Emily Richardson, M.D.
AQI Practice Quality Improvement Committee
James M. Moore, M.D.
AQI Practice Quality Improvement Committee
What follows is an abridged version of the original article. The full version of the article can be found at www.aqihq.org/startingqualitymanagementprogram.aspx.
An anesthesia information management system (AIMS) offers great potential benefit to physician anesthesiologists and their patients. An ideal AIMS will result in an accurate, legible electronic record of anesthesia care that is easier to use and less distracting than paper documentation. An AIMS should facilitate electronic billing for anesthesia services and produce clinical data within a system that allows effective data use for a wide variety of purposes: quality improvement, risk management, clinical research, administrative management, regulatory compliance, and reporting to federal and state quality reporting programs as well as clinical data registries.1
However, fulfilling the potential of the ideal AIMS depends largely on the quality of its implementation as well as on the resources and supporting structures in place within the enterprise.
1. Decision to Implement an AIMS
The decision to implement an AIMS may accompany an enterprise electronic health record (EHR) implementation. The quality of an enterprise-wide EHR solution’s anesthesia component is usually not the basis for selecting an enterprise system, and that component will not be duly considered without leadership from physician anesthesiologists, both in enterprise administration and in clinical informatics.2
Reasons to install an AIMS include improved legibility of records, less distraction during anesthesia care, potential for improved billing and documentation compliance, integration with institutional EHR systems, and leveraging of data for quality improvement and clinical research. Impediments to an AIMS implementation include product immaturity, inadequate resources for implementation, disruptive change in documentation and questionable cost-effectiveness for the institution.
Integrating an AIMS with a different vendor’s enterprise EHR may be very difficult. If the enterprise is set on one system, in the long run it may be impractical to use a different brand of AIMS. Inevitably, physician anesthesiologists will need to access information from the EHR for patient care. Integrating information from other providers and using tools in the EHR as part of the pre-anesthesia and post-anesthesia workflows is much easier if all the EHR components are designed to integrate well, and implementation resources for a different brand may be limited.
2. Principles of AIMS Implementation
Device integration should be the first priority. Reliable device data correctly populating the record is a necessity and is the most basic functionality of an AIMS. Each monitor and anesthesia machine is connected to an interface that reliably translates the data coming from the device into the correct parameters for automated data transfer to the EHR. A device integration interface can be either a separate piece of hardware between the device and the AIMS computer or a software solution within the same computer as the AIMS.3
Recommendations for successful device integration include:
- Start early. Device integration testing almost always takes longer than first estimated.
- Ensure that hardware is available and properly configured when it is needed to start testing. One of the most common problems with EHR implementation generally is delayed hardware acquisition.
- Involve someone with clinical expertise in device testing. Technical people who validate parameter testing often are unfamiliar with how to operate the devices and what values and units are appropriate for the validated parameters.
Anesthesiologists faced with adopting an AIMS often express concern that they will be more distracted with electronic documentation than with paper records. In fact, a well-implemented AIMS should be less distracting during anesthesia care, and minimizing distraction should be the guiding principle for AIMS design. Workstation configuration is critical to reducing disruption of care and distraction. Position and adjustability of the AIMS workstation should permit documentation without turning away from the patient or monitors. If a touchscreen interface is used, the display size, selection, resolution and touch technology all are important. An AIMS touchscreen setup should permit a user to reliably select the correct elements on the screen using a variety of implements, including a gloved finger and a soft stylus. Too high a display resolution or too small a display prevents a touchscreen from being optimally effective. User interface design should minimize the time necessary to enter routine documentation, and most documentation can be entered with the touchscreen and mouse with minimal need for typing.4
3. Practical Aspects of AIMS Implementation
Pre-anesthesia Evaluation and Documentation
A structured pre-anesthesia evaluation can improve patient care and provide value to both the facility and the providers. Pre-anesthesia software can prompt providers to enter important information to ensure it is available to guide anesthesia management. Prompts improve documentation of comorbidities, which may increase reimbursement for the institution and can integrate with illness severity scores. The anesthesia record output format should be designed so that critical information, such as airway documentation, is easy to find and transfer to the pre-anesthesia documentation for the patient’s subsequent anesthetic. In the pre-anesthesia interface, preconfigured documentation elements minimize typing and allow rapid completion of the evaluation.
A preoperative clinic may begin a pre-anesthesia document that then becomes part of the final evaluation completed on the day of anesthesia care. The AIMS can support this workflow, but customization of enterprise EHR tools may be necessary.
Intraoperative Anesthesia Documentation
The AIMS should permit a large majority of the documentation to be done without typing. Minimizing free text entry allows more discrete data to be designed and captured in the documentation.
The AIMS should support the most commonly needed anesthesia documentation. However, also consider that managing medically complex patients or complicated cases may involve unusual documentation at a time when one is least able to devote time and concentration to entering free text. Thus an AIMS should support documentation of the most common cases as well as selected emergencies and complex cases. In addition, testing should ensure that short cases can be documented without delays.
The implementation team must collaborate with the pharmacy to ensure that all appropriate medications are available for use in the AIMS and that medication documentation is intuitive and easy to use. Similarly, proper interfacing with blood bank resources is necessary to ensure that blood product orders and documentation function well.
A handoff/transfer of care note should facilitate effective transfer of care during the critical transition at the end of anesthesia care.
Post-anesthesia evaluation processes vary greatly, and the documentation must be tailored to accommodate the desired post-anesthesia workflow. A well-designed post-anesthesia evaluation is critical for compliance and for capturing quality data.
System Design Process
The AIMS implementation team must include a clinical anesthesia provider who has the authority to guide changes to and approve clinical content. The design process is iterative, and the responsible anesthesia provider should meet in person on a regular basis with the team members who create and modify the AIMS content, to review the current state of AIMS components and make changes on the fly while meeting together. Interactive demonstrations of the system are more useful than reviewing static screenshots, and the earlier that displays are selected for the AIMS, the better the build can approximate the final user interface as part of the design process.
A project plan updated after each meeting should clearly lay out all tasks and activities yet to be completed, and for each it should list the start date, the team member responsible for the task, its priority, its current status with respect to completion, the next step needed plus the person tasked to perform the next step, and the projected completion date. This protocol keeps all team members aware of the outstanding tasks and helps the EHR leadership understand the necessary resources.
The AIMS team should solicit input from all relevant subspecialties to ensure that documentation meets all the needs of the department. In particular, obstetric anesthesia requirements can differ substantially from those of non-obstetric anesthesia services.
Thorough procedures for periods of scheduled and unscheduled downtime (loss of connectivity of the system or of devices) must be in place.1 Downtime workstations can permit access to copies of patient records stored from before downtime occurred and should be clearly labeled and available on all units.
Detailed training materials must be created, and users should be given ample time to become familiar with the system in a non-production environment before the system is live. The best time to train users on a new clinical information system is usually shortly before going live with the system. “Shadow charting” – documenting in a non-production system environment prior to “go live” while still documenting in the official medical record in the usual way – is an essential part of training for anesthesia documentation.
Billing and Compliance
All information necessary to support billing must be included in the system build. Billing and compliance requirements should be delineated early in the design. The billing service should review whatever output will be used as the basis for billing. Records, data and billing service access should be tested and validated before going live with the new system to avoid costly disruptions in the revenue cycle. If all communications and data transfer with the billing service are to be electronic, consideration should be given to a transition period with hard copies of electronic records available until the new electronic process is confirmed to be sound.
Compliance considerations vary between states, but federal regulations apply broadly. Each anesthesiology department may have its own interpretation of how best to document to support medical direction and compliance with Medicare regulations. The AIMS build should be tailored to incorporate these elements.
Data Use and Warehousing
Many commercial AIMS systems fall short of expectations for reporting and use of data for various purposes, including departmental administration, quality assessment and reporting, risk management, regulatory compliance, registry reporting and clinical research.1 An external data warehouse can receive transactional data exported from the EHR database in a format that is more conducive to reporting and analyses. For the enterprise’s anesthesiology department, a data mart can be created as a subset of the data warehouse with a collection of related tables and data for anesthesia-specific analyses and reports.
Physician anesthesiologists should work with administration leaders to align data collection goals and processes. For data to be effectively reportable and available for analyses, the system design team should include someone dedicated to understanding where in the EHR all the data elements exist that are desired for reporting. A technical expert trained to export data from the EHR database may be necessary to make effective use of data in the ways physician anesthesiologists expect.
- Muravchick S, Caldwell JE, Epstein RH, et al. Anesthesia information management system implementation: a practical guide. Anesth Analg. 2008;107(5):1598-1608.
- Leviss J, Charney P, Corbit C, Gugerty B. HIT or Miss: Lessons Learned from Health Information Technology Implementations. 2nd ed. Bethesda, Maryland: AHIMA Press; 2013.
- Marian A, Moore J. Device integration: an essential step in AIMS implementation. ASA Newsl. 2012;76(8):14-17.
- Marian AA, Dexter F, Tucker P, Todd MM. Comparison of alphabetical versus categorical display format for medication order entry in a simulated touch screen anesthesia information management system: an experiment in clinician-computer interaction in anesthesia. BMC Med Inform Decis Mak. May 29, 2012;12:46. doi: 10.1186/1472-6947- 12-46.
Implementing an AIMS as Part of an Enterprise HER / Copyright 2015 is reprinted with permission of the American Society of Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173-4973