Anesthesia information management systems have been in existence for more than 30 years. Historically, the adoption of AIMS has been slow; statistics vary, but studies estimate that in 2007 only 5 percent of U.S. operating rooms had an AIMS.1
Recently, however, the use of electronic anesthesia records has accelerated dramatically. According to a 2011 report in Anesthesiology Clinics, 14.8 percent of hospitals had a live AIMS or sites under construction. That number swelled to 27 percent when the number of sites under contract was included in the total.2 This trend was confirmed by a 2011 survey in which more than 30 percent of participating chief information officers (CIOs) reported that their institutions had purchased an AIMS.3
This positive trend seems to be driven primarily by:
• The need to address increased regulatory reporting and quality metrics requirements
• Financial impetus, including meeting meaningful use criteria and the potential for a positive return on investment (ROI)
• The healthcare-wide movement toward electronic health record systems
As more and more institutions acquire and implement an AIMS, it is important that anesthesiologists and other decision makers carefully consider their role in the process and what they can do to help ensure system success. This paper examines ten significant factors that can prove critical to the successful adoption of an AIMS.
1. Advocating for an AIMS in Your Institution
If your institution does not currently have an AIMS, you and other anesthesiologists in your group can play an important role advocating for its acquisition. To have a significant impact, our panelists believe that, as physician leaders, you must be prepared to present a business case backed by solid empirical data.
According to our team, the most compelling arguments center on ROI and improved revenue for the hospital. They believe you should focus on the ability of an AIMS to:
• Increase revenue for the hospital by mining data for Centers for Medicare & Medicaid Services (CMS) projects
• Streamline workflow and improve operating room (OR) efficiency
• Optimize nursing, anesthesia and OR time by decreasing double documentation
• Improve billing and speed payments
One of our panelists, Dr. Norbert Topf, sees ROI as the primary driver. “Electronic record systems have shown that they can improve your ROI,” he says. “Since the OR is the area of the highest profitability in most hospitals, an electronic system can generate a big return for the entire hospital, not just for the OR.”
Dr. Gary Friedman concurs. “To convince your institution to spend money on an anesthesia record-keeping system, first you need to convince them that there will be a significant ROI,” he says. “In our hospital, we needed to show a financial ROI, as well as returns in other areas such as patient satisfaction, provider satisfaction, efficiency and market share.”
Dr. John MacCarthy feels that better reporting holds the most sway. He states, “The health information data that is needed for pay-for-performance projects and things like Leapfrog Group4 is growing rapidly. These projects have requirements where they need to report on several hundred, if not thousands, of charts. You couldn’t possibly read the writing or even know where to look on most paper charts to find the data that people are looking for.”
2. Role of Anesthesiologists in the Selection Process
As noted in a recent issue of Becker’s Hospital Review, a hospital’s anesthesia department plays a key role in many areas of the facility’s operations, including OR efficiency (on-time starts, recovery time, etc.); patient safety and clinical outcomes; and patient, surgeon and surgical staff satisfaction.5 This wide range of responsibilities makes anesthesiologists a valuable resource not just in the selection of an AIMS but also for OR automation in general.
“Anesthesiologists are very central to the functionality of an OR,” says Dr. Topf. “We have a lot of contact with surgeons. We have an in-depth understanding about OR workflows. And we are very interested in efficiency, reporting and managing OR throughput. This expertise can be invaluable in selecting the right OR management system. While we might not make the ultimate decision on each aspect, we should get involved in all levels of the selection process and definitely should be on the selection committee.”
Dr. Friedman believes that one of the biggest barriers to system success is excluding or minimizing the role of anesthesiologists in the decision process. “You want to see the biggest barrier to adoption?” he asks. “Fail to include an anesthesiologist in the decision to bring in a system. If you are trying to change something, you need to have all the stakeholders
in the room and get buy-in.”
3. Must-Have Features and Capabilities
The capabilities of AIMS vary, depending on the vendor. Our physician team feels that any system being considered should be proven at multiple sites and come from a company with extensive experience providing integrated OR management and electronic anesthesia record systems.
In addition, they have compiled a list of must-have features for any successful AIMS:
• Integrated electronic billing capabilities
• The ability to easily capture pay-for-performance data required for CMS
• Easy reporting, including predefined reports that cover requirements such as Surgical Care Improvement Project (SCIP) and meaningful use parameters
• Flexible and robust workflow management that doesn’t interfere with workflow and actually improves it
• Data integration with other systems so that items such as allergies and medications and nursing staff documentation automatically flow into the chart
4. Overcoming the Biggest Barriers to Achieving a Timely and Successful Implementation
While our panel lists several key factors, they feel that the most important ingredient in the recipe for success is leadership buy-in. A strong commitment is needed from your hospital management and the leadership of the anesthesia group.
“If you have leadership support from the hospital side, not just the OR but the chief of medical staff, it is usually a good driver to get things done,” says Dr. Topf. “The second part is strong support from anesthesia management, whether the group is independent or employed by the hospital. If the leadership backs off or doesn’t really seem motivated, then obviously the group itself never really picks up motivation.”
Information technology (IT) department support and a comprehensive training program are other key components, according to our panelists. They emphasize that a strong IT-anesthesiologist relationship and thorough system testing are essential. Dr. MacCarthy says that IT departments need to work closely with anesthesiologists so that practice requirements are accurately reflected in system setup. He also feels that it is vital for physician users not to lose confidence in the system, especially in the beginning.
“I think it’s important that the system be thoroughly tested for a couple of weeks—if not a month—by a core group that knows what the system is supposed to do,” says Dr. MacCarthy.“This ensures that the system is doing what it’s supposed to before it’s rolled out.”
Since physician participation and buy-in is essential for success, hospitals also need to find creative ways to get physicians on board. One proven method is to identify physician users who enthusiastically embrace the new system and have them informally mentor the ones who are struggling.
“You need to appeal to a broad spectrum of people to make it successful,” says Dr. Friedman.
“You have some younger physicians who have used computers a lot more in their early education, medical school and residency. Naturally, they are going to adapt a little easier than a seasoned veteran who has used a written record in a practice for 20 or 30 years. The younger early adopters can help the later adopters along.”
In addition to an internal mentoring program, all three physicians agree that a formal physician adoption program can significantly enhance implementation success. This involves the support of practicing anesthesiologists with real-world AIMS experience. As part of the program, experienced anesthesiologists move from one OR to another and give one-on-one attention to your physicians. During the process, physicians who are less technologically savvy are identified and given extra attention.
5. Getting Anesthesiologists to Agree on the System Build
Getting a group of physicians to agree on anything is, at best, challenging. However, our panel believes that you can apply a proven system-build methodology at virtually any institution:
• Form a leadership group with physicians who do a wide range of anesthetics.
• Have one or two people in your anesthesia group drive the process and come up with a general system framework.
• Reach an agreement on the basic items to be documented.
• Check with key players in subspecialties for additional information and unique requirements.
• Build the system and get feedback from the leadership group in weekly or monthly meetings.
“Our group has more than 60 members, and you would never be able to get a consensus,” says Dr. Topf. “It is better to cherry-pick the leaders of individual groups and subspecialties and use those key people to talk to about setup, reporting and compliance issues.”
Dr. MacCarthy emphasizes the need to have a well-rounded team participating in the system build. He states, “It’s best to have a core group of anesthesiologists who have done each form of anesthetic and do a number of cases every year of each type, including regional anesthetics and invasive monitoring. You want a skill set that’s diverse to make sure you have all of the documentation that’s required. Otherwise, things tend to get missed.”
6. Building Relationships with Other Departments
Your most important relationship is, of course, the connection between the anesthesia group and your IT department. The better this relationship is managed, the faster and more successful your system implementation will be.
Our panel recommends the following:
• One or two physicians from your system-implementation group should take the lead. The participants need to have a working understanding of technology and be well versed in your functional requirements.
• During the build period, regular meetings, perhaps once a week, should take place between your designated representatives and their IT counterparts to review status and test the system.
• Requests and changes should be documented in writing to minimize misunderstanding.
• In order to resolve problems quickly and efficiently, it is also important to establish a good relationship with the IT customer support team after the system goes live.
“One of the most critical components to implementing a successful system is to have good technical support from both your IT department and your software supplier,” says Dr. Friedman. “You can’t be successful without both.”
In addition to IT, other departments that can play an important role in successfully implementing your system include pharmacy, nursing and OR management.
7. The Most Indispensable Benefit of an Electronic Record
We asked our panel what they would miss most if they had to go back to a paper record. The unanimous response was the automatic recording of physiologic data. They feel that an electronic record is much more accurate because you get a constant stream of accurate data. It was pointed out that with a paper record, you are not charting as it is happening. It is retrospective, with data being entered from memory two, ten or 20 minutes later. As a result, you are never sure how accurate it is, especially with a challenging case.
“If a patient has a problem and I’m dealing with a clinical issue, it is difficult to completely, accurately and legibly document what’s happening at that moment,” says Dr. Friedman. “They say that the first victim of a crisis is the medical record. Using an electronic record helps me focus on the patient and the patient monitor instead of a piece of paper.”
Dr. Topf adds, “I don’t have to sit down for hours and hours to document all vital signs. It’s all automated in the system. I would miss that the most because I find that it frees me to spend more time with the patient.”
8. The Legal Ramification of Using an Electronic Record
Ironically, the very feature that our panel of experienced electronic users considers indispensable—the automatic recording of physiologic data—is the biggest concern to anesthesiologists currently documenting on paper.
“One of the biggest concerns when I talk to people is the medical/legal risk of adopting an electronic record where the physiological data that the system is recording may not necessarily be accurate,” says Dr. Friedman. “They are concerned that the system may record physiological data that’s reflective of artifacts from an electrical surgical device or interference from a surgeon leaning on a blood pressure cuff or a pulse oximeter that may be misplaced.”
When it comes to dealing with inaccurate data being recorded because of human error or device malfunction, all three physicians agree on the solution:
• Dr. Topf: “If something is not right in the record, like one blood pressure is off, I write a comment on the individual data and say why I think it’s not relevant.”
• Dr. Friedman: “We can attach a comment to that particular vital sign to say why the data was picked up that way and why it is not reflective of what was really happening to the patient.”
• Dr. MacCarthy: “The reality is that the number of faulty blood pressures and faulty pulse oximeter readings that you get is very, very low. Usually, bad things happen when there is a trend of bad things happening—not isolated incidents. I just make a note in the record of what happened.”
Dr. MacCarthy also gives advice on how to minimize faulty readings. “The other thing that we’ve done is we’ve started putting the monitors on in a little bit better manner. We won’tput a pulse ox on an arm that has a blood pressure cuff on it. We tend to put them on the feet if we’re working on the arms.”
Our panel also feels that an electronic record may actually provide better protection than a paper record in case of legal action. “There is anecdotal evidence, not just from my institution but from some of the largest institutions in this country, that shows that the AIMS has actually saved anesthesia practices and individual providers from litigation because the documentation we provide is so comprehensive and so complete and is very legible,” says Dr. Friedman.
Dr. Topf agrees. “I think it’s intuitive,” he says. “I’ve never done a study, but I would say that the electronic record would actually help you prove your case.” Dr. MacCarthy was the most definitive of all, stating, “I would say, by far, that electronic records are a better defense in a medical legal situation than they are a problem. I think they help you rather than hurt you.”
9. The Importance of a Physician Champion
The need to have a physician or a small core group of physicians within the group that champions the project cannot be overstated. The physician champion fills several important roles:
• Helps sell the system to management as well as to anesthesiologists within the group
• Serves as the “translator” between clinicians and IT
• Acts as the go-to resource for issues related to the system
According to our panel, the physician champion needs to be someone who is well respected, knows your practice and whom you work with daily. Other qualifications that are seen as important include experience across different areas of anesthesia and subspecialties and a thorough understanding of your workflow and operations.
“You need someone with a strong will, good background and lots of experience,” says Dr. MacCarthy. “I think it’s a huge mistake putting a junior member of the group or a nurse anesthetist in charge. You may dodge some of the workload up front, but you are going to pay for it in the end.”
10. Lessons Learned
We asked our panel: “If you knew then what you know now, what would you have done differently?”
• Dr. Topf: “When we implemented the system, there was no physician adoption program. Having early input from people who have installed the system gives you a better idea about its capabilities, including the plusses and minuses. I think it could have saved us a tremendous amount of time, instead of having to go back to the drawing board.”
• Dr. MacCarthy: “I would have done more testing and made sure that everything was exactly right before we rolled the system out.”
• Dr. Friedman: “Rather than going live in phases, I would have liked to have gone ‘all in’ in the beginning and installed other components of the overall perioperative system so we would have been able to use our system on a more comprehensive basis from the start.”
With the momentum for electronic health records (EHRs) growing throughout healthcare, it is no longer a matter of if your hospital is going to implement an AIMS but rather a matter of when. Physician involvement is important at each step of the process, from advocating for an electronic anesthesia record to selecting the right AIMS for your hospital to successfully implementing and adopting the system.
Your hospital and your practice can learn a lot from the pioneers that have gone before you. Our panel summarizes their thoughts into three key takeaways:
1. Select a system from a vendor with years of experience providing AIMS. It is important that institutions of a similar size and type as yours are among the vendor’s implementation experience.
2. Apply proven best practices and lessons learned from other implementations. This will help you speed adoption, optimize resources and create an environment where this critical tool will be an enormous success.
3. Take advantage of peer-to-peer implementation support. A formal physician adoption program and coaching from fast-learning anesthesiologists in your practice can improve productivity and speed acceptance.
The physicians who make up our panel have a collective experience of more than 45 years of practicing anesthesia in a variety of different hospital settings. Each one has been a driving force in implementing an AIMS in his facility, as well as providing physician adoption consulting services to other hospitals that are implementing electronic records in anesthesia.
Gary Friedman, MD
Dr. Friedman has served as chief of medical staff at Southern New Hampshire Medical Center, Nashua, New Hampshire, where he has been a practicing anesthesiologist since 1998. A board-certified anesthesiologist, Dr. Friedman has served as an instructor in anesthesiology at Harvard Medical School. He is the recipient of the “Leading Physician / Top Doctor Award” from New Hampshire Magazine for 2010 - 2012.
John MacCarthy, MD
Dr. MacCarthy is president of Fullerton Anesthesia Associates and serves as co-director of surgical services at St. Jude Medical Center, Fullerton, California. A board-certified anesthesiologist, Dr. MacCarthy was a medical officer in the U.S. Navy and has been a practicing anesthesiologist since 1992.
Norbert Topf, MD, PhD
Dr. Topf is a vice president at Anesthesia Associates of New Mexico and a practicing anesthesiologist at Presbyterian Hospital, Albuquerque, New Mexico. A board-certified anesthesiologist, Dr. Topf was an assistant professor at New York Presbyterian Hospital, Weill Medical College of Cornell University and has published numerous academic articles and abstracts.
1. “Anesthesia information management systems: A survey of current implementation policies and practices,” Anesthesia & Analgesia, 2007;105(2);405-411.
2. “Anesthesia information management systems marketplace and current vendors,” Anesthesiology Clinics, September 2011.
3. Picis-sponsored College of Healthcare Information Management Executives (CHIME) Foundation Survey on Implications for an Anesthesia EMR , August 2011.
4. The Leapfrog Group is an initiative driven by organizations that buy health care who are working to initiate breakthrough improvements in the safety, quality and affordability of healthcare for Americans.
5. “Anesthesia involvement in hospital strategy, leadership crucial to department, facility success,” Becker’s Hospital Review, April 11, 2012.