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Problems in the adoption of automated anaesthesia record-keeping devices
13 Problems in the adoption of automated anaesthesia record-keeping devices JOHN
BIONDI
Of all the tasks performed at the anaesthesia work station, the completion of the anaesthesia work record would seem a natural application of computing. It is, for the most part, a repetitive task with predictable variations. Attempts at the computerization of the anaesthesia work record have been the focus of considerable discussion and developmental work. Individually developed computer record-keepers have been reported since the late 1970s and the first commercially available units appeared in 1983-4. As many as five or six commercial products have been available at one time. Numerous articles and papers on the topic have appeared in the scientific and clinical literature, not to mention books, publications and societies that have been formed around computing in anaesthesia. Despite all this interest and information, no product has been commercially successful in the world market to date, and no clinician-developed system has spread beyond a small circle of colleagues. This leads us to ask two questions: are automated anaesthesia recordkeepers (AARKs) merely solutions in search of an application--that is, are we trying to computerize something that does not require computerizing? Or, have the solutions offered to date been unacceptable? We can certainly find evidence to suggest that a feasible solution should be available, and that once found would find clinical acceptance. There are several analogues for the application of computers to similar problems within the hospital environment. Computerized record-keeping has been available and successful in intensive care units for some time. Other clinical departments in the hospital, although not keeping records in real time, have their own highly specialized computer systems. The laboratory, pharmacy and radiology departments are examples of these. As mentioned above, the nature of the task of record-keeping makes it very suitable for the application of computer processing. Indeed, much of the data needed to complete an anaesthesia record is available from the processors residing in the monitors and measuring instruments used to deliver anaesthesia, It would not seem unreasonable, therefore, to assume that a workable A A R K is technically possible and that once achieved would find use in the clinical community. Such indications seem to point out that the lack of general adoption of Bailli~re's Clinical Anaesthesiology--
Vol. 4, No. 1, June 1990 ISBN 0-7020-1343-9
153 Copyright9 1990,by Bailli6reTindall All rights of reproductionin any form reserved
154
J. BIONDI
AARKs is due more to the absence of an acceptable solution rather than the lack of an acceptable or recognized application. If we examine the problems that must be solved in designing an AARK, we may develop an appreciation for what may be needed to achieve a more acceptable device than those that have been available to date. The first problem to be overcome is that the individual monitors comprising the monitoring array of any given anaesthesia system must be interfaced to the AARK. This is not a complex technical problem once the communication protocols of the monitors to be used are known. Obtaining these protocols for the wide variety of companies and monitors around the world is, however, nearly impossible. Frequently, interfaces must be adapted in the field to the particular monitoring set on any given machine. This is generally done by using electronic devices to decipher the data stream out of a given monitor. This problem, although not insignificant from a technical or business standpoint, only affects the clinical acceptability of the device if the interface is poor, resulting in bad data and artefacts. From the clinician's point of view, the next problem is much more significant. As has been mentioned, some input to the record comes automatically from the monitors themselves. To form a complete record, however, information other than this automatically transducible information needs to be entered. Drug and fluid administration and general comments are examples of information that typically would have to be entered on the record by hand or through the computer via some type of input device. The solutions of this problem that have been offered can be divided into two principal categories. The first category comprises systems that do not use a computer input device. These units merely take the automatically transduced information and format it into some type of a grid or graph. Frequently this type of record-keeper will allow the clinician to add to this physiologic grid 'drug' and 'event' marks denoting times when the clinician has taken some action. The clinician then annotates the record by hand to explain what occurred at each of these drug entry or event markers. This type of device has the advantage of being fairly simple, relatively inexpensive and labour-saving. It has the disadvantage that not all of the information is entered into the computer, and generally lacks data storage and retrieval capability. Although such a device has the benefits of saving labour and increasing the accuracy and legibility of the anaesthesia record, it could not be used for billing, quality assurance, inventory management, epidemiology or research requiring creation and sorting of a database. The other category of system uses one or more input devices to capture all pertinent data available at the anaesthesia work station. Keyboards, touchsensitive screens, light pencils, bar code readers, character recognition and voice recognition have all been used experimentally, either alone or in combination. Most of these input devices have been used in commercial products. The use of one or more input devices has the advantage of entering all information into the data storage facility of the computer. Once there, it can later be sorted and retrieved for a variety of purposes. These data could also be moved around the hospital if the A A R K were to be interfaced with
PROBLEMS IN AUTOMATED ANAESTHESIA RECORD-KEEPING DEVICES
155
the larger hospital information system. With such an interface, information from other hospital computers could also be brought into the A A R K and used in the operating room. Such input devices have disadvantages, however. First, they do not save labour or time. Even voice recognition, seemingly the ultimate input device, takes considerable user training and increases the time necessary to make an entry. The combination of an input device with the software scheme necessary to its function is still slower than the hand-held pen that these devices are intended to replace. Here lies one of the problems with acceptance of these devices. If they increase rather than reduce labour, some other reason must be found to justify the expense and learning burden that these devices entail. Expense is another factor. Generally, the more elaborate the input device the more expensive it becomes. Highly specialized input devices for particular applications can increase the amount of data automatically transduced, and have been developed. Combination electronic scales and bar code readers have been developed for automatic drug entry; sensor systems have been developed for fluid entries. However, such specialized input devices, in conjunction with a more generalized device such as a keyboard or touchsensitive screen, do add significant cost to a system. The search for the ultimate combination of input devices and sofware schemes therefore still continues. Another problem is the format of the record. There are as many record formats as there are hospitals, and there is only so much modification of the computer record that can be achieved. New formats sometimes have to be accepted by the hospital's medical records committee before being recognized as an official medical record. This is certainly not a major impediment to adoption, but is another difficulty. The next problem impeding the adoption of AARKs is what we will call the 'complexity' issue. Anaesthesia delivery systems are becoming burdened with more and more devices. Monitoring devices have proliferated in recent years; each with its own alarm and display scheme; some with their own printers or chart recorders. An automatic record-keeper can now add another display, input device and printer to an already crowded work station. A stand-alone A A R K that is added to an existing monitoring configuration runs the risk of degrading rather than improving overall data management at the anaesthesia work station. The correct record-keeping solution must address the entire data management problem, not just the record-keeping portion. Data management consists not just of recordkeeping and alarm management, but also the integration of all monitoring and trending into a centralized display with uniform presentation of all information. This is a dilemma that is central to the adoption problem. What is needed is an elegant stand-alone solution that can acceptably incorporate existing monitoring and machine configurations, as well as a solution that is integrated completely within the design of a unified machine-monitoring package. This point brings us to another barrier to acceptance. Solutions for existing machines must be sought, along with more integrated solutions for
156
J. BIONDI
new models of equipment. The conversion of one or a small number of operating rooms to an A A R K system probably achieves little. If the same limited number of clinicians use the machines with AARKs, this might have some benefit. If, however, the entire anaesthesia staff rotates through all machines on a regular basis, being forced to keep records by hand in some rooms and using the A A R K in others, generally what happens is that the AARKs fall into disuse. Furthermore, networking a minimum number of systems into the hospital information system is neither cost-effective nor practical. The resulting database is incomplete and not useful for quality control, billing, utilization and certain types of research. To derive maximum benefit from conversion to AARKs it is probable that all sites should be changed at the one time. The discussion so far has centred on interoperative data--information created and gathered during the surgery itself. Since preoperative and historical information could also be helpful in decision-making during surgery, the ideal system might allow the anaesthetist to access this information from the hospital information system. The anaesthesia record itself forms the basis for care in the immediate postoperative environment. As anaesthesia case record information ages, it becomes less important as a basis for care postoperatively, but can once again merge into the historical data stored in the hospital information system. Certainly a computer link between the A A R K in each surgical theatre and the hospital information system would facilitate the use of computer-gathered information from the anaesthesia work station and might provide a powerful reason for entering this information to an A A R K in the first place. At present such links are the rare exception. Indeed, although such links exist in other areas of the hospital, the operating theatre may well be the last major hospital area to become computerized and networked to the hospital information system. The twin issues of first having an A A R K in every surgical area, and then networking these operating-room units into the hospital information system, are probably at the heart of the slow adoption of computerized record-keeping. As pointed out above, the solution that must be achieved goes well beyond computerizing the record; what is needed is an overall scheme of data management for the anaesthesia work station. Similarly, what must be achieved overall from the hospital perspective is not merely the manipulation of data within the operating room, but the integration of intraoperatively generated data with preoperative and postoperative information, and the linking of all this information with other areas of the hospital. Other hospital computer information systems potentially benefiting from such linkage could be billing, materials management, pharmacy, quality assurance, laboratory and medical records. It will probably be the postoperative use of intraoperatively generated data that will fuel the need for AARKs and other types of anaesthesia data management products. Currently there are a variety of operating department management systems available in certain parts of the world. These products are basically software packages that deal with case scheduling, management of supplies and staff posting and performance. These packages do not, in any way, deal with the information generated during a surgical
PROBLEMS IN AUTOMATED ANAESTHESIA RECORD-KEEPING DEVICES
157
case. The marriage of the information dealt with in these surgical department packages and interoperatively generated information should correlate three main activities: scheduling, materials management and data management (including patient data). The result of this marriage would be improvement in the timeliness of patient care, better departmental reports and statistics, a database to analyse information leading to improved quality of care and a variety of management controls to contain costs and improve care. Other barriers to adoption, such as concerns about artefact and fears that a machine-generated record may prove to be a liability risk rather than a liability reducer, will be removed when the overall system produces sufficient value and benefits to overcome personal objections. CONCLUSION The lack of implementation of automated anaesthetic record systems is not caused by resistance to the idea of a computerized record-keeper, but by the necessity for a holistic data management solution that will integrate the anaesthesia work station with the operating room department management system and, ultimately, with the hospital information system network. These three developments are happening concurrently, and computerization is being adopted at a different rate in each area. All the technical barriers are surmountable. Possibly, by combining these separate capabilities at a business level, the adoption of computerized record-keeping and data organizing machines in the operating room will be speeded up. This might be facilitated by one company bringing the interoperative data management system together with the extraoperative department management system; thereby providing the technical capability of interfacing these components with the hospital information system. After this is accomplished, the probable remaining barrier to adoption will be cost.
BIONDI
Of all the tasks performed at the anaesthesia work station, the completion of the anaesthesia work record would seem a natural application of computing. It is, for the most part, a repetitive task with predictable variations. Attempts at the computerization of the anaesthesia work record have been the focus of considerable discussion and developmental work. Individually developed computer record-keepers have been reported since the late 1970s and the first commercially available units appeared in 1983-4. As many as five or six commercial products have been available at one time. Numerous articles and papers on the topic have appeared in the scientific and clinical literature, not to mention books, publications and societies that have been formed around computing in anaesthesia. Despite all this interest and information, no product has been commercially successful in the world market to date, and no clinician-developed system has spread beyond a small circle of colleagues. This leads us to ask two questions: are automated anaesthesia recordkeepers (AARKs) merely solutions in search of an application--that is, are we trying to computerize something that does not require computerizing? Or, have the solutions offered to date been unacceptable? We can certainly find evidence to suggest that a feasible solution should be available, and that once found would find clinical acceptance. There are several analogues for the application of computers to similar problems within the hospital environment. Computerized record-keeping has been available and successful in intensive care units for some time. Other clinical departments in the hospital, although not keeping records in real time, have their own highly specialized computer systems. The laboratory, pharmacy and radiology departments are examples of these. As mentioned above, the nature of the task of record-keeping makes it very suitable for the application of computer processing. Indeed, much of the data needed to complete an anaesthesia record is available from the processors residing in the monitors and measuring instruments used to deliver anaesthesia, It would not seem unreasonable, therefore, to assume that a workable A A R K is technically possible and that once achieved would find use in the clinical community. Such indications seem to point out that the lack of general adoption of Bailli~re's Clinical Anaesthesiology--
Vol. 4, No. 1, June 1990 ISBN 0-7020-1343-9
153 Copyright9 1990,by Bailli6reTindall All rights of reproductionin any form reserved
154
J. BIONDI
AARKs is due more to the absence of an acceptable solution rather than the lack of an acceptable or recognized application. If we examine the problems that must be solved in designing an AARK, we may develop an appreciation for what may be needed to achieve a more acceptable device than those that have been available to date. The first problem to be overcome is that the individual monitors comprising the monitoring array of any given anaesthesia system must be interfaced to the AARK. This is not a complex technical problem once the communication protocols of the monitors to be used are known. Obtaining these protocols for the wide variety of companies and monitors around the world is, however, nearly impossible. Frequently, interfaces must be adapted in the field to the particular monitoring set on any given machine. This is generally done by using electronic devices to decipher the data stream out of a given monitor. This problem, although not insignificant from a technical or business standpoint, only affects the clinical acceptability of the device if the interface is poor, resulting in bad data and artefacts. From the clinician's point of view, the next problem is much more significant. As has been mentioned, some input to the record comes automatically from the monitors themselves. To form a complete record, however, information other than this automatically transducible information needs to be entered. Drug and fluid administration and general comments are examples of information that typically would have to be entered on the record by hand or through the computer via some type of input device. The solutions of this problem that have been offered can be divided into two principal categories. The first category comprises systems that do not use a computer input device. These units merely take the automatically transduced information and format it into some type of a grid or graph. Frequently this type of record-keeper will allow the clinician to add to this physiologic grid 'drug' and 'event' marks denoting times when the clinician has taken some action. The clinician then annotates the record by hand to explain what occurred at each of these drug entry or event markers. This type of device has the advantage of being fairly simple, relatively inexpensive and labour-saving. It has the disadvantage that not all of the information is entered into the computer, and generally lacks data storage and retrieval capability. Although such a device has the benefits of saving labour and increasing the accuracy and legibility of the anaesthesia record, it could not be used for billing, quality assurance, inventory management, epidemiology or research requiring creation and sorting of a database. The other category of system uses one or more input devices to capture all pertinent data available at the anaesthesia work station. Keyboards, touchsensitive screens, light pencils, bar code readers, character recognition and voice recognition have all been used experimentally, either alone or in combination. Most of these input devices have been used in commercial products. The use of one or more input devices has the advantage of entering all information into the data storage facility of the computer. Once there, it can later be sorted and retrieved for a variety of purposes. These data could also be moved around the hospital if the A A R K were to be interfaced with
PROBLEMS IN AUTOMATED ANAESTHESIA RECORD-KEEPING DEVICES
155
the larger hospital information system. With such an interface, information from other hospital computers could also be brought into the A A R K and used in the operating room. Such input devices have disadvantages, however. First, they do not save labour or time. Even voice recognition, seemingly the ultimate input device, takes considerable user training and increases the time necessary to make an entry. The combination of an input device with the software scheme necessary to its function is still slower than the hand-held pen that these devices are intended to replace. Here lies one of the problems with acceptance of these devices. If they increase rather than reduce labour, some other reason must be found to justify the expense and learning burden that these devices entail. Expense is another factor. Generally, the more elaborate the input device the more expensive it becomes. Highly specialized input devices for particular applications can increase the amount of data automatically transduced, and have been developed. Combination electronic scales and bar code readers have been developed for automatic drug entry; sensor systems have been developed for fluid entries. However, such specialized input devices, in conjunction with a more generalized device such as a keyboard or touchsensitive screen, do add significant cost to a system. The search for the ultimate combination of input devices and sofware schemes therefore still continues. Another problem is the format of the record. There are as many record formats as there are hospitals, and there is only so much modification of the computer record that can be achieved. New formats sometimes have to be accepted by the hospital's medical records committee before being recognized as an official medical record. This is certainly not a major impediment to adoption, but is another difficulty. The next problem impeding the adoption of AARKs is what we will call the 'complexity' issue. Anaesthesia delivery systems are becoming burdened with more and more devices. Monitoring devices have proliferated in recent years; each with its own alarm and display scheme; some with their own printers or chart recorders. An automatic record-keeper can now add another display, input device and printer to an already crowded work station. A stand-alone A A R K that is added to an existing monitoring configuration runs the risk of degrading rather than improving overall data management at the anaesthesia work station. The correct record-keeping solution must address the entire data management problem, not just the record-keeping portion. Data management consists not just of recordkeeping and alarm management, but also the integration of all monitoring and trending into a centralized display with uniform presentation of all information. This is a dilemma that is central to the adoption problem. What is needed is an elegant stand-alone solution that can acceptably incorporate existing monitoring and machine configurations, as well as a solution that is integrated completely within the design of a unified machine-monitoring package. This point brings us to another barrier to acceptance. Solutions for existing machines must be sought, along with more integrated solutions for
156
J. BIONDI
new models of equipment. The conversion of one or a small number of operating rooms to an A A R K system probably achieves little. If the same limited number of clinicians use the machines with AARKs, this might have some benefit. If, however, the entire anaesthesia staff rotates through all machines on a regular basis, being forced to keep records by hand in some rooms and using the A A R K in others, generally what happens is that the AARKs fall into disuse. Furthermore, networking a minimum number of systems into the hospital information system is neither cost-effective nor practical. The resulting database is incomplete and not useful for quality control, billing, utilization and certain types of research. To derive maximum benefit from conversion to AARKs it is probable that all sites should be changed at the one time. The discussion so far has centred on interoperative data--information created and gathered during the surgery itself. Since preoperative and historical information could also be helpful in decision-making during surgery, the ideal system might allow the anaesthetist to access this information from the hospital information system. The anaesthesia record itself forms the basis for care in the immediate postoperative environment. As anaesthesia case record information ages, it becomes less important as a basis for care postoperatively, but can once again merge into the historical data stored in the hospital information system. Certainly a computer link between the A A R K in each surgical theatre and the hospital information system would facilitate the use of computer-gathered information from the anaesthesia work station and might provide a powerful reason for entering this information to an A A R K in the first place. At present such links are the rare exception. Indeed, although such links exist in other areas of the hospital, the operating theatre may well be the last major hospital area to become computerized and networked to the hospital information system. The twin issues of first having an A A R K in every surgical area, and then networking these operating-room units into the hospital information system, are probably at the heart of the slow adoption of computerized record-keeping. As pointed out above, the solution that must be achieved goes well beyond computerizing the record; what is needed is an overall scheme of data management for the anaesthesia work station. Similarly, what must be achieved overall from the hospital perspective is not merely the manipulation of data within the operating room, but the integration of intraoperatively generated data with preoperative and postoperative information, and the linking of all this information with other areas of the hospital. Other hospital computer information systems potentially benefiting from such linkage could be billing, materials management, pharmacy, quality assurance, laboratory and medical records. It will probably be the postoperative use of intraoperatively generated data that will fuel the need for AARKs and other types of anaesthesia data management products. Currently there are a variety of operating department management systems available in certain parts of the world. These products are basically software packages that deal with case scheduling, management of supplies and staff posting and performance. These packages do not, in any way, deal with the information generated during a surgical
PROBLEMS IN AUTOMATED ANAESTHESIA RECORD-KEEPING DEVICES
157
case. The marriage of the information dealt with in these surgical department packages and interoperatively generated information should correlate three main activities: scheduling, materials management and data management (including patient data). The result of this marriage would be improvement in the timeliness of patient care, better departmental reports and statistics, a database to analyse information leading to improved quality of care and a variety of management controls to contain costs and improve care. Other barriers to adoption, such as concerns about artefact and fears that a machine-generated record may prove to be a liability risk rather than a liability reducer, will be removed when the overall system produces sufficient value and benefits to overcome personal objections. CONCLUSION The lack of implementation of automated anaesthetic record systems is not caused by resistance to the idea of a computerized record-keeper, but by the necessity for a holistic data management solution that will integrate the anaesthesia work station with the operating room department management system and, ultimately, with the hospital information system network. These three developments are happening concurrently, and computerization is being adopted at a different rate in each area. All the technical barriers are surmountable. Possibly, by combining these separate capabilities at a business level, the adoption of computerized record-keeping and data organizing machines in the operating room will be speeded up. This might be facilitated by one company bringing the interoperative data management system together with the extraoperative department management system; thereby providing the technical capability of interfacing these components with the hospital information system. After this is accomplished, the probable remaining barrier to adoption will be cost.