apsf.org/article/apsf-president-reports-on-the-state-of-the-foundation/
7. ↑ Dutton RP. Quality Management and Registries, Anesthesiology Clinics June 2014;32(2):577-586. DOI: 10.1016/j.anclin.2014.02.014
8. ↑ The Anesthesia Quality Institute, AQI, https://www.aqihq.org
9. ↑ The Multicenter Perioperative Outcomes Group, MPOG, https://www.mpog.org
10. ↑ Wake Up Safe, https://www.wakeupsafe.org
11. ↑ Doyle CA. “Health Information Technology Use for Quality Assurance and Improvement," in Ruskin KJ, Stielger MP, Rosenbaum, SH (eds): Quality and Safety in Anesthesia and Perioperative Care, Oxford University Press, 2016.
12. ↑ Trentman TL, Mueller JT, Ruskin KJ, Doyle CA, Noble BN. “Adoption of Anesthesia Information Management Systems by US Anesthesiologists,” Journal of Clinical Monitoring and Computing, 25(2): 129-135, 2011.
13. ↑ Galvez JA, Rothman BS, Doyle CA, Morgan S, Simpao AF, Rehman MA. A Narrative Review of Meaningful Use and Anesthesia Information Management Systems, Anes & Analg Sep 2015;121(3):693-706. DOI: 10.1213/ANE.0000000000000881
14. ↑ https://www.healthit.gov/data/quickstats/percent-hospitals-type-possess-certified-health-it
15. ↑ ARRA/HITECH Act, Enacted 2/18/2009, https://www.healthit.gov/sites/default/files/hitech_act_excerpt_from_arra_with_index.pdf
16. ↑ https://www.ama-assn.org/practice-management/digital/ehr-switch-poses-learning-curve-surgical-suite
17. ↑ McDowell J, Wu A, Ehrenfeld JM, Urman RD. Effect of the Implementation of a New Electronic Health Record Sy stem on Surgical Case Turnover Time. J Med Syst. 2017 Mar;41(3). https://pubmed.ncbi.nlm.nih.gov/28130725/
18. ↑ Macario A. Are your hospital operating rooms “efficient”? A scoring system with eight performance indicators. Anesthesiology 2006; 105(2): 237-40. doi: 10.1097/00000542-200608000-00004.
19. ↑ Sittig DF, SIngh H. Legal, Ethical, and Financial Dilemmas in Electronic Health Record Adoption and Use. Pediatrics Apr 2011;127(4):e1042-e1047. DOI: 10.1542/peds.2010-2184
20. ↑ Baker & Gilchrist. Electronic Health Records (EHRs) and Medical Malpractice Litigation. April 2015. https://www.bakerandgilchrist.com/blog/electronic-health-records-in-medical-malpractice-litigation-blessing-or-curse-for-patients-and-providers/
21. ↑ Norcal ClaimsRx, Electronic Health Records: Recognizing and Managing the Risks. October 2009. https://www.norcal-group.com
22. ↑ 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. DOI: 10.1213/ane.0b013e318187bc8f