Can You Feel IT Coming?

April 10, 2013
Anesthesia errors can not only be life threatening for patients, but are a significant source of hospital malpractice settlements. Though most agree that anesthesiology information management systems (AIMS) are one way to address these issues, the rate of adoption is notoriously low. According to a recent report by Orem, Utah-based KLAS, only 5 percent of United States hospitals today are using an AIMS.
Jason Hess

Anesthesia errors can not only be life threatening for patients, but are a significant source of hospital malpractice settlements. Though most agree that anesthesiology information management systems (AIMS) are one way to address these issues, the rate of adoption is notoriously low. According to a recent report by Orem, Utah-based KLAS, only 5 percent of United States hospitals today are using an AIMS.

As the use of IT in hospitals grows, however, a gradual move to automated information systems and resulting databases is just as inevitable in anesthesia as it has been in other areas of healthcare, says Jason Hess, a principal researcher at KLAS. “What's adding steam to this is the advent of ARRA and the notion of getting all that data into the EMR. But the market is still very immature.”

Lynn Vogel

That market, however, is growing at the rate of 15 to 20 percent per year, he says. The benefit of incorporating the anesthesia record into the EMR for ARRA may be the most obvious benefit, but there are serious gains in patient safety that come from the automating record keeping. “The anesthesiologist is not making a note every three minutes of the vitals and can focus completely on the patient,” says Hess.

There are also opportunities that can be realized in increased billing and capture of anesthesia-related charges, and monitoring for diversion of controlled substances. In addition, using an AIMS can help improve cost savings by analyzing the utilization of drugs and supplies in a systematic manner, and provides a retrospective analysis of the anesthesia record to improve care outcomes.

But so far, the unique qualities of anesthesiology has made for a slow adoption - one in which the niche vendors are the winners. Hess says part of that has to do with the specialty of anesthesiology itself. “Anesthesiologists like to practice their medicine like art,” he says, and “don't want to be encumbered by what can be perceived as bulky steps that would slow them up.”

Another key distinction between an AIMS and other HIT systems is the medication order. In most other cases, a physician specifies an order and someone else, often a nurse, executes it. But in the operating room, the anesthesiologist both gives and executes the order, and AIMS must be designed with this in mind. Hess says that means it can't require too many steps, distract from focus on the patient, or be cumbersome.

The biggest issue, many believe, is that in the operating room, anesthesiologists face a complex environment. Not only do they need to assimilate multiple information inputs, but they must instantaneously integrate, analyze and prioritize this information to respond appropriately. Record-keeping often represents a significant distraction from more immediate patient care needs. “When you take it to the OR, you're looking at vitals,” says Hess. “There are all these variables in play and the person is cut open and you're trying to keep them from bleeding to death.”

In addition, anesthesiology groups are typically contracted to the hospital. “The hospital doesn't own these folks so it's sometimes a little harder to come in and say, ‘You will do this,” he says. “They pay the highest malpractice of any specialty, and they have these huge incentives to make sure their record is absolutely clean.” The perception of having the AIMS record is shifting from a liability to an asset that can protect the physicians, particularly against spurious lawsuits, according to KLAS.

Another benefit is the improvement in patient care. The University of Texas Anderson Cancer Center in Houston has been using the Picis (Wakefield, Mass.) AIMS to go back and review the anesthesiology record. “What changes behavior is data,” says vice president and CIO Lynn Vogel, Ph.D. “Our anesthesiologists use the data to go back and change their patterns of practice.” He cites incidences of nausea and vomiting post-anesthesia, and says that by looking at the record, his anesthesiologists have been able to adjust practice patterns to improve care. “The way you improve the quality of care for your patients is not split-second decisions,” he says. “It's by changing patterns of practice, and that's where retrospective view of the data is important.”

Hess agrees that a retrospective view of the record is valuable, and that decision support at the time of care can be perceived negatively. “It's one thing for a doctor doing rounds to be asked ‘Do you want to use this drug?’” he says. “For an anesthesiologist in the middle of surgery, it is outrageous.” The products currently on the market, are often designed by anesthesiologists themselves are easy to use. And he says for that reason, best of breed has ruled, until now.

Ochsner Health System, a seven-hospital network based in New Orleans, uses Atlanta-based DocuSys' AIMS, integrated with Pyxis (CareFusion, San Diego) medication carts. “Anesthesiology is time critical and best of breed works better than anything,” says Lynn Witherspoon, M.D., system vice president and CMIO. “This is very much a niche market and the reason these best of breed solutions work is because anesthesiologists are very picky with their stuff.”

The creativity and art of the anesthesiologist's craft is echoed by Vogel. “Anesthesiologists seem to have a knack for cobbling things together in the hospital, and you basically have homegrown systems that meet the needs of a specific department,” he says. “That goes a long way to explaining why we don't see many commercial products in that space.”

Of the commercial products in use, KLAS says Picis and GE evolved from perioperative surgery management systems. And though a seamless periop solution is the goal, the interface with anesthesiology is notoriously difficult, and is another reason for the slow adoption of AIMS.

“Historically, that has been a challenge,” Vogel says. “You're relying on HL7 data from your anesthesiology IS system and are limited in what you can send by how the vendor defines the HL7 interface.”

Witherspoon also cites the integration factor as a top of mind issue. “We're really struggling with how you knot these pieces together,” he says, adding that the interoperability requirements between pre-surgical and anesthesiology are high. “I think hospitals should look at integrated solutions, but they have to be cautious about the quality of the solution; that was a real sticky point with our anesthesiologists.” He cites his anesthesiologists' dissatisfaction with the anesthesiology solutions offered by surgery systems as the reason behind their choice of DocuSys AIMS (a best of breed). “Several vendors' products are maturing, but I don't think the enterprise systems can do this well,” he says. “I think the physician's preference is pretty much going to sway the day.”

And whether it's an enterprise or niche vendor, reliability is paramount. “Nobody in the OR wants to wait a few minutes while something gets fixed,” says Vogel. “In other areas, if something goes down for an hour or two, people complain, but you'll eventually catch up. For an OR system, that's unacceptable.”

Though the challenges are many, most believe that AIMS will continue to grab a foothold. “All of the folks that we talked to that are live on the anesthesia systems would not go back to paper,” says Hess. “They've gone through the challenges and are seeing the benefits.”

Healthcare Informatics 2010 January;27(1):14-16

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