Making real-time data available to all

Research published in October 2008 in the journal Anesthesia and Analgesia stated that 44 percent of 140 U.S. academic departments had implemented or were planning to acquire an anesthesia information-management system (AIMS). Industry data suggests that outside of academic environments, however, 90 percent or more of anesthesia care providers still use paper-based documentation.

The fact that so few perioperative encounters are documented electronically is surprising. An industry-wide movement toward electronic health records (EHRs) is well underway, if not complete in some areas. In most settings, the benefits of electronic records over paper are well established:

•  Records are complete and legible, leading to fewer mistakes in care delivery or billing;

•  Automated data capture, for example of physiological data, relieves providers of costly and error-prone transcription; and

•  Data collected in an electronic record is immediately accessible for review and reporting.

Despite this, many hospitals continue to have isolated anesthesia records. “Essentially, these records remain a paper island in a sea of digital information,” says R. Allen Johns, M.D., a diplomate of the American Board of Anesthesiology and a staff anesthesiologist at Piedmont Hospital in Atlanta.

Many of today's hospital information-management systems can be interfaced with an AIMS to effectively share vital patient information and case data. Through HL7 and XML interfaces, mature AIMS solutions are being bridged with the modern hospital to provide complete fluency of information between systems. Yet, in most hospitals today, the flow of complete, accurate and up-to-date patient information is not reaching the OR, nor is the OR bridged to systems beyond its walls.

Many hospitals and anesthesia groups are concerned that an EMR simply isn't suited to the OR and, as such, will neither improve patient care nor reduce costs. Johns disagrees: “In fact, an electronic medical record (EMR) is uniquely suited to the demands of the OR.”

Like all medical records, anesthesia records are destined to transition to an electronic format. “This change will be necessary both to coexist with other systems and to claim the inherent benefits of going paperless,” says Johns.

The accuracy and completeness of patient records can contribute to the clinician's ability to optimize care. Paperless records are also important in optimizing pay-for-performance (P4P) initiatives.

Since 2006, Piedmont Hospital's anesthesia group has used Merge Healthcare's AIMS solution. Piedmont is a 450-bed facility with 30 operating rooms. “Our experience has shown that the move to this electronic record has not only brought value in short-term ROI, but has also allowed the hospital to improve both the quality and cost effectiveness of care over the long term,” Johns says.

Enabling P4P documentation at the point of care

Electronic records are natural tools to aid in the capture of pay-for-performance revenue such as DRG (diagnosis-related group) reimbursement, payer reimbursement for complications and co-morbidities (CC) and SCIP (surgical care improvement project) compliance and measures. These initiatives are data driven. Thus, they rely on information being accurately captured at the point of care, with reminders being presented to clinicians at the appropriate time and outcomes being made easily accessible for billing, reporting and review.

An AIMS improves providers' capacity to comply with these initiatives by enabling accuracy and speed with documentation. “An unobtrusive system can allow the clinician to care for the patient with complete focus, confident in the knowledge that the system and its reminders will be there when the time is right,” says Johns.

In order to accomplish this, the AIMS must be flexible enough to provide reminders that support hospital-specific initiatives as well as emerging national standards (e.g., Medicare/Medicaid, The Joint Commission).

Piedmont Hospital uses its AIMS to track antibiotic administration at the point of care. For several years, the AIMS has reminded Piedmont's anesthesia staff to document the location, time and type of antibiotic given. Clinicians select onscreen reminders to directly document this important clinical data. In addition, the AIMS provides automatic reminders to document antibiotic re-dosing at the appropriate time. Re-dosing is an important step in the prevention of surgical infections, and accurate documentation feeds outcome analysis for further improvements.

Electronically aggregating this type of data eliminates manual, retrospective data analysis and enables compliance tracking for outcome analysis. “Moreover, the data is more reliable than paper-based data because clinicians are reminded to [document], and have the tools to document at hand,” Johns says.

These reminders ensure that clinicians are completing the documentation necessary for SCIP. SCIP data accuracy and compliance impacts reimbursement from many major payers. Piedmont's AIMS includes tools to track SCIP compliance and identify where improvements can be made to maximize reimbursement.

Dollars saved; safety enforced

Using customized reminders as described above for antibiotics, Piedmont estimated that its AIMS helped capture between $280,000 and $699,000 through improved documentation practices in a single year. The same documentation practices also accounted for an estimated increase in pharmacy charge capture between $340,000 and $680,000. These estimates are a percentage of the overall improvement that year, Johns explains, because the AIMS was only one part of the hospital's practice changes and improvement initiatives.

This same workflow can be valuable for patient safety. “Our AIMS on-screen record is designed to present the most important information at every point during patient care,” says Johns, adding that any necessary and incomplete documentation, such as patient allergies, is highlighted, thus prompting the appropriate clinicians to complete it. “In the intense and time-constrained perioperative environment, a system becomes invaluable when it proactively provides reminders and makes important data accessible at a glance,” he says.

Increasing OR throughput and utilization with real-time data

An AIMS not only makes information more accessible to individual anesthesia care providers, but it also makes important information instantaneously accessible to other users in the OR environment. By broadcasting select pieces of information throughout the OR, staff can balance surgery workloads more effectively, turn rooms and optimize the use of OR time.

In order to best maximize OR usage, perioperative staff must juggle the day's planned schedule against the inevitable changes as each surgical case develops. OR staff members need to understand how each case is progressing so that they can be prepared when an OR suite becomes available — whether early or late. “With paper records, it is impossible to understand the status of cases currently in the OR,” Johns says.

Alternatively, in the routine course of electronic charting, an anesthesiologist can capture procedure information, such as the start, close and end of the procedure, simultaneously. At Piedmont, documentation reminders for these times are presented in the same way that antibiotics documentation is described above. Most AIMS also collect real-time physiological data from patient monitors, allowing for seamless presentation of charted case information and physiological data. Taken together, case times and physiological data provide an excellent view of an individual case's progress and status.

“With a low-cost software add-on, Piedmont's AIMS solution delivers data to large-panel plasma TVs mounted in strategic locations throughout the perioperative area. The entire staff uses this OR dashboard to understand how cases are progressing and determine if a specific OR will be available on time or is behind schedule,” says Johns. “This simple step has allowed us to recapture OR time, which can translate into thousands of saved dollars each day.”

Collecting the benefits

An AIMS is necessary for any CMO, CIO or CTO looking to revolutionize patient care in the OR. Even if it were financially possible to hire enough staff to aggregate data from hundreds, if not thousands, of paper records, manual data capture will never be as reliable as electronic data capture. Clinician's records are often filled with shorthand, much of which may be illegible or incomplete. A state-of-the-art AIMS with customized input devices can help clinicians create better documentation just as quickly as their shorthand, with none of the drawbacks.

As such, the AIMS takes over many tedious aspects of documentation — from protocol reminders to transcribing physiological data. An AIMS visual reminder is a simple and reliable mechanism to help clinicians document care. The system is then automatically capturing and aggregating data, making it readily available for review and analysis to improve compliance initiatives.

OR managers and anesthesia care providers can use data from the AIMS to better understand various aspects of their practice and to effectively collaborate on improvement initiatives. Piedmont's system produces customized reports to track numerous compliance measures and review outcomes. One example is the tracking of compliance with sterile barrier techniques for the insertion of a central line catheter. “This report helps us identify providers who do not document correct techniques,” says Johns. “We can then counsel providers who are not in compliance. The review can be done within one month of the occurrence, unlike a typical hospital quality-assurance program that may take four to six months for an event to be tracked and acted on.”

Looking forward

The past decade has seen incredible growth and maturity in AIMS, giving hospitals and surgery centers an opportunity to improve patient care and optimize the return on investment. As all of healthcare IT moves toward electronic records, AIMS will continue to see growth. Today, AIMS developers are moving ahead with next-generation offerings, including mobile solutions, integration with EHRs and connectivity with other systems, such as patient portals and kiosks.

An AIMS can deliver immediate benefits and lay a foundation for new approaches in the future. “In the first year, a newly deployed AIMS can be effectively used to capture an ROI that exceeds the costs of implementation,” Johns says. “After the first year, the AIMS should help drive improvements in perioperative processes that allow for additional ROI. Ultimately, the AIMS will serve a critical role in all hospitals' efforts to ensure high-quality, cost-effective care.” 

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