Automating the recording and improving the presentation of the anesthesia record

Although anesthesia records have been kept for over a hundred years, there is still discussion of their value and content. Two uses of the record are widely accepted: (1) review after the anesthetic event (as in medicolegal disputes), and (2) support of patient care during the delivery of an anesthetic. Although the anesthetic record is mandatory in much of the world, there is not a single standard for its format. Automating the generation and presentation of the record will enhance its value and help develop a consensus as to content. Merely automating the steps used to produce the manually generated record does not realize the full benefit of automation. For maximum benefit, the primary goal of automation should be to support the uses of the record. Specific techniques that are discussed include increasing time resolution, optimizing the type and location of input and display equipment, and tailoring the human interface. Particular attention is paid to the issue of how much detail is acceptable in the record, how to use visual cues to present detail properly, how to exclude extraneous detail, and how to avoid misleading presentations (erroneous interpretation of the data). Specific elements discussed include line width, the use of color, presentation of gradients, statistical summaries, contexts for reporting data, graphical techniques for increasing data content, and pictorial presentations. Current records are more often confusing because presented information is inconsistently displayed or irrelevant than because too much information is offered, and automation can ameliorate this problem.Electrical EngineeringPhysiology     

The uses of the anesthesia record

The typical, handwritten anesthesia record of the 1980s does not satisfy its many users. The document is used for clinical care by the anesthetist, nurses, physicians, and technicians in postanesthesia, intensive, and postoperative surgical care units; for historical information by the billing officer, the statistician, and the anesthetist in preparation for a future anesthetic; and for the review of the quality of care by clinical peers and lawyers. For all of these users the typical record contains some to much unnecessary information and lacks some to much needed information. Electronic capture, storage, retrieval, and formatting of data can generate electronic displays or paper records tailored to answer the needs of specific users. The anesthetist in particular will benefit from a well-designed system that takes the place of the traditional handwritten anesthesia record.     

An anesthesia information system for monitoring and record keeping during surgical anesthesia

We have developed an anesthesia information system (AIS) that supports the anesthesiologist in monitoring and recording during a surgical operation. In development of the system, emphasis was placed on providing an anesthesiologist-computer interface that can be adapted to typical situations during anesthesia and to individual user behavior. One main feature of this interface is the integration of the input and output of information. The only device for interaction between the anesthesiologist and the AIS is a touch-sensitive, high-resolution color display screen. The anesthesiologist enters information by touching virtual function keys displayed on the screen. A data window displays all data generated over time, such as automatically recorded vital signs, including blood pressure, heart rate, and rectal and esophageal temperatures, and manually entered variables, such as administered drugs, and ventilator settings. The information gathered by the AIS is presented on the cathode ray tube in several pages. A main distributor page gives an overall view of the content of every work page. A one-page record of the anesthesia is automatically plotted on a multicolor digital plotter during the operation. An example of the use of the AIS is presented from a field test of the system during which it was evaluated in the operating room without interfering with the ongoing operation. Medical staff who used the AIS imitated the anesthesiologist’s recording and information search behavior but did not have responsibility for the conduct of the anesthetic.     

The present and future medicolegal importance of record keeping in anesthesia and intensive care: The case for automation

The anesthesia record is often crucial to successful defense in a meritless claim, because the adversarial role of the plaintiff's medical expert witness requires an attack on the record. Likewise the record may be pivotal in determining whether a defense should even be mounted as an alternative to an early settlement, because the failure of meaningful, supportive, or exculpatory documentation raises serious questions about the quality of care rendered. Advancing technology has made possible revolutionary changes in real-time monitoring and data recording. Concepts favoring the development and adoption of automated record systems for anesthesia are outlined through historic medicolegal perspectives on record keeping in general and computerization of the monitoring and recording methods in specific as a means of providing the best medicolegal evidence in defense of the anesthesiologist's performance. The analogy is often made between the successful development and acceptance of the flight data recorder and cockpit voice recorder combination in aviation and ongoing software development for automated recordkeeping and the quest for its use and professional acceptance in both anesthesia and intensive care settings.     

How can a standard software package for data management in anesthesia be achieved?

Collecting data for administrative, statistical, medical, and organizational purposes is becoming increasingly important in anesthesia. In 1986 the Swiss Society for Anesthesiology decided to create a program that would be compatible for different computers and would expedite data collection. The system developed was called Information System for Operations (ISOP), which was written in the database and programming system Massachusetts General Hospital Utility Multi Programming System (MUMPS). It was installed in eight hospitals and met the initial requirements, but the individual requirements of the hospitals were greatly underestimated. MUMPS has an impressive data storage capability and handling when used in a personal computer (PC) network. The user-interface, however, is inferior to other PC packages, partly because windowing and mouse support were not implemented when the ANSI standard was set. Improved statistical programs, a module for on-line data acquisition, and intensive care unit (ICU) use will be additional modules to the program.An address delivered on the occasion of the First Annual Meeting of the European Society for Computing in Anesthesia and Intensive Care, Goldegg, Austria, Oct 26, 1990.     

How can a standard software package for data management in anesthesia be achieved?

Collecting data for administrative, statistical, medical, and organizational purposes is becoming increasingly important in anesthesia. In 1986 the Swiss Society for Anesthesiology decided to create a program that would be compatible for different computers and would expedite data collection. The system developed was called Information System for Operations (ISOP), which was written in the database and programming system Massachusetts General Hospital Utility Multi Programming System (MUMPS). It was installed in eight hospitals and met the initial requirements, but the individual requirements of the hospitals were greatly underestimated. MUMPS has an impressive data storage capability and handling when used in a personal computer (PC) network. The user-interface, however, is inferior to other PC packages, partly because windowing and mouse support were not implemented when the ANSI standard was set. Improved statistical programs, a module for on-line data acquisition, and intensive care unit (ICU) use will be additional modules to the program. An address delivered on the occasion of the First Annual Meeting of the European Society for Computing in Anesthesia and Intensive Care, Goldegg, Austria, Oct 26, 1990.     

Interactive microcomputer for acquisition of patient information

Written records and first-generation hospital information systems do not meet their primary purpose to assist physicians in solving patients' problems. Simply automating the present chart formats is not the answer. An example of the concept needed for charting is the intensive care unit chart. Anesthesiology charts provide little useful information for the continued care of the patient postoperatively. They serve principally as legal archival documents. Automation of the anesthesia record should free the anesthesiologist of the need to search for preoperative information and to manually record most information intraoperatively. Decisions about how much data to archive and how to extract the data pertinent to continuing care are the challenges for physicians. The technologic tools are available for the design and implementation of a software system that focuses on effective communication of the patient's problems throughout the perioperative period as the patient moves from ward to operating room, through the recovery room and intensive care unit, and to the ward and home.     

Automated anesthesia records and anesthetic incidents

A case report is presented in which the cause of an anesthetic mishap would have remained a mystery had it not been for an automated anesthesia record.     

Automated anesthesia records and anesthetic incidents

A case report is presented in which the cause of an anesthetic mishap would have remained a mystery had it not been for an automated anesthesia record.     

A reference system in clinical anesthesia

We have developed, as a pilot project, a hypertext-based reference system for anesthesia in a neurosurgical clinic. The intention is to give passive decision support prior to the operation. The information is presented according to the different needs and knowledge levels of the anesthesiologists. Therefore, with the aid of a simple and universal user interface (mouse and screen keys, no keyboard) the information is structured from basic to more detailed information. To complete the operation-related material the system also offers relevant data from the anesthesia-related background knowledge (pre-existing diseases, drugs, and medication, etc.). As an example, a short path through the system is shown to illustrate the presentation and linkage of information.This reference system was developed and implemented while Dr Zapf was an anesthesiologist at the Institute of Anesthesiology at the University of Erlangen-Nuremberg.     

Normal fluctuation of physiologic cardiovascular variables during anesthesia and the phenomenon of “smoothing”

With the advent of automated anesthesia record keeping devices, concern has arisen that “abnormal” values will appear in the record and possibly lead to medicolegal compromise. A retrospective review of automated records from a series of anesthesia cases was undertaken to determine if abnormal values do occur, how frequent they are, and whether they cause problems. A total of 14,826 (4,942 each) noninvasive heart rate, systolic, and diastolic blood pressure readings from 118 case printouts generated by a Diatek Arkive Patient Information Management System (63 cases) or a Data-scope Datatrac record keeper (55 cases) were recorded. The study sample covered a broad range of surgical operations, anesthetic procedures, and patient ages and medical histories. During these 118 anesthetics, the majority of readings of all three variables fell within normal ranges (defined for this study as 80 to 180 and 50 to 110 mm Hg for systolic and diastolic blood pressures, respectively, and 60 to 140 beats/min for heart rate). During the anesthetics, 3.6% of the systolic pressure readings, 13.25% of the diastolic readings, and 4.25% of the heart rate readings were recorded outside these ranges. No serious intraoperative or postoperative anesthesia complications were associated with these out-of-range readings, nor would they be expected in a sample of this size, since serious anesthetic complications are rare. This preliminary observation of one person's experience may help address the concern associated with allowing high and low blood pressure and heart rate readings to be automatically recorded “unsmoothed.” In medicolegal situations, it should also begin to demonstrate that such fluctuations are neither uncommon nor abnormal, and that a true record of these readings should be neither a cause for concern nor an opportunity for medicolegal exploitation.     

An expert system to teach troubleshooting of common problems associated with the automated anesthesia recordkeeper

Automated anesthesia recordkeepers have been used to monitor patients during surgery in up to 90% of cases at The Ohio State University. The record-keeping devices are complex and can be difficult to troubleshoot. The 1st-CLASS Fusion Program, an expert system shell-program, has been programmed to allow the resident or nurse anesthetist to solve the two most common types of problems associated with the recordkeeper: printer problems and patient monitor problems. Use of this program allows the resident or nurse anesthetist to troubleshoot the recordkeeper quickly and accurately and promotes in the user a sense of competence and control over the technology.     

Using an anesthesia information management system to prove a deficit in voluntary reporting of adverse events in a quality assurance program

Objective.A deficit is suspected in the manual documentation ofadverse events in quality assurance programs in anesthesiology. In order toverify and quantify this, we retrospectively compared the incidence ofmanually recorded perioperative adverse events with automatically detectedevents. Methods.In 1998, data of all anesthetic procedures, includingthe data set for quality assurance of the German Society of Anaesthesiologyand Intensive Care Medicine (DGAI), was recorded online with the AnesthesiaInformation Management System (AIMS) NarkoData4® (Imeso GmbH). SQL(Structured Query Language) queries based on medical data were defined for theautomatic detection of common adverse events. The definition of the SQLstatements had to be in accordance with the definition of the DGAI forperioperative adverse events: A potentially harmful change of parameters ledto therapeutic interventions by an anesthesiologist. Results.During16,019 surgical procedures, anesthesiologists recorded 911 (5.7%) adverseevents manually, whereas 2966 (18.7%) events from the same database weredetected automatically. With the exception of hypoxemia, the incidence ofautomatically detected events was considerably higher than that of manuallyrecorded events. Fourteen and a half percent (435) of all automaticallydetected events were recorded manually. Conclusion.Using automaticdetection, we were able to prove a considerable deficit in the documentationof adverse events according to the guidelines of the German quality assuranceprogram in anesthesiology. Based on the data from manual recording, theresults of the quality assurance of our department match those of othercomparable German departments. Thus, we are of the opinion that manualincident reporting seriously underestimates the true occurrence rate ofincidents. This brings into question the validity of quality assurancecomparisons based on manually recorded data.     

Hypotension after spinal anesthesia for cesarean section: identification of risk factors using an anesthesia information management system

Objective. To determine risk factors for developing hypotension after spinal anesthesia for cesarean section to prevent obstetric patients from hypotensive episodes potentially resulting in intrauterine malperfusion and endangering the child. Methods. The data from 503 women, having received spinal anesthesia for cesarean sections were investigated using online gathered vital signs and specially checked manual entries employing an anesthesia information management system. Blood pressure, heart rate, and oxygen saturation were measured throughout and hypotension was defined as either a drop in mean arterial blood pressure of >20% from baseline value or readings of <90 mmHg systolic arterial blood pressure. Thirty-two variables were studied for association with hypotensive episodes using univariate analysis and logistic regression employing a forward stepwise algorithm to identify independent variables (P < 0.05). Results. Hypotension was found in 284 cases (56.5%). The univariate analysis identified the neonate’s weight, mother’s age, body mass index, and peak sensory block height associated with hypotension. Body mass index, age and sensory block height were detected as independent factors for hypotension (odds-ratio: 1.61 each). Conclusions. Knowledge of these risk factors should increase the anesthesiologist’s attention to decide for the necessity to employ prophylactic or therapeutic techniques or drugs to prevent the neonate from any risk resulting of hypotension of the mother.     

Use of data from a hospital online medical records system by physicians during preanesthetic evaluation

Objective. There is no data on the use of hospital-wide online edical record (OLMR) systems by anesthesiologists. We measured how often anesthesiologists accessed the OLMR database maintained by the hospital, how often data was copied from this database into the clinic's computer system, and how much data was copied.Methods. In a preanesthetic evaluation clinic that has a computerized evaluation system designed for physician-entered data, a graphical user-interface prototype link provided access to the hospital OLMR database for users and was studied over a 37-day period. The software allowed the user to search the OLMR system by patient name, retrieve a text listing of the patient's record, and then copy and paste desired information into the forms of the preanesthetic system. Using embedded routines, we recorded how many times physicians searched for and retrieved medical records from the hospital OLMR database, as well as how many times they copied data to the preoperative database. As a measure of howmuch data was copied, the number of characters was also recorded.Results. Of 1,080 patients evaluated in the clinic during the study period, electronic searches of the hospital OLMR database for 221 patients (20.5%) were noted. Of these searches, 208 (94.1%, or 19.3% of 1,080 patients) successfullyretrieved data from the patient's record. Data wascopied for 170 patients — 81.7% of the successful searches. Of 7,525,153 characters retrieved, 262,269 were copied — an average of 1,543 characters per instance of copying.Conclusion. We conclude that anesthesiologists, given even crude graphical access to a hospital OLMR database, will retrieve and copy data, potentially increasing the accuracy of the medical records and saving time.     

Computer assisted management of information in an intensive care unit

Summary In order to use the capability of computers for handling large amounts of information, we developed a program for the acquisition, handling, storage and retrieval of administrative and clinical information generated in the 20 bedded multidisciplinary critical care unit of a University Hospital. At an initial phase a personal computer (PC) was used to collect information from 4362 patients, that included registration data, coded admission problems, techniques and special treatments, and final diagnosis. This information combined with free text provided a discharge report. Complementary programs allowed calculation and storage of hemodynamic and gas exchange parameters. This experience led to a second phase in which a computer with microprocessor Intel 80386 at 25MHz, 8MB RAM, 310 MB hard, disk and a streamer for 150MB cartridge tape back up, using UNIX operating system, permitted multiple users working simultaneously through 1 central console and 7 ASCII terminals. Data input included demographic data, previous and admission problems in coded form, present history and physical examination in free text, list of present problems in coded form, comments on evolution, record of special techniques and treatments, laboratory data, treatment, final diagnosis and facility for using all the information to elaborate the final report. Side modules provide help for drugs dosing, protocols for specific conditions and clerical routines. The system is open for connection to other areas of the Hospital. Data from more than 2000 patients have been included so far. The program is used by medical, nursing and clerical staff with high degree of acceptance. All patients have their clinical information filed and 100% of the final reports are elaborated with the program.We conclude that a PC supported application is not adequate for implementing a historical database. On the contrary the integration of a relational database management system with a text editor in a more potent multiuser set up, provides a highly efficient tool to handle all the data generated during the patients' admission.     

Tidal volume changes due to the interaction of anesthesia machine and anesthesia ventilator

Tidal volume (VT) delivered by mechanical ventilation during anesthesia may be influenced by factors related not only to the patient and the breathing circuit, but also to the interaction between the anesthesia machine and the anesthesia ventilator. To characterize this interaction, we studied in a test lung the effect of fresh-gas flow (FGF) (0.25, 2.5, 5, and 10 L/min), inspiratory-to-expiratory time ratio (I: E) (1 : 1, 1 : 2, and 1 : 3), and ventilatory frequency (8, 12, and 16 breaths/min) at fixed ventilator bellows excursions of 300, 600, and 900 ml. The influence of these variables was also estimated mathematically for a pediatric situation: a bellows excursion of 50 ml at 20 and 30 breaths/min. Each variable studied was associated with an increase, sometimes dramatic, in the delivered V_T compared with that which was set. The V_T augmentation was greatest at the highest FGF rate, largest I : E ratio, and slowest respiratory rate. Because the magnitude of the augmentation is independent of the V_T setting, the percent increase is much larger for pediatric settings. For example, with V_T set at 50 ml, delivered V_T ranged from 71 ml (FGF 2.5 L/min, I : E 1:3, and 30 breaths/min) to 300 ml (FGF 10 L/min, I : E 1:1, and 20 breaths/min). Thus it is possible in the pediatric situation to increase the delivered VT by sixfold without changing the ventilator bellows excursion. The magnitude of the changes was slightly larger for the VT settings for adult patients because of the slower respiratory rate. This VT augmentation can be predicted by the product of FGF (ml/s) and inspiratory time (seconds). Therefore it is possible to dramatically affect delivered V_T without changing the ventilator bellows excursion; this is an important consideration when FGF, I : E, or ventilator rate settings are selected or adjusted.     

Implementation of an Emergency Department Computer System: Design Features That Users Value

Background

Electronic medical records (EMRs) can potentially improve the efficiency and effectiveness of patient care, especially in the emergency department (ED) setting. Multiple barriers to implementation of EMR have been described. One important barrier is physician resistance. The “ED Dashboard” is an EMR developed in a busy tertiary care hospital ED. Its implementation was exceptionally smooth and successful.

Study Objectives

We set out to examine the design features used in the development of the system and assess which of these features played an important role in the successful implementation of the ED Dashboard.

Methods

An anonymous survey of users of the ED Dashboard was conducted in January and February 2009 to evaluate their perceptions of the degree of success of the implementation and the importance of the design features used in that success. Results were analyzed using SPSS software (SPSS Inc., Chicago, IL).

Results

Of the 188 end-users approached, 175 (93%) completed the survey. Despite minimal training in the use of the system, 163 (93%) perceived the system as easy or extremely easy to use. Users agreed that the design features employed were important contributors to the system's success. Being alerted when new test results were ready, the use of “most common” lists, and the use of color were features that were considered valuable to users.

Conclusion

Success of a medical information system in a busy ED is, in part, dependent on careful attention to subtle details of system design.