Challenges and opportunities for computerizing the anesthesia record

Anaesthesia personnels' perspectives on digital anaesthesia information management systems - a qualitative study

Background

In Norway, the anaesthesia team normally consists of a nurse anaesthetist and an anaesthetist. Digital anesthesia information management systems (AIMS) that collect patient information directly from the anaesthesia workstation, and transmit the data into documentation systems have recently been implemented in Norway. Earlier studies have indicated that implementation of digital AIMS impacts the clinical workflow patterns and distracts the anaesthesia providers. These studies have mainly had a quantitative design and focused on functionality, installation designs, benefits and challenges associated with implementing and using AIMS. Hence, the aim of this study was to qualitatively explore anaesthesia personnel’s perspectives on implementing and using digital AIMS.

Methods

The study had an exploratory and descriptive design. The study was conducted within three non-university hospitals in Southern Norway. Qualitative, individual interviews with nurse anaesthetists (n = 9) and anaesthetists (n = 9) were conducted in the period September to December 2020. Data were analysed using qualitative content analysis according to the recommendations of Graneheim and Lundman.

Results

Four categories were identified: 1) Balance between clinical assessment and monitoring, 2) Vigilance in relation to the patient, 3) The nurse-physician collaboration, and 4) Software issues. Participants described that anaesthesia included a continuous balance between clinical assessment and monitoring. They experienced that the digital AIMS had an impact on their vigilance in relation to the patient during anaesthesia. The digital AIMS affected the nurse-physician collaboration. Moreover, participants emphasised a lack of user participation and aspects of user-friendliness regarding the implementation of digital AIMS.

Conclusion

Digital AIMS impacts vigilance in relation to the patient. Hence, collaboration and acceptance of the mutual responsibility between nurse anaesthetists and anaesthetists for both clinical observation and digital AIMS administration is essential. Anaesthesia personnel should be included in development and implementation processes to facilitate implementation.

Integration of the enterprise electronic health record and anesthesia information management systems

Fewer than 5% of anesthesia departments use an electronic medical record (EMR) that is anesthesia specific. Many anesthesia information management systems (AIMS) have been developed with a focus only on the unique needs of anesthesia providers, without being fully integrated into other electronic health record components of the entire enterprise medical system. To understand why anesthesia providers should embrace health information technology (HIT) on a health system-wide basis, this article reviews recent HIT history and reviews HIT concepts. The author explores current developments in efforts to expand enterprise HIT, and the pros and cons of full enterprise integration with an AIMS.

User acceptance of an anaesthesia information management system

BACKGROUND AND OBJECTIVE

This paper describes the user acceptance of an anaesthesia information management system at the University Hospital in Giessen, Germany, after 5 yr of routine use.

METHODS

A questionnaire with 75 items was distributed to all anaesthesiologists and anaesthetic nurses of the Department of Anaesthesiology. The questions were answered anonymously on a five-point Likert scale.

RESULTS

The return rate was 60% (44 physicians and 24 nurses). The results indicated that the system generally met user expectations. The respondents thought that electronic record keeping improved the quality of their work, and they did not want to switch back to paper records. Problems arose with hardware placement and software features, e.g. coding tools for diagnoses and type of surgery. The perceived quality of training strongly influenced user acceptance.

CONCLUSIONS

Despite the deficits revealed by the survey, the respondents did not want to switch back to manual record keeping. A structured user survey is a useful tool for the development, adaptation and implementation of an anaesthesia information management system. A training strategy that takes the needs of the users into account is recommended.

The employment of an iterative design process to develop a pulmonary graphical display

OBJECTIVE

Data representations on today's medical monitors need to be improved to advance clinical awareness and prevent data vigilance errors. Simply building graphical displays does not ensure an improvement in clinical performance because displays have to be consistent with the user's clinical processes and mental models. In this report, the development of an original pulmonary graphical display for anesthesia is used as an example to show an iterative design process with built-in usability testing.

DESIGN

The process reported here is rapid, inexpensive, and requires a minimal number of subjects per development cycle. Three paper-based tests evaluated the anatomic, variable mapping, and graphical diagnostic meaning of the pulmonary display.

MEASUREMENTS

A confusion matrix compared the designer's intended answer with the subject's chosen answer. Considering deviations off the diagonal of the confusion matrix as design weaknesses, the pulmonary display was modified and retested. The iterative cycle continued until the anatomic and variable mapping cumulative test scores for a chosen design scored above 90% and the graphical diagnostic meaning test scored above 75%.

RESULTS

The iterative development test resulted in five design iterations. The final graphical pulmonary display improved the overall intuitiveness by 18%. The display was tested in three categories: anatomic features, variable mapping, and diagnostic accuracy. The anatomic intuitiveness increased by 25%, variable mapping intuitiveness increased by 34%, and diagnostic accuracy decreased slightly by 4%.

CONCLUSION

With this rapid iterative development process, an intuitive graphical display can be developed inexpensively prior to formal testing in an experimental setting.

On-line novelty detection for artefact identification in automatic anaesthesia record keeping

We report the design of a kernel-based on-line novelty detector (ADDaM - Automatic Dynamic Data Mapper) and its use in the detection of artefacts in an automatic anaesthesia record keeper (AARK).ADDaM produces a partitioned history of any ordered data stream and constructs a probability distribution function (PDF) from that history using Gaussian kernels. Two forms of PDF are possible: a static PDF where the prior probability of each kernel is determined by the number of observations it represents and a temporal PDF where more recent observations have a higher prior probability. Testing against the current PDF assesses the novelty of the next point entering the stream. The performance of this method for artefact detection in heart rate data was compared to Kalman, ARIMA and moving mean filters using receiver operator characteristic (ROC) curves. Performance was measured using the area under the curves (AUC), and the false positive rate (FPR) and positive predictive value (PPV) calculated at the optimal cost-point on the curves. The results obtained were: ADDaM (Static PDF) AUC 0.92, FPR 0.12, PPV 0.12 and ADDaM (Temporal PDF) AUC 0.97, FPR 0.12, PPV 0.15. Both ADDaM-based methods out performed all other on-line methods tested.

Automatic artifact identification in anaesthesia patient record keeping: a comparison of techniques

The anaesthetic chart is an important medico-legal document, which needs to accurately record a wide range of different types of data for reference purposes. A number of computer systems have been developed to record the data directly from the monitoring equipment to produce the chart automatically. Unfortunately, systems to date record artifactual data as normal, limiting the usefulness of such systems. This paper reports a comparison of possible techniques for automatically identifying artifacts. The study used moving mean, moving median and Kalman filters as well as ARIMA time series models. Results on unseen data showed that the Kalman filter (area under the ROC curve 0.86, false positive prediction rate 0.31, positive predictive value 0.05) was the best single method. Better results were obtained by combining a Kalman filter with a seven point moving mid-centred median filter (area under the ROC curve 0.87, false positive prediction rate 0.14, positive predictive value 0.09) or an ARIMA 0-1-2 model with a seven point moving mid-centred median filter (area under the ROC curve 0.87, false positive prediction rate 0.14, positive predictive value 0.10). Only one method that could be used on real-time data outperformed the single Kalman filter which was a Kalman filter combined with a seven point moving median filter predicting the next point in the data stream (area under the ROC curve 0.86, false positive prediction rate 0.23, positive predictive value 0.06).

Computerized data collection in the operating room during coronary artery bypass surgery: a comparison to the hand-written anesthesia record

OBJECTIVE

To investigate variability between hand-written and computerized anesthesia records and evaluate any associated bias.

DESIGN AND MEASUREMENTS

A computer system that was used to collect intraoperative data for a study of hemodynamic management during coronary artery bypass graft surgery is described. The system collected and recorded hemodynamic data automatically downloaded from the anesthesia monitor as well as surgical events and drug administration data entered through menu options. The system then combined, summarized, and graphed the data as well as formatted it for export to a commercially available database program. In a sample of 14 patients, blood pressure data collected by the computer system was compared with the blood pressure data charted in the hand-written anesthesia record.

MAIN RESULTS

Although general linear models controlling for within-patient variation and randomization assignment for mean arterial pressure range on cardiopulmonary bypass showed a significant relationship; low R2 values indicated that much of the variability could not be explained and that there was, therefore, poor agreement between the two records. Furthermore, a systematic bias in the hand-written anesthesia record was found when the computer system record was compared with the hand-written record and to the difference of the two records, so that extremes seen in the computer system record tended to be minimized in the hand-written anesthesia record.

CONCLUSIONS

Because of the lack of explained variability between the computer system and hand-written anesthesia records and the bias in the hand-written anesthesia record, the hand-written anesthesia record should not be relied on as a source of accurate data for research purposes.

An integrated graphic data display improves detection and identification of critical events during anesthesia

OBJECTIVE

To show that an integrated graphic data display can shorten the time taken to detect and correctly identify critical events during anesthesia.

METHODS

We developed a graphic display which presents 30 anesthesia-related physiologic variables as shapes and colors, rather than traditional digits and waveforms. To evaluate the new display, we produced four critical events on a computer-based anesthesia simulator and asked two groups of five anesthesiologists to identify the events as quickly as possible. One group observed the new display while the other group viewed a traditional cardiovascular monitor with digital and waveform displays.

RESULTS

The group which observed the integrated graphic display saw changes caused by inadequate paralysis 2.4 min sooner, and changes caused by a cuff leak 3.1 min sooner than those observing the traditional display. The integrated display group correctly identified the reason for the change 2.8 min sooner for inadequate paralysis, 3.1 min sooner for cuff leak and 3.1 min sooner for bleeding. These differences were all statistically significant.

CONCLUSIONS

The results show that some simulated critical events are detected and correctly identified sooner, when an anesthesiologist views an integrated graphic display, rather than a traditional digital/waveform monitor.

Patient data management systems in anaesthesia: an emerging technology

The purpose of this review is to define the expectations of an on-line automatic patient data management system (PDMS) into anaesthesia work-stations in and around the operating room suite. These expectations are based on review of available information in the medical literature, and trials of several systems that are available commercially, three of them in a more detailed fashion (i.e. Informatics, Datex and North American Drager). The ideal PDMS should: -- communicate with and capture the information from different monitors, anaesthesia machines and electronic gadgets (e.g., infusion pumps) used in the operating room (OR), while presenting selected relevant values and trends on a screen. -- inform the anaesthetist of deviations from preselected limits of physiological and technical values. In the future, the system will hopefully be upgraded to include an algorithm-based decision support system. -- communicate with the hospital mainframe computer, and automatically transfer demographic data, laboratory and imaging results, and records obtained during preoperative consultations. -- at the end of each anaesthetic procedure, create an anaesthetic record with relevant data automatically collected by the system, as well as that which was entered manually by the physician during the procedure. A copy of this anaesthesia file must be kept on a computerized archive system. None of the systems so far evaluated fulfilled all our expectations. We have therefore adopted approach for the gradual introduction of such a system into our OR environment over the next two to five years, during which expected improvements may be incorporated to upgrade the system.

Integrating computerized anesthesia charting into a hospital information system

BACKGROUND

Systems for computerization of anesthesia records have typically been 'stand-alone' computers many times connected to monitoring devices in the operating theater. A system was developed and tested at LDS Hospital in Salt Lake City, Utah, USA that was an integral part of the Health Evaluation through Logical Processing (HELP) hospital information system.

METHODS

The system was evaluated using time and motion studies to assess impact of the system on the anesthesiologists use of time, an assessment for completeness of the anesthesia record was conducted, and a questionnaire was used to assess anesthesiologists attitudes. Timing studies were performed on 44 surgical cases before computerization and 41 surgical cases after computerization. For both before and after computerization, about 80% of procedures were D&C, vaginal hysterectomy, laparoscopy, tubal ligation, or A&P repair.

RESULTS

The study showed a major reduction in time required for charting from 20.4% to 13.4% which was statistically significant (p = 0.0001). Other significant factors were a reduction in the time spent scanning the entire area which dropped from 10.5% to 5.6% (p = 0.001), patient preparation time increased from 10.1% to 13.1% (p = 0.02), the time spent arranging equipment increased from 6.4% to 8.1%, and the average time spent on non-anesthesia activities increased from 6.3% to 11.3%. The computerized anesthesia record was more legible, and complete than the manual record. The overall assessment of computer charting by anesthesiologists questionnaire was positive. The computerized anesthesia charting was preferred by the anesthesiologists, who, after one or two training sessions, used the system on their own.

CONCLUSIONS

It appears that having a computerized anesthesia charting system that is an integral part of a hospital information system not only saves anesthesiologists charting time, but also improves the quality of the record and was well accepted by busy private practice anesthesiologists.