This is the second in a series of CSA Online First articles about anesthesia information management systems (AIMS), written by Drs. Johnathan Pregler and James Moore from the Department of Anesthesiology at UCLA. UCLA is in the process of adopting such a system, and these blog articles will provide insight into the experience from their perspectives. The editorial comments are based upon the editor, Dr. Linda Hertzberg’s perspective, as a consequence of having gone through this process first hand in her own hospital, several years ago.
With the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs providing financial incentives for "meaningful use" of EHR technology, hospital administrators and clinicians have new motivation for implementing electronic medical record systems.
Automated anesthesia record (AAR) systems have existed for decades. When an AAR system combines with a perioperative database to form a comprehensive anesthesia information management system (AIMS), the potential uses can be substantial: clinical research, quality improvement, risk management, billing, and compliance efforts all can benefit.[i] However, these benefits should be weighed against concerns over cost, disruption of clinical workflow during implementation and sharing data with outside agencies, which may be perceived as either beneficial or detrimental.
The anesthesia workstation consists of the anesthesia machine, monitors, computer, display screen (preferably a touch screen) and any associated hardware interface linking the system to the AIMS server via a network connection. Most AIMS vendors include a hardware interface solution as part of the package, providing the critical communication between anesthesia devices—machines and monitors—and the AIMS. If the vendor does not include such an interface solution, solving this problem may be one of the most critical steps to AIMS implementation. Even with a hardware interface included, particular attention must be paid to integrating all necessary biomedical devices for data capture. Hardware and networking needs must be carefully assessed well in advance, so that necessary equipment and configurations will be in place, as well as to accurately assess the cost involved. A network devoted exclusively to the AIMS and a second/redundant network (in case one network fails) is desirable but not always practical. On the other hand, the intensive and rapidly changing nature of anesthesia care demands that data acquisition and documentation be supported by a robust, stable infrastructure, even more so than in any other patient care environment.
Sharing clinical data with the ASA’s Anesthesia Quality Institute (AQI) or other outcomes and clinical databases such as the University of Michigan’s Multicenter Perioperative Outcomes Group (MPOG) can provide practice benchmarking and aid clinical research. However, AIMS use and AQI participation also facilitate sharing data with outside agencies, such as the Centers for Medicare and Medicaid Services (CMS). CMS will use submitted data for “pay-for-performance” efforts and to guide its “value-based purchasing” of healthcare for Medicare patients. Individual practices will decide whether to participate in programs such as CMS’s Physician Quality Reporting Initiative, which will exact financial penalties from physicians who do not measure up accordingly. Ideally, data used for quality measures and benchmarking should be clinical data of reasonably high quality.[ii] However, CMS uses Patient Safety Indicators from the Agency for Healthcare Research and Quality for hospital profiling and pay-for-performance purposes, and these indicators, based largely on simple administrative data including billing codes, demonstrate major shortcomings compared to measures based on clinical data.[iii]
Ultimately, individual practices must decide for themselves whether to participate in public data sharing and federal benchmarking, but anesthesiologists should realize that doing so may result in public reports and financial penalties based on administrative data without appropriate risk adjustment.
If a hardware interface solution is not part of the package, beware. Integrating components may not be easily accomplished with overstretched local hospital IT resources. Think about every single monitor you use and how it might be integrated (BIS, ICP etc.), not just the standard hemodynamic monitoring. Hardware implementation comes with a unique set of issues and pitfalls. It is important to have excellent vendor and local IT support to solve problems as they occur—and they will occur. It is imperative that your institution factor in the costs of adding sites and new technology as the need dictates. Otherwise, you will have multiple sites using paper records, as is the result where I practice.
A clear advantage of using an AIMS system is that electronic data sharing and reporting with outside agencies and entities is possible; however, each individual group and facility must carefully consider the costs and benefits of doing so. We have yet to be able to have our AIMS download quality data to our local quality database, and are obtaining the data by other means. If participation in a quality and outcomes database is important to you and your facility, try to get this in place initially, rather than as an add-on, later. Part 3 in this “AIMS Insights” series will discuss AIMS Implementation. Please provide feedback about your own experiences by leaving comments below.
For more information on meaningful use see the ASA Update on Electronic Health Records and Meaningful Use
AIMS Insights, Part 1
AIMS Insights, Part 3
[i] Muravchick S, et al. Anesth Analg 2008 November;107(5):1598-1608
[ii] Glance L. ASA Newsletter 2010 May;74(5):17-18
[iii] Romano PS. Health Serv Res 2009 Feb;44(1):182-204