This is the third and final article 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 throughout the article 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.
AIMS Implementation: Personnel
An AIMS implementation team consists of several vital roles that should be defined and assigned in advance. A project manager with expertise in information technology leads the AIMS implementation and interfaces with clinical team members to ensure that the system build and workflows are appropriate. The project’s clinical leader should be an anesthesiologist who understands all the department’s clinical workflows in detail and will guide the implementation team on configuring the user interfaces, determining appropriate documentation, establishing workflows and defining the necessary output formats, reporting and data analysis. Underestimating the clinical leader’s time commitment could prove hazardous. This role may become a full-time job, especially as live implementation approaches. The clinical leader’s duties may need to be shared with other clinicians, particularly if the implementation is for a large enterprise or one with multiple physical facilities.
Many anesthesia information systems require extensive software customization to suit the needs of a particular practice, and appropriate personnel need to be assigned to this task. An AIMS vendor may offer basic customization, but other onsite programmers are often necessary, employed by the anesthesia group or the parent institution. These programmers need to learn how to make changes to the system software to adapt it to the end users’ needs. After initial implementation, a system administrator remains responsible for system troubleshooting, maintenance and adaptation. This may be the original project manager or another team member, and the role may be shared with the clinical leader. Many others will play important roles in AIMS implementation, including an “executive sponsor,” who may be the department chair or other key administrator, who can interface with the institution’s administration and advocate on behalf of the AIMS project. In an enterprise-wide EHR implementation, or when an AIMS is added to an existing large clinical information system, a large number of departments and services throughout the enterprise will impact the AIMS rollout, and the implementation team needs to interact with them. Biomedical support staff and information technology personnel and resources need to be identified and influenced to work together to accomplish successful hardware integration and system support. Failing to provide sufficiently for either of these services could have grave results.
For any new AIMS adoption it is important that there be an “executive sponsor” or “clinical champion” in the department who understands the departmental dynamics and culture as well as having a good working knowledge of the AIMS. In addition, there should be several other anesthesiologists who can serve as “super user” resources to their colleagues as the system is implemented. These individuals can anticipate obstacles to the clinical adoption of the AIMS by their colleagues and make suggestions to the information technology department and hospital administration as to how to overcome resistance to the use of the new AIMS. Without several strong colleagues who can provide support to the anesthesiologists as a new system is rolled out, AIMS implementation will be unsuccessful.
AIMS Implementation: Strategies
The executive sponsor or clinical champion works with other anesthesiologists/anesthesia care team members for input on documentation needs, including perhaps one clinician with expertise in each key clinical area or case type. Different intraoperative documentation may be needed, for example, for pediatrics, cardiac surgery, ophthalmology, liver transplantation, neurosurgery, outpatient surgery and obstetrics. Customized preoperative documentation may be required for pediatrics, obstetrics, and others. If an anesthesia simulator is available, interfacing it to the AIMS for system development can facilitate developing the documentation across a wide variety of case scenarios.
In an integrated EHR, the team that develops the AIMS needs to consider how it interacts with the other system components. Implementation involves working together with the teams that manage operating room scheduling, outpatient clinics, inpatient admitting physicians and consultants, nursing care and the pharmacy, just to name a few. In an integrated EHR system, the anesthesia documentation will include data fields that are shared with other applications, such as a pharmacy’s drug list or nursing documentation of fluid intake and output. As a result, the implementation team may face decisions where customizing certain formatted information is desirable, but doing so may mean that it cannot be shared with other applications or users. Whatever compromises must be made, no concession should be permitted to detract from patient safety, with regards to what documentation is preferable or necessary for anesthesia applications. For instance, if an AIMS requires a process for documenting transfused blood units which is so cumbersome that using it would distract clinicians from patient care during episodes of acute hemorrhage, it is imperative to find an alternate solution.
When faced with a great level of customization, the clinical leader needs to decide to what extent system users can customize individual user experiences. Provided that doing so does not adversely affect other users, the risk of allowing someone to create personal routines and templates within the AIMS interface may be simply that it could distract the user from learning to use the standard templates well. Creating sufficient standardized preoperative and intraoperative documentation templates to meet a large majority of needs should reduce the desire to create custom templates.
Not all EHR systems excel in every aspect of clinical documentation. Thus, outside information systems may remain in use for some aspects of patient care, even after adoption of a comprehensive EHR. The EHR must reliably incorporate access to key outside systems.
One of the most fundamental strategic decisions is whether to “go live” with the AIMS everywhere at once, or whether to roll out implementation in discrete phases. Implementing everywhere at once compresses the time during which initial system troubleshooting occurs. Also, in a staged rollout with different facilities coming online at different times, it is more likely that a clinician could get assigned to the live AIMS facility without having been trained yet, especially if the facility’s staff includes anesthesiologists who also work at other locations. On the other hand, a staged rollout at one location at a time allows a limited number of problems to occur for a limited number of users during the initial clinical use. This may reduce the chance of adversely affecting both patient care and the system’s adoption by skeptical users. For this reason, the staged introduction may be preferable in many cases. Larger groups and those covering multiple physical facilities, especially with different clinical populations at each facility, are more likely to benefit from a staged rollout. The first phase of adoption is where the most problems and troubleshooting should occur, so a substantial delay before the second stage of rollout may be followed by shorter periods between subsequent rollout stages. Initial training may be done with the AIMS connected to a live operating room environment but still with paper charting as the official medical record. This is easier in the anesthesia care team model, when two providers can be present: one training on the AIMS and one charting on paper. Even after the AIMS is live, it may be prudent to continue paper as the official record until the stability and performance of the AIMS is well established. Whatever the strategy, the implementation team should work to ensure that patient safety is not compromised, that the anesthesia documentation is adequate throughout and that billing is not adversely affected.
Although the AIMS and the perioperative database can aid clinicians well beyond providing clinical documentation, features such as clinical decision support, quality improvement, risk management, billing, compliance efforts, pay-for-performance reporting and clinical research may not be in place at the time the automated anesthesia record goes live. Having the AIMS facilitate such efforts is desirable but may take a back seat chronologically as the basic AAR is first brought online. Nevertheless, if the AAR does not come packaged with a robust perioperative database or good tools for decision support or performance measure reporting, foresight is required to see that such features will eventually be available.
Finally, no anesthesia practice should need to implement an AIMS without the benefit of conferring with current users of the system at other institutions. (Implied is this axiom: don’t be the first user of a new system.) The experience and advice of fellow clinicians who have successfully implemented the same AIMS can prove invaluable. Perhaps as AIMS implementation becomes a more common necessity, resources for support from colleagues across institutions--including professional networking and web-based communities online--will as well.
During the rollout of the AIMS you will experience both “early adopters” and “resistors”. As the executive sponsor or clinical champion, it is important to listen to the concerns of the resistors and address appropriate clinical issues, while not getting sidetracked by emotions, personalities or potential manipulation of circumstances. In any event, it is critical that all members of the department are informed and understand up front that a “drop dead” date exists, beyond which the AIMS use is mandatory. Otherwise, an undesirable hybrid system will exist for an extended period of time. I recommend making the time for initial adoption at the primary site as short as is reasonable for your individual facility.
The entire AIMS three part series may within the CSA’s Practice Resources. The CSA believes it will be a useful resource to members as more departments move to adopt EHRs and AIMS into daily practice. Please leave comments and questions about your own experience with AIMS implementation below.
(Conclusion of the series)
AIMS Insights, Part 1
AIMS Insights, Part 2