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Computerized recordkeeping and information management in cardiothoracic and vascular anesthesia
Journal of
Cardiothoracic and Vascular Anesthesia VOL 11, NO 5
AUGUST 1997
EDITORIAL Computerized Recordkeeping and Information Management in Cardiothoracic and Vascular Anesthesia HE DRAMATIC ADVANCES in personal computer (PC) technology and the relatively low cost have opened the door to a variety of computer applications for anesthesiologists. I predict that computerized anesthesia recordkeeping and information management systems (CAR-IMS) will become the predominant method of perioperative data-gathering in the next decade. Cardiothoracic and vascular anesthesiologists will be in the forefront of this trend because of the complexity of the cases, and the medical and economic implications of the data that are generated. This prediction is not based on medicolegal issues, which were discussed in some detail in the June 1995 issue of the American Society of Anesthesiologists Newsletter, 1,2 but rather on quality management, economic, and academic issues that will be cited here.
T
QUALITY M A N A G E M E N T
Malpractice premiums for anesthesiologists have fallen dramatically and are not an overriding concern now. The concerns of anesthesiologists have largely shifted to competition for managed care contracts. As physician reimbursement decreases to levels where cost-containment is achieved, insurers and employers of large organizations are increasingly seeking to use quality of care as the primary criterion for choosing providers) In other words, the stakes have changed--the penalty for a bad outcome may not only be a successful lawsuit with damages paid by an insurer. The new risk is the loss of managed care contract(s) worth many millions of dollars in actual revenue over the long term based on adverse assessments by peer-review organizations and/or insurers. The anesthesiologists' best defense in documenting quality of care is hard data. The creation of a legible and accurate anesthesia record is certainly the first measurable effect of implementing a CARIMS, and the quality of the anesthesia record is key in defending against unjustified allegations of substandard care. Of equal importance in the new environment, though, is having the data and processing power to analyze the risk factors. In other words, while most are aware that risk factors (eg, diabetes mellitus, peripheral vascular disease, coronary artery disease, surgeon, emergency operations) are associated with higher morbidity and mortality, it is essential to present these data to put complication rates in their proper perspective.
ECONOMICS
The creation of an economically competitive operating room (OR) and anesthesia group requires minimization of costs and maximal utilization of resources. The properly constructed CAR-IMS provides reports of consumption of anesthesiarelated items and OR use. It is not sufficient to review annual pharmacy budgets of anesthesia-specific drugs. The costs must be reviewed by practitioner and by procedure to generate more current and useful data. Current CAR-IMS systems can also provide immediate on-line feedback regarding comparable drug costs during the procedure. The OR manager requires information about OR turn-around times, procedure lengths, and empty ORs in order to maximize the efficiency of OR staffing. The huge costs associated with preoperative test ordering may be appropriately reduced based on risk assessment by validated computer algorithms.4 The bottom line issue for most anesthesiologists and administrators is the cost-effectiveness of CAR-IMS. Originally, the startup cost for such systems was approximately $20,000 to $35,000 per OR. Currently, it is possible to install a networked system for as little as $13,000 to $15,000 per OR. The cost of installing and maint~Lning these systems must be defrayed by some benefits. These may include the following: 1. Decreased billing company charges; 2. Decreased anesthesia drug-related expenditures from on-line feedback and post-fioc reports (eg, 820 vials of pancuronium used instead of a proprietary neuromuscular blocker equate with approximately $15,000 in savings); 3. Decreased length of Post-Anesthesia Care Unit (PACU) stay based on administrative changes (eg, re-engineering of cleaning and transportation services); 4. Decreased cancellations and delays of surgery attributed to inadequate preoperative testing and preparation; 5. Improved OR use based on improved OR management; and 6. More effective bids for managed care contracts based on a knowledge of the above. ACADEMIC ISSUES
The paucity of anesthesia research based on the large caseloads of stored computerized anesthesia records is surpris-
Journal of Cardiothoracic and Vascular Anesthesia, Vol 11, No 5 (August), 1997: pp 543-544
543
544
DAVID L. REICH
ing, given the current emphasis on outcomes research. The sample sizes needed to assess the relationship between intraoperative events and relatively rare outcomes are present in many departmental databases. On a smaller level, clinical research projects (especially hemodynamic studies of drug effects) are facilitated by accurate and detailed source documentation. Lerou et al 5 demonstrated in 1988 that the proportion of missing and erroneous data was quite high in hand-written anesthesia records. Three other studies showed that the proportion and severity of abnormal numbers was less in hand-written compared with computerized records. 6-8 The article by Hollenberg et al 9 in this issue of the JOURNALis another contribution to this literature regarding the accuracy of computer versus hand-written anesthesia records. Figure 4 in that article is an elegant demonstration of the hemodynamic smoothing phenomenon of hand-written records. In no case were actual (computer) systolic blood pressures less than 100 mmHg documented, and there was only one instance where an actual systolic blood pressure greater than 150 mmHg was documented. The data also describe a nearly linear smoothing phenomenon between actual systolic blood pres-
sures of 80 and 160mmHg. This relationship is very strong evidence that the systolic blood pressure values recorded on the hand-written record represent the results of intentional smoothing rather than random error or faulty recall. Additionally, the technological resources available in an anesthesiology department (eg, CAR-IMS, simulators, Internet access) may also be a factor in recruiting residents in an increasingly competitive environment. In conclusion, the medicolegal issue is not the only one to consider when assessing the future role of CAR-IMS in anesthesiology. Quality management, economic, and academic needs will most likely be the major factors that influence decisions to purchase these systems. As the medical environment changes, the need for accurate, abundant, and analyzable data will be driven by the economic as well as the scientific needs of cardiothoracic and vascular anesthesiologists. David L. Reich, MD Associate Professor of Anesthesiology Mount Sinai Medical Center New York, NY
REFERENCES
1. Ferrari HA: Defending anesthesia malpractice claims: Role of computerized records. Am Soc Anesthesiologists News159:14-16, 1995 2. Zeitlin GL: Automated records do not reduce anesthesia liability. Am Soc Anesthesiologists News159:21-23, 1995 3. NobleHB: Qualityis focus for health plans. The New York Times, July 3, 1995, p. 1 4. Roizen MF: Cost-effective preoperative laboratory testing. JAMA 271:319-320, 1994 5. Lerou JG, Dirksen R, van Daele M, et al: Automated charting of physiological variables in anesthesia: A quantitative comparison of automated versus handwritten anesthesia records. J Clin Monit 1988;4: 37-47
6. Block FE Jr: Normal fluctuation of physiologic cardiovascular variables during anesthesia and the phenomenon of "smoothing." J Clin Monit 72:141-145, 1991 7. Thrush DN: Are automated anesthesia records better? J Clin Anesth 4:386-389, 1992 8. Cook RI, McDonald JS, Nunziata E: Differences between handwritten and automatic blood pressure records. Anesthesiology 71:385390, 1989 9. Hollenberg JP, Pirraglia PA, Witliams-Russo R et al: Computerized data collection in the operating room during coronary artery bypass graft surgery: A comparison to the hand-written anesthesia record. J Cardiothorac Vasc Anes 11:545-551, 1997
Cardiothoracic and Vascular Anesthesia VOL 11, NO 5
AUGUST 1997
EDITORIAL Computerized Recordkeeping and Information Management in Cardiothoracic and Vascular Anesthesia HE DRAMATIC ADVANCES in personal computer (PC) technology and the relatively low cost have opened the door to a variety of computer applications for anesthesiologists. I predict that computerized anesthesia recordkeeping and information management systems (CAR-IMS) will become the predominant method of perioperative data-gathering in the next decade. Cardiothoracic and vascular anesthesiologists will be in the forefront of this trend because of the complexity of the cases, and the medical and economic implications of the data that are generated. This prediction is not based on medicolegal issues, which were discussed in some detail in the June 1995 issue of the American Society of Anesthesiologists Newsletter, 1,2 but rather on quality management, economic, and academic issues that will be cited here.
T
QUALITY M A N A G E M E N T
Malpractice premiums for anesthesiologists have fallen dramatically and are not an overriding concern now. The concerns of anesthesiologists have largely shifted to competition for managed care contracts. As physician reimbursement decreases to levels where cost-containment is achieved, insurers and employers of large organizations are increasingly seeking to use quality of care as the primary criterion for choosing providers) In other words, the stakes have changed--the penalty for a bad outcome may not only be a successful lawsuit with damages paid by an insurer. The new risk is the loss of managed care contract(s) worth many millions of dollars in actual revenue over the long term based on adverse assessments by peer-review organizations and/or insurers. The anesthesiologists' best defense in documenting quality of care is hard data. The creation of a legible and accurate anesthesia record is certainly the first measurable effect of implementing a CARIMS, and the quality of the anesthesia record is key in defending against unjustified allegations of substandard care. Of equal importance in the new environment, though, is having the data and processing power to analyze the risk factors. In other words, while most are aware that risk factors (eg, diabetes mellitus, peripheral vascular disease, coronary artery disease, surgeon, emergency operations) are associated with higher morbidity and mortality, it is essential to present these data to put complication rates in their proper perspective.
ECONOMICS
The creation of an economically competitive operating room (OR) and anesthesia group requires minimization of costs and maximal utilization of resources. The properly constructed CAR-IMS provides reports of consumption of anesthesiarelated items and OR use. It is not sufficient to review annual pharmacy budgets of anesthesia-specific drugs. The costs must be reviewed by practitioner and by procedure to generate more current and useful data. Current CAR-IMS systems can also provide immediate on-line feedback regarding comparable drug costs during the procedure. The OR manager requires information about OR turn-around times, procedure lengths, and empty ORs in order to maximize the efficiency of OR staffing. The huge costs associated with preoperative test ordering may be appropriately reduced based on risk assessment by validated computer algorithms.4 The bottom line issue for most anesthesiologists and administrators is the cost-effectiveness of CAR-IMS. Originally, the startup cost for such systems was approximately $20,000 to $35,000 per OR. Currently, it is possible to install a networked system for as little as $13,000 to $15,000 per OR. The cost of installing and maint~Lning these systems must be defrayed by some benefits. These may include the following: 1. Decreased billing company charges; 2. Decreased anesthesia drug-related expenditures from on-line feedback and post-fioc reports (eg, 820 vials of pancuronium used instead of a proprietary neuromuscular blocker equate with approximately $15,000 in savings); 3. Decreased length of Post-Anesthesia Care Unit (PACU) stay based on administrative changes (eg, re-engineering of cleaning and transportation services); 4. Decreased cancellations and delays of surgery attributed to inadequate preoperative testing and preparation; 5. Improved OR use based on improved OR management; and 6. More effective bids for managed care contracts based on a knowledge of the above. ACADEMIC ISSUES
The paucity of anesthesia research based on the large caseloads of stored computerized anesthesia records is surpris-
Journal of Cardiothoracic and Vascular Anesthesia, Vol 11, No 5 (August), 1997: pp 543-544
543
544
DAVID L. REICH
ing, given the current emphasis on outcomes research. The sample sizes needed to assess the relationship between intraoperative events and relatively rare outcomes are present in many departmental databases. On a smaller level, clinical research projects (especially hemodynamic studies of drug effects) are facilitated by accurate and detailed source documentation. Lerou et al 5 demonstrated in 1988 that the proportion of missing and erroneous data was quite high in hand-written anesthesia records. Three other studies showed that the proportion and severity of abnormal numbers was less in hand-written compared with computerized records. 6-8 The article by Hollenberg et al 9 in this issue of the JOURNALis another contribution to this literature regarding the accuracy of computer versus hand-written anesthesia records. Figure 4 in that article is an elegant demonstration of the hemodynamic smoothing phenomenon of hand-written records. In no case were actual (computer) systolic blood pressures less than 100 mmHg documented, and there was only one instance where an actual systolic blood pressure greater than 150 mmHg was documented. The data also describe a nearly linear smoothing phenomenon between actual systolic blood pres-
sures of 80 and 160mmHg. This relationship is very strong evidence that the systolic blood pressure values recorded on the hand-written record represent the results of intentional smoothing rather than random error or faulty recall. Additionally, the technological resources available in an anesthesiology department (eg, CAR-IMS, simulators, Internet access) may also be a factor in recruiting residents in an increasingly competitive environment. In conclusion, the medicolegal issue is not the only one to consider when assessing the future role of CAR-IMS in anesthesiology. Quality management, economic, and academic needs will most likely be the major factors that influence decisions to purchase these systems. As the medical environment changes, the need for accurate, abundant, and analyzable data will be driven by the economic as well as the scientific needs of cardiothoracic and vascular anesthesiologists. David L. Reich, MD Associate Professor of Anesthesiology Mount Sinai Medical Center New York, NY
REFERENCES
1. Ferrari HA: Defending anesthesia malpractice claims: Role of computerized records. Am Soc Anesthesiologists News159:14-16, 1995 2. Zeitlin GL: Automated records do not reduce anesthesia liability. Am Soc Anesthesiologists News159:21-23, 1995 3. NobleHB: Qualityis focus for health plans. The New York Times, July 3, 1995, p. 1 4. Roizen MF: Cost-effective preoperative laboratory testing. JAMA 271:319-320, 1994 5. Lerou JG, Dirksen R, van Daele M, et al: Automated charting of physiological variables in anesthesia: A quantitative comparison of automated versus handwritten anesthesia records. J Clin Monit 1988;4: 37-47
6. Block FE Jr: Normal fluctuation of physiologic cardiovascular variables during anesthesia and the phenomenon of "smoothing." J Clin Monit 72:141-145, 1991 7. Thrush DN: Are automated anesthesia records better? J Clin Anesth 4:386-389, 1992 8. Cook RI, McDonald JS, Nunziata E: Differences between handwritten and automatic blood pressure records. Anesthesiology 71:385390, 1989 9. Hollenberg JP, Pirraglia PA, Witliams-Russo R et al: Computerized data collection in the operating room during coronary artery bypass graft surgery: A comparison to the hand-written anesthesia record. J Cardiothorac Vasc Anes 11:545-551, 1997