9 key takeaways on anesthesia information management systems

Surgical Information Systems (SIS) brought together four anesthesiologists for a panel discussion on the merits of and advice for using an anesthesia information management system (AIMS) rather than paper anesthesia charts. Participants were the following:

• Ian Darling, MD, of Johnson City (Tenn.) Medical Center, a Mountain States Health Alliance facility
• Tamim Khaliqi, MD, of Faxton-St. Luke's Healthcare in Utica, N.Y., a Mohawk Valley Health System facility
• Shea Patel, MD, of The Williamsport Hospital and Medical Center in Williamsport, Pa., a Susquehanna Health System facility
• Jensen Wong, MD, CMIO, of Zuckerberg San Francisco General Hospital and Trauma Center

The following are 9 of the key takeaways. Note: Attributions may have been edited for space and clarity. To view a longer Q&A with these anesthesiologists, click here.

1. AIMS is part of the complete OR management system for flow of information. A comprehensive, fully integrated perioperative system that includes AIMS can replace disjointed documentation processes from scheduling to nursing to anesthesia. This is one reason all facilities represented in the discussion chose a comprehensive OR management system that included an AIMS.

The result for each facility is a complete perioperative experience from the time patients are seen and scheduled in the preop clinic and/or during nursing preop on the day of surgery to the point they are discharged from the PACU.

"The flow of information is tremendous," Dr. Patel noted.

2. Ease of use is critical to adoption. Panelists stated that the electronic anesthesia chart must be easy to use and look like the paper anesthesia chart to help get widespread adoption.
"I've seen other [electronic charts] where you needed to get comfortable with a new look," Dr. Darling stated. "Knowing the group that was going to use the AIMS, it had to look and feel like you were filling out an actual anesthesia chart. Another important feature was a minimal amount of typing. We wanted mostly point-and-click functionality. The ability to design how the solution looked and felt rather than needing to adapt to an out-of-the-box product was important."

Dr. Patel noted, "We had people who were going to use our AIMS who were very computer savvy and some who were computer illiterate, so how easily one could be trained was a big deciding factor. We had some recovery room nurses who said they were going to retire if they had to go to an electronic medical record. By selecting an electronic chart that still felt familiar, they learned how to use the system fluently within a single shift."

3. Ability of the AIMS to support the anesthesiologists' intraop workflow improves care. AIMS, through automatic vital sign capture and retrospective documentation, allows anesthesiologists to take care of the patient at the beginning of the case when the situation is intense and then go back and correlate the documentation to the vital signs based on when the drugs are administered.

As Dr. Wong said, "There's high cognitive loading in an OR, especially in cases that require a lot of active management. As anesthesiologists, we're well trained to be multi-taskers, but we all know that the human brain is not really designed to multitask well. To take some of the load off, the ability to automate the recording of vital signs for a patient in the AIMS is really helpful. You can correlate the patient's vital signs to drugs you administered. You can state when you pushed propofol and accurately chart that data subsequent to a pretty intense period of time at the beginning of a case."

4. Paper charts require work to support compliance and billing. When using paper anesthesia charts, significant work and rework is often required to ensure records are fully compliant and permit proper coding and billing. An AIMS, if built properly, can reduce and even eliminate some of the workload.

Dr. Wong stated, "A proper build of an AIMS puts the correct elements of a complete chart at your fingertips so you're not forgetting steps necessary to be compliant and drop accurate bills."

5. AIMS supports transitions of care. Easy access to intraoperative data outside of the OR is critical as care transitions are an important safety issue. Dr. Patel said the type of information staff could pull from the AIMS that would assist in transitions was important in the system selection.

"The hospitalist program is quite prevalent in our healthcare system," he said. "They do about 80% of the admissions, including 90% of the surgical cases. It was important for them to have very accurate intraoperative information, which is passed onto the floor once these patients are admitted. Having an AIMS made their life significantly easier in helping get them all of the intraoperative information, such as medications used, antibiotics given, and fluids given."

Note: Gaining access to such information is just as important during the transition of care to PACU.

6. Turn data collected into actionable information. Data captured in an AIMS can be turned into information through analytics and used to make various improvements that benefit the hospital and its anesthesiologists.

The biggest impacts noted by Dr. Patel have been the ability to run the OR more efficiently and the associated cost savings. As an example, he notes the hospital had a group of orthopedic surgeons who did not want to take their cases to a different facility, which was underutilized. This facility was only at 40% efficiency rate whereas the site the surgeons were performing most of their cases was at 85%- 90% efficiency rate.

"There was no wiggle room," Dr. Patel said. "We pulled the metrics from our AIMS and showed the surgeons the data, which indicated that 60% of their cases were outpatient procedures. We were able to explain to them that if they move their cases over to the other facility, they would get their work completed in an expeditious manner and we could open up the busier facility for add-on emergent cases."

He cited another example, noting the information from AIMS indicated it was practical to shut down the OR and facilities after 3:30 PM and on the weekends. "We looked at the number of cases scheduled in the evenings and on weekends and transferred those patients to a different facility," Dr. Patel said. "This led to an annual savings of a million dollars for our hospital system. There was no delay of care and patient outcomes did not negatively change."

Dr. Darling shared a story of how use of an AIMS financially benefitted both the hospital and anesthesiologists. "When our anesthesia group negotiated our last contract with the hospital, we tied some bonus money to performance metrics that we can pull directly out of the AIMS. From a financial standpoint, the hospital gains because they use the data in many ways for financial improvement and we also benefit."

7. AIMS provides access to historical information. When anesthesiologists can view extensive details about a patient's medical history, it can positively impact safety and satisfaction.

Dr. Darling said, "I feel I have so much information at my fingertips that I don't have to go hunting for what I want or need. This is particularly helpful when I'm in the OR and time is of the essence. From a safety standpoint, I feel the information is very easy to access and read. From a patient satisfaction standpoint, if patients were here before, their information flows forward and I just need to update it. This gives patients a sense that you already know about them and are on top of their care."

Paper records create challenges to such flow, Dr. Patel said. "In the past, we would have to spend 15, 20 minutes foraging through old records to find out if there were any bad outcomes associated with a patient. When patients came for future surgery, we would need to get historical information from medical records, which were copies and often had legibility issues."

He continues, "Historical information is very important. If a patient has a "sux" (suxamethonium chloride) allergy or difficult airway, for example, an AIMS carries this information from one record to the next years down the line."

8. Once you use AIMS, it's difficult to switch back. Hospitals are sometimes concerned that anesthesiologists will be hesitant to use an AIMS and document electronically, so an investment in a system may not be worth the risk. The panelists noted that once their peers had an opportunity to use an AIMS, that hesitation usually faded fast.

Dr. Khaliqi noted, "I had people who said they would not use an AIMS. A few weeks after we went live, they said they would never go back to paper. It's amazing how quickly the people that used to be naysayers became attuned to such changes. It's been a very good experience for our whole department."

Dr. Darling stated, "Almost all of the providers were hesitant to use an AIMS because they thought it would be a lot of work and take away from time interacting with patients. I would bet 98% of our providers would never go back to paper. Our AIMS makes it so easy to just click through and let the system take care of most of the charting. This allows us to focus on what's going on with the patient."

9. Implementing an AIMS takes work, but it pays off. As with the implementation of nearly any electronic system, adding an AIMS requires some time and effort. When it's done correctly, the organization-wide benefits can be substantial.

Each of the panelists offered guidance for helping bring about a successful implementation:

• Dr. Patel said, "Once you start using an AIMS, designate two or three superusers and stick with them. You don't want to make changes on a weekly basis. Give it a few months before you make any changes unless it's a very major change that needs to be done overnight. Let everyone get used to it."
• Dr. Khaliqi said, "Determine what you want and then design the system to fit your wants and how it will work best with your specific group. I think that makes the go-live much easier. Also, have one person in charge, and only that person. Give that person the ability to make the decisions after speaking with everybody. If everybody can do whatever they want, it will create problems."
• Dr. Darling said, "Know your audience. The day we went live I had two of my doctors ask me how to log into the computer."
• Dr. Wong said, "There's a lot of hard work in implementing an AIMS. I think if you do it right — put in the hard stops where there need to be hard stops and nowhere else — it will be a people pleaser. Standardizing the workflow in the documentation is very important. Putting one person in charge is a great way to standardize, but you want to make sure that you pick a practical decision-maker who is well respected."

As these anesthesiologists noted, when an AIMS is implemented and used effectively, the automation it brings will help decrease the cognitive load in the OR. The system becomes a tool most providers will not want to turn their back on once they have used it. An AIMS has the potential to improve patient outcomes and boost physician, staff and patient satisfaction, all of which should be music to hospital leaders' ears.

As a former OR nurse, Carolyn Cordtz, RN, applies her real-world knowledge of perioperative clinical workflows to her role of director of product innovation for Surgical Information Systems (SIS). In this role, Ms. Cordtz is responsible for assessing market needs to determine problems that can be solved by technology. Prior to this role, Ms. Cordtz served SIS as clinical product manager and implementation consultant.

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